What are the doses of albumin for large volume paracentesis in cirrhosis, spontaneous bacterial peritonitis, and hepatorenal syndrome?

Albumin Dosing Guidelines for Cirrhotic Complications

For large volume paracentesis (LVP), spontaneous bacterial peritonitis (SBP), and hepatorenal syndrome (HRS), albumin should be administered at specific doses: 6-8 g/L of ascites removed for LVP >5L, 1.5 g/kg at diagnosis and 1 g/kg on day 3 for SBP, and variable doses for HRS depending on clinical context. 1

Large Volume Paracentesis (LVP)

Dosing Guidelines:

• For paracentesis removing >5 liters (defined as large volume paracentesis), administer 6-8 g of albumin per liter of ascites removed 1
• For example, after removing 5 liters, approximately 40 g of albumin should be infused, and after removing 8 liters, approximately 64 g should be given 1
• For paracentesis <5 liters, albumin replacement is generally not required as these smaller volume removals are not associated with significant hemodynamic changes 1, 2
• It is preferable to limit ascites removal to <8 liters in a single procedure as the risk of paracentesis-induced circulatory dysfunction (PICD) increases with >8L removed 1

Clinical Rationale:

• Albumin prevents paracentesis-induced circulatory dysfunction (PICD), which occurs in up to 70% of cases when paracentesis is performed without plasma expansion 1, 3
• PICD is associated with increased rates of recurrent ascites, development of hepatorenal syndrome, hyponatremia, and reduced survival 1, 3
• Albumin has been shown to be superior to other volume expanders for preventing PICD 1

Administration Considerations:

• Albumin should be administered as 20% or 25% solution after paracentesis is completed 2, 3
• Some evidence suggests that half-dose albumin (4 g/L of ascites removed) may be effective in preventing PICD in selected patients with lower severity cirrhosis, but this requires further validation 4

Spontaneous Bacterial Peritonitis (SBP)

Dosing Guidelines:

• For patients with SBP, administer 1.5 g/kg albumin at diagnosis (within 6 hours), followed by 1 g/kg on day 3 1, 2
• This dosing is particularly important for high-risk patients (serum bilirubin >4 mg/dL or serum creatinine >1 mg/dL) 1

Clinical Rationale:

• Albumin administration in SBP significantly reduces the incidence of renal impairment (10% vs 33%) and mortality (10% vs 29%) compared to antibiotics alone 1
• This regimen prevents hepatorenal syndrome development in patients with SBP 1

Hepatorenal Syndrome (HRS)

Dosing Guidelines:

• For HRS, albumin dosing varies based on clinical context and is typically used in combination with vasoconstrictors 5, 6
• Optimal doses for survival benefit in patients at high risk of HRS were found to be approximately 87.5-100 g total albumin administered within the first 48 hours of hospitalization 5

Clinical Considerations:

• Albumin has a dose-dependent effect on both survival and complications in patients with cirrhosis with acute renal failure (including HRS) 5
• Long-term albumin administration in decompensated cirrhosis may reduce mortality and incidence of complications, but specific dosing regimens require further validation 7

Important Caveats and Pitfalls

• Avoid removing >8 liters of ascites in a single session when possible, as this increases the risk of PICD even with albumin administration 1
• Monitor for signs of volume overload, especially in patients with cardiac dysfunction 6
• The timing of albumin administration is important - it should be given after paracentesis completion for LVP, and within 6 hours of diagnosis for SBP 2, 3
• While some evidence suggests lower albumin doses might be effective (4 g/L for LVP), the standard recommendation remains 6-8 g/L until more definitive studies are available 4