What is the indication for albumin (human albumin) use during ascitic fluid tapping of more than 5 litres to prevent circulatory dysfunction and impaired renal function?

Albumin Administration for Large Volume Paracentesis of More Than 5 Liters

Human albumin should be administered at a dose of 8 g per liter of ascitic fluid removed during large volume paracentesis (LVP) of more than 5 liters to prevent post-paracentesis circulatory dysfunction (PPCD). 1

Rationale for Albumin Administration

• LVP is the first-line treatment for large (grade 3) ascites in patients with cirrhosis, but it can cause significant hemodynamic changes that may lead to circulatory dysfunction 1
• PPCD is characterized by a reduction in effective blood volume that can lead to rapid re-accumulation of ascites, hepatorenal syndrome, hyponatremia, and increased mortality 1
• The removal of large volumes of ascitic fluid causes a marked reduction in intra-abdominal and inferior vena cava pressure, leading to decreased right atrial pressure and pulmonary capillary wedge pressure 1
• Without volume expansion, these hemodynamic changes can lead to activation of the renin-angiotensin-aldosterone system, resulting in renal impairment and electrolyte disturbances 1

Dosing Recommendations

• For LVP of more than 5 liters, albumin should be administered at a dose of 8 g per liter of ascitic fluid removed 1
• Albumin should be given as a 20% or 25% solution after the paracentesis is completed 1, 2
• The albumin should be administered slowly to avoid cardiac overload, especially in patients with latent cirrhotic cardiomyopathy 1
• For paracentesis of less than 5 liters, the risk of developing PPCD is lower, but albumin administration is still generally recommended due to concerns about alternative plasma expanders 1

Efficacy of Albumin vs. Alternative Plasma Expanders

• Albumin is more effective than other plasma expanders (dextran-70, polygeline) in preventing PPCD, particularly when more than 5 liters of ascites are removed 1
• The use of artificial plasma expanders is associated with significantly greater activation of the renin-angiotensin-aldosterone system 1
• Albumin reduces the odds of PPCD by 60% compared to other volume expanders 3
• Albumin administration is associated with a lower incidence of hyponatremia (8% vs 17%) compared to other plasma expanders 1
• Despite higher initial costs, albumin is more cost-effective than alternative plasma expanders due to fewer liver-related complications within 30 days post-paracentesis 1

Clinical Outcomes

• Albumin administration post-paracentesis is associated with:
  • Lower number of liver-related complications within 30 days 1
  • Reduced incidence of hyponatremia 3
  • Decreased risk of renal impairment 1
  • Improved survival (the severity of PPCD correlates inversely with patient survival) 1
• In patients with acute-on-chronic liver failure, albumin infusion decreases the incidence of PPCD even with modest-volume paracentesis (<5 L) 4

Practical Considerations

• LVP should be performed under strict sterile conditions using disposable sterile materials 1
• After LVP, patients should receive the minimum dose of diuretics necessary to prevent re-accumulation of ascites 1
• There are no absolute contraindications to LVP other than loculated ascites 1
• Hemorrhagic complications after LVP are infrequent, even in patients with coagulopathy 1
• The risk of PPCD increases with >8 L of fluid evacuated in one single session 1

Common Pitfalls to Avoid

• Failure to administer albumin after LVP >5 L can lead to PPCD with impaired renal function and electrolyte disturbances 1
• Administering albumin too rapidly can cause cardiac overload in patients with cirrhotic cardiomyopathy 1
• NSAIDs, ACE inhibitors, angiotensin II antagonists, and α1-adrenergic blockers should be avoided in patients with cirrhosis and ascites due to increased risk of renal impairment 1
• Limiting paracentesis volume to <8 L per session may help preserve renal function and improve survival 1

Human albumin remains the plasma expander of choice for large volume paracentesis of more than 5 liters due to its superior efficacy in preventing post-paracentesis circulatory dysfunction and associated complications.