What is the recommended dose of albumin (human albumin) for large volume paracentesis?

Albumin Dosing for Large Volume Paracentesis

For large volume paracentesis (>5 liters), administer 6-8 grams of intravenous albumin per liter of ascitic fluid removed to prevent paracentesis-induced circulatory dysfunction and its associated complications. 1, 2

Volume-Based Dosing Algorithm

For paracentesis >5 liters:

• Standard dose: 6-8 g albumin per liter of ascites removed 1, 2
• Practical calculation examples:
  • 6 liters removed = 36-48 g albumin 2
  • 8 liters removed = 48-64 g albumin 2
  • 10 liters removed = 60-80 g albumin 2

For paracentesis <5 liters:

• Albumin replacement is generally not required, as smaller volume removals are not associated with significant hemodynamic changes 1, 2
• The risk of paracentesis-induced circulatory dysfunction is low in this setting 1

For paracentesis >8 liters:

• Consider limiting fluid removal to <8 liters per session, as the risk of circulatory dysfunction increases significantly beyond this threshold 1, 2, 3
• If >8 liters must be removed, albumin at 8 g/L is particularly important 2

Clinical Rationale and Evidence

Albumin is superior to all other plasma expanders for preventing paracentesis-induced circulatory dysfunction (PICD), which manifests as a >50% rise in plasma renin activity 4-6 days post-procedure 1, 3. The 2020 meta-analysis demonstrated that albumin reduces:

• PICD by 61% (OR 0.39,95% CI 0.27-0.55) 1, 3
• Mortality by 36% (OR 0.64,95% CI 0.41-0.98) 1, 3
• Hyponatremia by 42% (OR 0.58,95% CI 0.39-0.87) 1, 3

Alternative plasma expanders (dextran-70, gelatin, hydroxyethyl starch, saline) are inferior and show higher rates of PICD compared to albumin 1, 3. Notably, hydroxyethyl starch can cause Kupffer cell dysfunction and worsen portal hypertension 1.

Formulation and Administration

Use 20-25% albumin solution (25 g per 100 mL for 25% solution) 2, 3

• Both 20% and 25% solutions are isotonic 1
• Avoid 5% albumin as it increases sodium load five-fold 1

Timing: Administer during or immediately after paracentesis completion 2, 3

Infusion rate: Give slowly to prevent cardiac overload, particularly in patients with preexisting cirrhotic cardiomyopathy 1, 3

Evidence on Reduced Dosing

While one pilot study in 70 patients with low-severity cirrhosis (MELD 16-17) suggested that 4 g/L may be non-inferior to 8 g/L 4, and a quality improvement study using 6.5 g/L showed no difference in outcomes compared to 8.3 g/L 5, the standard 6-8 g/L dose remains the guideline recommendation 1, 2. The studies comparing high-dose (6-8 g/L) versus low-dose (2-4 g/L) albumin showed no statistical difference in PICD rates, but uncertainty exists regarding the risk-benefit profile due to small sample sizes (N=120; RR 1.00,95% CI 0.22-4.49) 1.

Critical Distinctions

Do not confuse with spontaneous bacterial peritonitis (SBP) dosing, which uses a completely different weight-based regimen:

• SBP: 1.5 g/kg within 6 hours of diagnosis, then 1.0 g/kg on day 3 1, 2, 3
• Large volume paracentesis: 6-8 g per liter removed (volume-based, not weight-based) 1, 2, 3

Special Populations

High-risk patients (acute-on-chronic liver failure, high risk of acute kidney injury) should receive albumin at 8 g/L even for volumes <5 liters 2

Important Caveats

• Monitor for circulatory overload, especially in patients with cardiac dysfunction 1, 3
• Despite albumin administration, PICD may still occur in 14-20% of patients, though this is significantly lower than without albumin 4, 6
• The 2024 Chest guidelines note that while albumin prevents PICD better than alternatives, evidence for mortality benefit remains uncertain in some analyses, though the most rigorous meta-analyses excluding inappropriate controls show mortality benefit 1
• Serial paracenteses deplete proteins and may aggravate malnutrition 1