Albumin Dosing for Large Volume Paracentesis
For large volume paracentesis (>5 liters), administer 6-8 grams of intravenous albumin per liter of ascites removed to prevent postparacentesis circulatory dysfunction and reduce morbidity and mortality. 1, 2, 3
Standard Dosing Protocol
Volume-Based Recommendations
Paracentesis >5 liters: Albumin replacement at 6-8 g per liter of ascites removed is the established standard and strongly recommended 1, 2, 3
Paracentesis <5 liters: Albumin replacement is generally not required as smaller volume removals are not associated with significant hemodynamic changes 2, 3
High-risk patients (acute-on-chronic liver failure, high risk of acute kidney injury): Consider albumin at 8 g/L even for volumes <5 liters 2, 3
Formulation and Administration
Use 20-25% albumin solution (25% solution contains 25 g albumin per 100 mL) 3
Administer the albumin infusion after completing the paracentesis 2, 3
Infuse slowly to prevent cardiac overload in patients with preexisting cardiomyopathy 1
Evidence Supporting This Dosing
The 2024 International Collaboration for Transfusion Medicine Guidelines reviewed a 2019 Cochrane systematic review of 27 RCTs (N=1,592) showing that albumin at 6-8 g/L significantly reduces paracentesis-induced circulatory dysfunction compared to other plasma expanders (RR 1.98; 95% CI 1.31-2.99) 1. A 2020 meta-analysis of 17 RCTs (N=1,225) demonstrated that albumin at 8 g/L reduced postparacentesis circulatory dysfunction by 61% (OR 0.39; 95% CI 0.27-0.55), hyponatremia by 42% (OR 0.58; 95% CI 0.39-0.87), and mortality by 36% (OR 0.64; 95% CI 0.41-0.98) 1.
Lower Dose Considerations
While the standard remains 6-8 g/L, emerging evidence suggests potential flexibility in select patients:
A 2011 pilot study (N=70) in low-severity cirrhosis patients (mean MELD 16-17) showed that 4 g/L (half-dose) was non-inferior to 8 g/L for preventing postparacentesis circulatory dysfunction (14% vs 20%, p=NS), with similar rates of hyponatremia and renal impairment 4
A 2020 retrospective study (N=200) using a standardized order set with reduced albumin doses (6.5 g/L vs 8.3 g/L) showed no differences in hyponatremia, renal impairment, or hypotension 5
However, these lower doses should only be considered in carefully selected low-risk patients, as the standard 6-8 g/L dose has the strongest evidence base for preventing complications. 1
Volume Limitations
Limit paracentesis to ≤8 liters per session when possible, as the risk of postparacentesis circulatory dysfunction increases substantially with >8 L removed 1, 2, 6
If >8 L must be removed, ensure full albumin replacement at 8 g/L 2
Clinical Rationale
Postparacentesis circulatory dysfunction occurs in up to 70% of patients without albumin replacement and manifests as 1, 2:
- Deterioration of renal function and potential hepatorenal syndrome
- Dilutional hyponatremia (<125 mEq/L)
- Hepatic encephalopathy
- Hypotension
- Increased mortality and shorter time to readmission
Albumin is superior to artificial plasma expanders (dextran, gelatin, hydroxyethyl starch, hypertonic saline) because it more effectively prevents activation of the renin-angiotensin-aldosterone system 1, 2.
Important Caveats
Do not confuse this dosing with spontaneous bacterial peritonitis, which requires a different regimen: 1.5 g/kg within 6 hours of diagnosis, followed by 1 g/kg on day 3 3
The 2024 guidelines note that while high-dose (6-8 g/L) versus low-dose (2-4 g/L) albumin showed no statistical difference in small studies (N=120), uncertainty exists regarding the risk-benefit profile due to limited sample size 1
Historical studies used fixed doses of 20-40 g regardless of volume removed, but volume-based dosing (6-8 g/L) is now the standard 1