What is the proper dosing for albumin infusion followed by furosemide (Lasix)?

Albumin and Furosemide Administration Protocol for Ascites Management

For patients requiring albumin infusion followed by furosemide, the proper dosing is to administer albumin 8 g/L of ascites removed for paracentesis >5 L, followed by oral furosemide starting at 40 mg daily (in combination with spironolactone 100 mg) for ongoing ascites management. 1, 2

Albumin Dosing Guidelines

• For large volume paracentesis (>5 L), administer 20% or 25% albumin solution at a dose of 8 g albumin/L of ascites removed after the procedure is completed 1
• For paracentesis <5 L, albumin (20% or 25% solution) can be considered at the same dose (8 g/L) in patients with acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury 1
• In spontaneous bacterial peritonitis (SBP), administer albumin 1.5 g/kg within 6 hours of diagnosis, followed by 1 g/kg on day 3, particularly in patients with increased serum creatinine or rising creatinine 1
• Albumin infusions should be completed before administering furosemide to maximize efficacy and minimize complications 3

Furosemide Dosing Guidelines

• For cirrhosis with ascites, start with oral furosemide 40 mg combined with spironolactone 100 mg as a single morning dose 2
• Doses can be increased simultaneously every 3-5 days if weight loss and natriuresis are inadequate, up to a maximum of 160 mg/day of furosemide and 400 mg/day of spironolactone 1, 2
• Oral administration is preferred in cirrhotic patients due to good bioavailability and to avoid acute reductions in glomerular filtration rate associated with IV administration 2
• If IV furosemide is necessary, administer slowly (1-2 minutes) to avoid ototoxicity 4

Sequential Administration Protocol

• Administer albumin and furosemide separately, using different infusion sites 3
• Complete the albumin infusion first, followed by furosemide administration 3
• Monitor electrolytes, kidney function, and hemodynamic parameters closely during treatment 3

Special Considerations

• Combination therapy with albumin and furosemide may enhance diuresis in patients with serum albumin levels <2.5 g/dL or in those with impaired renal function 5
• The diuretic effect of albumin-furosemide combination is most significant within the first 12 hours after administration 5
• Discontinue diuretics if severe hyponatremia, acute kidney injury, worsening hepatic encephalopathy, or incapacitating muscle cramps develop 3
• In patients with refractory ascites, consider transjugular intrahepatic portosystemic shunt (TIPSS) rather than escalating diuretic doses 1

Monitoring During Treatment

• Monitor for adverse events, as nearly half of patients require diuretic discontinuation or dose reduction 1
• Check electrolytes regularly, particularly sodium and potassium 2
• Assess kidney function through urine output and serum creatinine 2
• Evaluate fluid status through weight, blood pressure, and clinical examination 2

Common Pitfalls to Avoid

• Avoid simultaneous administration of albumin and furosemide in the same infusion, as this may reduce efficacy 3
• Do not administer furosemide in patients with marked hypovolemia, as it could worsen hypovolemia and promote thrombosis 2, 6
• Avoid high doses of furosemide (>6 mg/kg/day) for periods longer than 1 week due to risk of ototoxicity 6
• Do not use albumin in patients with cirrhosis and infections other than SBP, as it does not reduce the risk of acute kidney injury or mortality and may cause pulmonary edema 1