Should albumin infusion be done before or after paracentesis (percutaneous abdominal paracentesis)?

Albumin Infusion Should Be Administered After Paracentesis

Albumin should be infused after paracentesis is completed, not before, at a dose of 8 g albumin per liter of ascites removed. 1

Evidence-Based Recommendations for Albumin Administration

Large Volume Paracentesis (>5L)

• Albumin (as 20% or 25% solution) should be infused after paracentesis of >5L is completed at a dose of 8 g albumin/L of ascites removed 1
• This timing and dosing has strong evidence and a strong recommendation in clinical guidelines 1, 2
• The purpose is to prevent post-paracentesis circulatory dysfunction (PICD), which can lead to complications including:
  • Hyponatremia
  • Renal impairment
  • Increased mortality

Smaller Volume Paracentesis (<5L)

• For paracentesis <5L, albumin can be considered after the procedure in:
  • Patients with acute-on-chronic liver failure (ACLF)
  • Patients at high risk of post-paracentesis acute kidney injury 1, 2
• The risk of PICD is lower with smaller volume paracentesis, but certain high-risk patients may still benefit from albumin administration

Rationale for Post-Paracentesis Administration

Albumin is administered after paracentesis for several important reasons:

1. Prevention of PICD: Albumin infusion reduces the odds of PICD by 61% (OR = 0.39,95% CI 0.27–0.55) 2, 3
2. Timing of volume replacement: The goal is to replace the oncotic pressure lost during fluid removal, which logically should occur after the fluid has been removed
3. Assessment of total volume: Administering albumin after paracentesis allows precise calculation of the required dose based on the actual volume removed

Clinical Benefits of Proper Albumin Administration

Meta-analysis evidence shows that post-paracentesis albumin administration provides significant benefits compared to alternative treatments 3:

• 61% reduction in PICD
• 42% reduction in hyponatremia (OR = 0.58,95% CI 0.39–0.87)
• 36% reduction in mortality (OR = 0.64,95% CI 0.41–0.98)

Practical Implementation

1. Complete the paracentesis procedure
2. Measure the total volume of ascites removed
3. Calculate albumin dose at 8 g/L of ascites removed
4. Administer albumin (20% or 25% solution) intravenously after the procedure

Important Considerations and Caveats

• Volume limitation: Consider limiting paracentesis to less than 8 liters per session to minimize PICD risk 2, 4
• No need for coagulation testing: Routine measurement of prothrombin time and platelet count before therapeutic or diagnostic paracentesis is not recommended 1
• Ultrasound guidance: Should be considered when available to reduce adverse events 1
• Post-procedure monitoring: Patients should be monitored for signs of hypotension during and after paracentesis 2
• Alternative dosing: Some centers have implemented standardized protocols with slightly lower albumin doses (e.g., 25g for 5-6L, 50g for 7-10L) with similar outcomes 5, but the guideline-recommended dose remains 8g/L

While some studies have investigated lower albumin doses (4g/L) 6, current guidelines still strongly recommend the standard 8g/L dose based on the highest quality evidence and strongest recommendations 1, 2.