Albumin Dosage for Large Volume Paracentesis (>5 Liters)
The recommended dosage of albumin for patients undergoing paracentesis with more than 5 liters of drainage is 6-8 grams of albumin per liter of ascitic fluid removed. 1
Dosing Guidelines Based on Volume Removed
- For paracentesis removing >5 liters (large volume paracentesis), albumin should be administered at a dose of 6-8 g per liter of ascitic fluid removed 1
- Albumin should be administered as a 20% or 25% solution after the paracentesis is completed 1, 2
- For example, after removing 5 liters, approximately 40g of albumin should be infused, and after 8L removal, approximately 64g of albumin should be given 1
- For paracentesis of <5 liters, albumin replacement is generally not required as these smaller volume removals are not typically associated with significant hemodynamic changes 1, 2
Clinical Rationale for Albumin Administration
Albumin administration prevents post-paracentesis circulatory dysfunction (PPCD), a serious complication that can lead to 1, 2:
- Renal impairment and hepatorenal syndrome
- Dilutional hyponatremia
- Hepatic encephalopathy
- Increased mortality
PPCD is characterized by a rise in plasma renin activity by 50% of baseline and occurs due to further reduction in effective arterial blood volume 1
Albumin has been shown to be superior to other volume expanders for preventing PPCD 1
The risk of PPCD increases significantly when >8L of fluid is evacuated in a single session 1
Special Considerations
- Some evidence suggests that half-dose albumin (4g/L of ascites removed) might be effective in preventing PPCD in patients with less severe cirrhosis, but this approach requires further validation 3
- For patients at higher risk, such as those with acute-on-chronic liver failure, albumin replacement at 8 g/L should be considered even for volumes <5 liters 4
- A standardized approach to albumin dosing based on volume removed (25g for 5-6L, 50g for 7-10L, and 75g for >10L) has been shown to be effective while potentially reducing albumin usage 5
Common Pitfalls
- Failure to administer albumin after large volume paracentesis can lead to significant complications including renal impairment (62.5% vs 30% with albumin), hyponatremia (67.5% vs 22.5% with albumin), and increased mortality 4
- Using alternative plasma expanders (dextran, gelatin, hydroxyethyl starch) instead of albumin is associated with higher rates of PPCD 6
- Removing >8L of ascitic fluid in a single session significantly increases the risk of PPCD, even with appropriate albumin replacement 1
- Leaving drains in overnight is not recommended; paracentesis should be completed in a single session over 1-4 hours 1
Practical Application
- Albumin should be infused after the paracentesis is completed 1
- The infusion should be done slowly to prevent potential cardiac overload, especially in patients with preexisting cardiomyopathy 1
- Diuretics should be reintroduced within 1-2 days after paracentesis to prevent recurrence of ascites 7
- Monitor for signs of PPCD such as hypotension, especially within the first 6 hours post-procedure when hemodynamic changes are maximal 7