Albumin Replacement for 5-Liter Paracentesis
For a 5-liter paracentesis, you should administer 40 grams of albumin, which equals two 100 mL vials of 20% albumin (each vial contains 20 grams). 1, 2
Dosing Calculation
- Standard dose: 8 grams of albumin per liter of ascites removed 1, 2
- For 5 liters removed: 5 L × 8 g/L = 40 grams total albumin 1
- Using 20% albumin solution: 40 g ÷ 0.2 g/mL = 200 mL total volume 1, 2
- This equals two 100 mL vials of 20% albumin 1, 2
Critical Administration Details
Timing matters: Infuse the albumin after paracentesis is completed, not during the procedure 1, 2. This prevents post-paracentesis circulatory dysfunction (PICD), which causes renal impairment, hyponatremia, and increased mortality 1, 3.
Why albumin is mandatory at 5 liters: The threshold of >5 liters triggers significant hemodynamic changes with marked activation of the renin-angiotensin-aldosterone system 1. Without albumin replacement, patients experience:
- 33% rate of renal impairment versus 10% with albumin 1
- 41% mortality versus 22% with albumin 1
- Significantly higher rates of hyponatremia 1, 3
Evidence Quality
The 2021 American Association for the Study of Liver Diseases guidelines provide the strongest recommendation, stating 6-8 g/L for volumes >5 liters 1. A 2020 meta-analysis of 17 randomized studies (1,225 patients) demonstrated albumin reduces PICD by 61%, hyponatremia by 42%, and mortality by 36% compared to alternative volume expanders 1.
Common pitfall: Some clinicians use synthetic plasma expanders (dextran, gelatin) to reduce costs, but these are associated with significantly greater renin-angiotensin-aldosterone activation and inferior clinical outcomes 1, 3. Albumin remains superior despite higher cost, with one study showing 50% lower 30-day hospital costs due to fewer complications 1.
Alternative Dosing Considerations
Recent data suggest 6.5 g/L may be adequate in lower-risk patients 4. One study showed no difference in outcomes using 25 g for 5-6 L removed versus the traditional 8 g/L calculation 4. However, for standard practice, use 8 g/L to ensure adequate protection against PICD 1, 2.
Higher-risk patients (acute-on-chronic liver failure, baseline renal dysfunction) may benefit from albumin even with <5 L removed 2, 5. In ACLF patients, PICD occurred in 70% without albumin versus 30% with albumin, even with modest-volume paracentesis 5.