What is the recommended dose of albumin (human albumin) to administer during paracentesis?

Albumin Dosing for Paracentesis

Administer 6-8 grams of albumin per liter of ascitic fluid removed when performing large volume paracentesis (>5 liters). 1, 2, 3, 4

Standard Dosing Protocol

For paracentesis removing >5 liters:

• Give 6-8 g of albumin per liter of ascites drained 1, 2, 3, 4
• Use 20% or 25% albumin solution 3, 4
• Administer after the paracentesis is completed, not during the procedure 3
• Infuse slowly to prevent cardiac overload in patients with preexisting cardiomyopathy 1

Practical dose calculations:

• 5 liters removed = 30-40 g albumin 2
• 8 liters removed = 48-64 g albumin 2
• Example: 100 mL of 20% albumin per 3 liters of ascites 3

Volume-Based Indications

Paracentesis >5 liters:

• Albumin is mandatory to prevent paracentesis-induced circulatory dysfunction (PICD) 1, 2, 3, 4
• Without albumin, PICD occurs in 70-80% of patients 1, 2
• PICD manifests as renal impairment, hepatorenal syndrome, hyponatremia, and increased mortality 1, 2, 4

Paracentesis <5 liters:

• Risk of PICD is low 1
• European guidelines (EASL) still recommend albumin due to concerns about alternative plasma expanders 1
• Consider albumin (8 g/L) in high-risk patients even with <5 liters: those with acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury 3, 4

Evidence for Mortality and Morbidity Benefit

The superiority of albumin is established by high-quality evidence:

• Reduces PICD by 61% (OR 0.39,95% CI 0.27-0.55) compared to alternative treatments 1, 2
• Reduces mortality by 36% (OR 0.64,95% CI 0.41-0.98) 1, 2
• Reduces hyponatremia by 42% (OR 0.58,95% CI 0.39-0.87) 1, 2
• Albumin is superior to dextran-70, gelatin, hydroxyethyl starch, and hypertonic saline 1, 2, 4

Reduced Dose Consideration

A pilot study suggests 4 g/L may be effective in select patients:

• Limited to patients with low-severity cirrhosis (MELD 16-17) 1, 5
• Showed similar rates of PICD (14% vs 20%, p=NS) and no difference in renal impairment or survival 5
• One institutional study using 6.5 g/L (vs 8.3 g/L) showed no difference in adverse outcomes 6

However, the standard 6-8 g/L remains the official recommendation because:

• The reduced-dose study was unblinded and underpowered 5
• EASL guidelines maintain full-dose recommendations due to risk-benefit concerns 1
• The mortality benefit was demonstrated with standard dosing 1, 2

Critical Safety Considerations

Limit ascites removal to <8 liters per session:

• PICD risk increases significantly when >8 liters are removed 1, 2
• Even with adequate albumin, limiting volume reduces complications 1, 2

Monitor for circulatory overload:

• Infuse albumin slowly in patients with cardiomyopathy 1, 2
• Watch for signs of pulmonary edema during infusion 1

Common Pitfall: Confusion with SBP Dosing

Do NOT confuse paracentesis albumin dosing with spontaneous bacterial peritonitis (SBP) treatment:

• SBP requires weight-based dosing: 1.5 g/kg on day 1 and 1.0 g/kg on day 3 1, 2, 3, 4
• SBP albumin is for patients with bilirubin >4 mg/dL or creatinine >1 mg/dL 4
• Paracentesis albumin is calculated per liter removed, not by body weight 2, 3, 4

Physiologic Rationale

The mechanism explains why albumin is essential:

• Rapid drop in intraabdominal pressure increases venous return and cardiac output transiently 2
• This hyperkinetic state increases vascular shear stress, paradoxically decreasing effective arterial volume 2
• Activation of renin-angiotensin-aldosterone system, sympathetic nervous system, and vasopressin follows 2
• Without albumin, plasma renin activity increases >50% by day 6, defining PICD 1, 2
• Albumin prevents this cascade and maintains effective circulating volume 1, 2