When should albumin be administered after paracentesis?

Albumin Administration After Paracentesis

Albumin should be administered after large volume paracentesis (>5 liters) at a dose of 8 g albumin per liter of ascites removed to prevent post-paracentesis circulatory dysfunction and associated complications. 1, 2

Dosing Guidelines Based on Volume Removed

• Large volume paracentesis (>5 liters): Administer albumin at 8 g/L of ascites removed (e.g., 100 ml of 20% albumin per 2.5 liters of ascites) 1, 2
• Modest volume paracentesis (<5 liters):
  • Standard patients: A synthetic plasma expander is recommended 1
  • High-risk patients (acute-on-chronic liver failure): Consider albumin at 8 g/L even for volumes <5 liters 3

Administration Protocol

• Infuse albumin after paracentesis is completed, not during the procedure 2
• Use 20% or 25% albumin solution for infusion 1, 2
• Complete the paracentesis in a single session, draining ascites to dryness over 1-4 hours 1, 2
• Reintroduce diuretics within 1-2 days after paracentesis to prevent ascites recurrence 1

Clinical Rationale

• Albumin prevents post-paracentesis circulatory dysfunction (PICD), which can lead to serious complications including 1, 2:

  • Renal impairment
  • Hyponatremia
  • Hepatorenal syndrome
  • Increased mortality

• Studies show significantly higher rates of renal impairment, hyponatremia, and activation of the renin-angiotensin-aldosterone system in patients not treated with albumin after large volume paracentesis 1

• A meta-analysis of 17 randomized studies (1225 patients) showed albumin infusion reduced the odds of PICD by 61%, hyponatremia by 42%, and mortality by 36% compared to alternative treatments 1

Special Considerations

• Albumin vs. synthetic plasma expanders: While synthetic plasma expanders show some clinical effectiveness, albumin is superior in preventing hyponatremia (8% vs 17% incidence) and shows less activation of the renin-angiotensin-aldosterone system 1

• Patients with acute-on-chronic liver failure: These patients may develop PICD even with modest-volume paracentesis (<5L) and benefit from albumin infusion 3

• Cost considerations: Despite higher upfront costs, albumin administration decreases liver-related complications and can reduce overall hospital costs compared to artificial plasma expanders 1

• Dose optimization: Some evidence suggests that half-dose albumin (4 g/L) may be effective in patients with low severity cirrhosis, but standard dosing remains recommended until more conclusive evidence is available 1

Potential Pitfalls

• Leaving drain in overnight: This is not recommended and may increase complications 2

• Failure to monitor for circulatory dysfunction: Monitor for hypotension, which can occur (though rarely) after paracentesis 1

• Exceeding safe volume removal: Consider limiting ascites removal to <8 liters during a single paracentesis procedure to minimize PICD risk 1

• Infusion rate: Administer albumin slowly to prevent potential cardiac overload, especially in patients with pre-existing cardiomyopathy 1

While one meta-analysis questioned albumin's effect on mortality 4, the preponderance of evidence and current guidelines strongly support albumin administration after large volume paracentesis to prevent complications and improve outcomes 1, 2.