What is the formula for albumin replacement after paracentesis (percutaneous abdominal paracentesis) for ascites?

Albumin Replacement Formula for Paracentesis in Ascites

The recommended dose of albumin replacement after paracentesis is 6-8 g of albumin per liter of ascites removed when the volume exceeds 5 liters. 1

Dosing Guidelines Based on Volume Removed

• For paracentesis of >5 liters (large volume paracentesis or LVP), albumin replacement at 6-8 g/L of ascites removed is strongly recommended 1
• For paracentesis of <5 liters, albumin replacement is generally not required as these smaller volume removals are not associated with significant hemodynamic changes 1
• For patients at higher risk (those with acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury), albumin replacement at 8 g/L should be considered even for volumes <5 liters 1

Practical Dosing Examples

• For 5 liters removed: approximately 40 g of albumin (using 8 g/L formula) 1
• For 8 liters removed: approximately 64 g of albumin (using 8 g/L formula) 1
• Standardized dosing approach:
  • 25 g albumin for 5-6 L removed
  • 50 g albumin for 7-10 L removed
  • 75 g albumin for >10 L removed 2

Clinical Rationale

• Albumin replacement prevents post-paracentesis circulatory dysfunction (PPCD), which can lead to serious complications including 1:

  • Renal impairment and hepatorenal syndrome
  • Dilutional hyponatremia
  • Hepatic encephalopathy
  • Increased mortality

• Albumin is superior to alternative plasma expanders (dextran, gelatin, hydroxyethyl starch, hypertonic saline) in preventing complications 3, 4

• Patients receiving albumin after large volume paracentesis have:

  • 61% lower odds of developing PPCD compared to alternative treatments 3
  • 42% lower odds of developing hyponatremia 3
  • 36% lower odds of mortality 3

Special Considerations

• The risk of PPCD increases with >8 L of fluid evacuated in a single session 1
• Some centers have successfully implemented standardized protocols using slightly lower albumin doses (average 6.5 g/L) without increased adverse effects 2
• For patients with spontaneous bacterial peritonitis (SBP), a different dosing regimen is recommended: 1.5 g albumin/kg within 6 hours of diagnosis, followed by 1 g/kg on day 3 1

Formulation Considerations

• Albumin should be administered as 20% or 25% solution 1, 5
• 25% albumin solution contains 25 g of albumin per 100 mL 5
• Infusion should occur after paracentesis is completed 1

Common Pitfalls

• Failure to administer albumin after large volume paracentesis can lead to PPCD, which is associated with shorter time to readmission and decreased survival 4
• Excessive albumin administration (>9 g/L) may not provide additional benefits and increases costs 2
• Albumin replacement should not be substituted with other plasma expanders, as they are less effective in preventing complications 3, 4