Albumin Replacement During Large Volume Paracentesis
For large volume paracentesis (>5 liters), albumin should be administered at a dose of 8g per liter of ascites removed to prevent post-paracentesis circulatory dysfunction. 1, 2
Rationale for Albumin Administration
Albumin administration during large volume paracentesis (LVP) is essential to prevent post-paracentesis circulatory dysfunction (PICD), which can lead to serious complications:
- PICD occurs in up to 80% of patients without volume expansion 2
- Albumin reduces the risk of PICD by approximately 61% 1
- Prevents complications including hyponatremia, renal impairment, and increased mortality 1, 2
Dosing Recommendations
Standard Dosing Protocol:
- >5 liters removed: Administer 8g albumin per liter of ascites removed 2, 1
- <5 liters removed: Plasma expansion generally not necessary unless patient has acute-on-chronic liver failure (ACLF) 2, 1
Timing of Administration:
- Albumin should be infused after paracentesis is completed, not before 1
- Use 20% or 25% albumin solution 2
Evidence Supporting Albumin Use
Multiple guidelines strongly support albumin administration for LVP:
- Albumin is superior to other plasma expanders in preventing PICD (OR=0.34,95% CI 0.23 to 0.51) 2
- Reduces hyponatremia (OR=0.61,95% CI 0.40 to 0.93) 2
- May reduce mortality compared to all other interventions (RR=0.77,95% CI 0.57 to 1.00) 2
- Reduces risk of complications (renal impairment, hyponatremia, death) in patients with ACLF even with <5L paracentesis 2
Alternative Approaches
Some evidence suggests that lower albumin doses might be effective:
- A pilot study showed that half-dose albumin (4g/L) may be similarly effective in preventing PICD (14% vs 20% incidence with standard dose) 3
- A standardized protocol using 25g (for 5-6L removed), 50g (for 7-10L), and 75g (for >10L) showed no difference in adverse effects compared to higher doses 4
However, these approaches have not been incorporated into major guidelines, which still recommend the standard 8g/L dose 2, 1.
Practical Considerations
- Perform paracentesis under strict sterile conditions 2
- Consider ultrasound guidance to reduce adverse events 2
- Routine measurement of prothrombin time and platelet count before paracentesis is not recommended 2
- Reintroduce diuretics within 1-2 days after paracentesis 1
- Complete drainage in a single session is preferred over repeated low-volume paracentesis 2, 1
Conclusion
While some recent research suggests lower albumin doses might be effective, current guidelines from multiple societies consistently recommend administering albumin at 8g per liter of ascites removed for paracentesis >5L to prevent circulatory dysfunction and associated complications.