What is the appropriate dosing and administration of Albumin (human albumin) for a patient with ascites?

Albumin Dosing for Ascites Management

Routine daily albumin administration at 6 g/day for ascites management is not supported by current evidence and should not be ordered. 1

Evidence-Based Albumin Indications in Ascites

Current guidelines do not recommend chronic daily albumin infusions for ascites management. Instead, albumin has specific, evidence-based indications:

Large-Volume Paracentesis (Primary Indication)

For paracentesis >5 liters, administer albumin at 6-8 g per liter of ascites removed after the procedure is completed. 1, 2, 3

• Use 20% or 25% albumin solution 1, 3
• This prevents post-paracentesis circulatory dysfunction (PPCD), which can cause renal impairment, hepatorenal syndrome, dilutional hyponatremia, hepatic encephalopathy, and death 1, 4
• High-quality evidence supports this practice with strong recommendation 1

Example calculation: If 8 liters of ascites are removed, administer 48-64 g of albumin (8 L × 6-8 g/L) 2, 5

Paracentesis <5 Liters (Selective Use)

• Albumin is generally not required for smaller volume paracentesis as these do not cause significant hemodynamic changes 1, 2
• Consider albumin at 8 g/L even for <5 liters only in high-risk patients with acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury 1, 2

Spontaneous Bacterial Peritonitis (Different Dosing)

Administer 1.5 g/kg albumin within 6 hours of SBP diagnosis, followed by 1 g/kg on day 3. 1, 2, 3

• This reduces hepatorenal syndrome and mortality 3
• Most beneficial when bilirubin >4 mg/dL or creatinine >1.0 mg/dL 3

Why Daily Albumin Is Not Recommended

At present, it is not possible to recommend outpatient albumin administration in patients with ascites due to cirrhosis. 1

• While some studies (Di Pascoli et al.) showed potential benefit with 20 g twice weekly albumin in refractory ascites, these were non-randomized, single-center studies 1
• The MACHT trial showed no prevention of cirrhosis complications or survival improvement with regular albumin 1
• Further research is needed to determine feasibility, efficacy, and cost-effectiveness 1
• Current evidence is insufficient to recommend long-term albumin infusions outside large-volume paracentesis 1

Standard Ascites Management

First-line treatment for ascites consists of sodium restriction (≤2 g/day) and diuretics (spironolactone 50-400 mg/day ± furosemide 20-160 mg/day). 3

• Albumin should not be used routinely with diuretics for uncomplicated ascites 3
• Studies have not shown consistent survival benefits or cost-effectiveness for chronic albumin use 3

Critical Pitfall to Avoid

Do not confuse the 6-8 g/L dosing for paracentesis with a daily 6 g dose. The 6-8 g/L formula is volume-dependent and procedure-specific, not a daily maintenance regimen. 1, 2, 6