When is albumin replacement warranted after paracentesis?

Albumin Replacement After Paracentesis

Albumin replacement is warranted when more than 5 liters of ascitic fluid are removed during paracentesis, administered at a dose of 6-8 grams of albumin per liter of ascites drained. 1, 2, 3

Volume-Based Threshold for Albumin Administration

Large Volume Paracentesis (>5 Liters)

• Albumin is mandatory when removing more than 5 liters of ascites to prevent post-paracentesis circulatory dysfunction (PICD), which leads to renal impairment, hyponatremia, and activation of the renin-angiotensin-aldosterone system. 1
• The standard dose is 8 grams of albumin per liter of ascites removed, using 20% or 25% albumin solution. 1
• A slightly lower range of 6-8 grams per liter is also supported by recent guidelines and may reduce costs without compromising safety. 1, 2, 3
• Albumin should be infused after paracentesis is completed, not during the procedure. 1, 2

Small Volume Paracentesis (<5 Liters)

• Albumin is generally not required for paracentesis removing less than 5 liters of ascites. 1
• Synthetic plasma expanders may be used if volume expansion is deemed necessary, though this recommendation is based on consensus rather than strong evidence. 1
• Exception: Consider albumin even for <5 liters in high-risk patients with acute-on-chronic liver failure or those at high risk for post-paracentesis acute kidney injury. 2, 3

Clinical Rationale: Prevention of Post-Paracentesis Circulatory Dysfunction

Why Albumin Matters

• Without albumin, patients experience significantly higher rates of renal impairment, severe hyponatremia, and marked activation of the renin-angiotensin-aldosterone system. 1, 4
• In a landmark randomized trial, 11 of 53 patients (21%) who underwent paracentesis without albumin developed renal impairment or severe hyponatremia, compared to only 1 of 52 patients (2%) who received albumin. 4
• The severity of PICD correlates inversely with patient survival. 1, 5

Hemodynamic Effects

• Large volume paracentesis causes marked reduction in intra-abdominal pressure, decreased right atrial pressure, increased cardiac output, and decreased pulmonary capillary wedge pressure. 1, 5
• These changes are maximal at 3 hours and continue to worsen without colloid replacement. 1

Albumin vs. Synthetic Plasma Expanders

Albumin is superior to artificial plasma expanders (dextran 70, gelofusine, haemaccel) for large volume paracentesis. 1

Evidence Supporting Albumin Superiority

• Synthetic expanders cause significantly greater activation of the renin-angiotensin-aldosterone system compared to albumin. 1, 6
• Albumin is more effective in preventing hyponatremia: 8% incidence with albumin vs. 17% with synthetic expanders in pooled analysis. 1
• One study showed albumin administration decreased liver-related complications and reduced 30-day hospital costs by more than 50% compared to artificial expanders. 1
• While dextran 70 may prevent immediate renal complications, it shows significant increases in renin and aldosterone by day 6 post-paracentesis (51% of patients vs. 15% with albumin). 6

Practical Dosing Protocol

Standard Dosing Examples

• 5-6 liters removed: 25 grams albumin (or 40-48 grams at 8 g/L) 7
• 7-10 liters removed: 50 grams albumin (or 56-80 grams at 8 g/L) 7
• >10 liters removed: 75 grams albumin (or >80 grams at 8 g/L) 7

Emerging Evidence on Lower Doses

• A pilot study suggested that 4 grams per liter (half the standard dose) may be equally effective, with similar rates of PICD (14% vs. 20%), hyponatremia (9% vs. 6%), and no renal impairment in either group. 8
• However, this was a small, unblinded pilot study, and the standard 6-8 g/L dose remains the guideline-recommended approach until larger confirmatory trials are completed. 1

Special Clinical Situations

Spontaneous Bacterial Peritonitis (Different Protocol)

• Use a completely different albumin dosing regimen: 1.5 g/kg albumin within 6 hours of diagnosis, followed by 1.0 g/kg on day 3. 2, 3
• This protocol reduces hepatorenal syndrome and mortality in SBP, particularly in high-risk patients with bilirubin >4 mg/dL or creatinine >1.0 mg/dL. 1, 3

Refractory Ascites

• Patients requiring repeated large volume paracentesis should receive albumin with each procedure. 1
• Consider transjugular intrahepatic portosystemic shunt (TIPS) or liver transplantation evaluation in patients with recurrent PICD. 5

Common Pitfalls to Avoid

• Do not withhold albumin to save costs when >5 liters are removed—the downstream complications (renal failure, longer hospitalizations) are more expensive than the albumin itself. 1
• Do not leave the drain in overnight—complete the paracentesis in a single session over 1-4 hours. 1, 2
• Do not administer albumin during the procedure—infuse it after paracentesis is completed. 1, 2
• Do not use the paracentesis albumin protocol for SBP—these are distinct clinical scenarios requiring different dosing. 2, 3
• Do not restrict the volume removed to <5 liters solely to avoid albumin use—drain ascites to dryness in a single session for optimal outcomes. 1, 2