Is the 8g of albumin (human albumin) administered from the first liter of ascites removed during large volume paracentesis?

Albumin Administration for Paracentesis

Albumin should be administered at a dose of 8g per liter of ascites removed regardless of the total volume of ascites removed, including from the first liter. 1

Evidence-Based Rationale

The European Association for the Study of the Liver (EASL) clinical practice guidelines clearly recommend albumin administration for all paracentesis procedures to prevent post-paracentesis circulatory dysfunction (PICD). The guidelines specifically state:

• "LVP should be performed together with the administration of albumin (8 g/L of ascitic fluid removed) to prevent circulatory dysfunction after LVP" 2
• For paracentesis of less than 5L: "patients should still be treated with albumin because of concerns about use of alternative plasma expanders" 2

The most recent Praxis Medical Insights guidelines (2025) reinforce this recommendation, indicating that albumin should be administered at 8g per liter of ascites removed 1. This applies to all paracentesis procedures, with no mention of starting only after a certain volume threshold.

Clinical Considerations

Volume-Based Approach

While the risk of PICD is higher with large-volume paracentesis (>5L), the guidelines recommend albumin administration for all volumes:

• For >5L: Albumin is strongly recommended (Level A1 evidence) 2
• For <5L: Albumin is still recommended (Level B1 evidence) 2

Special Populations

Patients with acute-on-chronic liver failure (ACLF) may be at even higher risk of PICD with modest-volume paracentesis (<5L). Research shows:

• PICD can develop even with modest-volume paracentesis in ACLF patients
• Albumin infusion significantly decreases PICD incidence (30% vs 70%) and mortality (27.5% vs 62.5%) in ACLF patients undergoing <5L paracentesis 3

Dosing Considerations

While the standard recommendation is 8g/L of ascites removed, some research has explored alternative dosing:

• A pilot study suggested that half-dose albumin (4g/L) might be similarly effective in preventing PICD (14% vs 20% incidence, not statistically significant) 4
• However, the most comprehensive meta-analysis shows that standard albumin dosing (8g/L) significantly reduces PICD (OR 0.39), hyponatremia (OR 0.58), and mortality (OR 0.64) compared to alternative treatments 5

Practical Implementation

1. Calculate total albumin dose: 8g × total liters removed
2. Administration timing: Administer during or immediately after paracentesis
3. Monitor for complications: Watch for signs of PICD (hypotension, tachycardia, increased plasma renin activity)
4. Follow-up care: Reintroduce diuretics within 1-2 days after paracentesis to prevent re-accumulation of ascites 1

Potential Pitfalls

• Underdosing albumin: Using less than the recommended 8g/L may increase PICD risk
• Delaying albumin administration: Albumin should be given during or immediately after paracentesis
• Neglecting diuretic therapy: Paracentesis treats the symptom (ascites) but not the underlying cause (sodium and water retention)
• Ignoring contraindications: Avoid NSAIDs, ACE inhibitors, and angiotensin II antagonists in patients with ascites due to increased risk of renal impairment 2

The evidence strongly supports administering albumin from the first liter of ascites removed during paracentesis, with the standard dose of 8g/L being the most well-supported approach for preventing PICD and its associated complications.