Is albumin administration necessary prior to paracentesis?

Albumin Administration for Paracentesis

For large-volume paracentesis (>5 liters), albumin administration at 6-8 g per liter of ascites removed is necessary and should be given after the procedure is completed to prevent paracentesis-induced circulatory dysfunction (PICD), reduce mortality, and prevent renal complications. 1, 2, 3

Volume-Based Recommendations

Large-Volume Paracentesis (>5 Liters)

• Albumin is mandatory at a dose of 6-8 g per liter of ascites removed 1, 2, 3
• The American Association for the Study of Liver Diseases specifically recommends 8 g/L of ascitic fluid removed 3, 4
• Administer as 20% or 25% solution intravenously after paracentesis completion 3
• Without albumin, PICD occurs in approximately 70% of cases, leading to recurrent ascites, hepatorenal syndrome, hyponatremia, and reduced survival 1

Small-Volume Paracentesis (<5 Liters)

• Albumin replacement is generally not required 2
• However, consider albumin in high-risk patients with acute-on-chronic liver failure or elevated baseline creatinine 2
• The European Association for the Study of the Liver still recommends albumin even for <5L due to concerns about alternative plasma expanders 1

Evidence for Albumin Superiority

Mortality and Morbidity Benefits

• Meta-analysis of 17 randomized trials (1,225 patients) demonstrated albumin reduces PICD by 61% (OR 0.39,95% CI 0.27-0.55) compared to alternative treatments 1, 5
• Albumin reduces mortality by 36% (OR 0.64,95% CI 0.41-0.98) compared to other volume expanders 1, 5
• Hyponatremia is reduced by 42% (OR 0.58,95% CI 0.39-0.87) with albumin versus alternatives 1, 5

Comparison to Alternative Plasma Expanders

• Albumin is superior to dextran, gelatin, hydroxyethyl starch, and hypertonic saline in preventing PICD 1, 5
• Artificial plasma expanders cause significantly greater activation of the renin-angiotensin-aldosterone system 3, 6
• Midodrine is not as effective as albumin and was associated with higher mortality in one trial, particularly in hepatocellular carcinoma patients 7

Practical Administration Details

Dosing Strategy

• Standard dose: 8 g per liter of ascites removed 1, 3
• Alternative lower dose: 4 g per liter may be effective in low-severity cirrhosis (MELD 16-17) based on pilot data, though this requires further validation 1, 8
• A tiered approach based on volume removed: 25 g for 5-6L, 50 g for 7-10L, 75 g for >10L has been shown effective 9

Timing and Administration

• Administer albumin after paracentesis is completed, not before 2, 3
• Infuse slowly to avoid cardiac overload, especially in patients with cirrhotic cardiomyopathy 3
• Use 20% or 25% solution (both are isotonic) 1, 3
• The 5% solution increases sodium load five-fold and should be avoided 1

Volume Limitations

• Limit paracentesis to <8 liters per session when possible, as PICD risk increases substantially above this threshold 1, 2, 3
• Removing >8L in a single session is associated with worse renal function and survival 2, 3

Common Pitfalls to Avoid

• Do not withhold albumin for cost reasons alone - albumin is more cost-effective than alternatives due to fewer liver-related complications within 30 days 3
• Do not use hydroxyethyl starch - it can fill Kupffer cells and cause portal hypertension even in patients without underlying liver disease 1
• Do not infuse albumin too rapidly - this can precipitate cardiac overload in patients with latent cirrhotic cardiomyopathy 3
• Do not assume all patients need the same dose - patients with higher baseline creatinine, larger volume removal, or history of hypotensive symptoms after prior procedures may require closer monitoring 1

Pathophysiology Context

• Large-volume paracentesis causes marked reduction in intra-abdominal pressure, inferior vena cava pressure, and right atrial pressure 2, 3
• This leads to activation of the renin-angiotensin-aldosterone system, resulting in renal impairment and electrolyte disturbances 2, 3
• PICD is conventionally diagnosed by plasma renin activity increase >50% to above 4 ng/mL/h on day 6 post-paracentesis 1
• The severity of PICD inversely correlates with patient survival 2, 3