What is the recommended dose of albumin (human albumin) to administer after a large volume paracentesis?

Albumin Dosing After Large Volume Paracentesis

For large volume paracentesis (>5 liters), administer 8 grams of albumin per liter of ascitic fluid removed, given as 20% or 25% albumin solution after the procedure is completed. 1

Standard Dosing Protocol

• Administer 8 g albumin per liter of ascites removed when more than 5 liters are evacuated 1
• This translates to approximately 100 mL of 20% albumin solution per 3 liters of ascites removed 1, 2
• Infuse the albumin after paracentesis is completed, not during the procedure 1, 3
• Use 20% or 25% hyperoncotic albumin solution 1

Volume-Based Thresholds

For paracentesis >5 liters:

• Albumin replacement is mandatory at 8 g/L of ascites removed 1, 2
• This prevents paracentesis-induced circulatory dysfunction (PICD), reducing its incidence by 61% compared to alternative treatments 1, 4
• Albumin also reduces hyponatremia by 42% and mortality by 36% 1, 4

For paracentesis <5 liters:

• Albumin is generally not necessary for routine cases 1, 3
• However, consider albumin at 8 g/L even for smaller volumes in high-risk patients with acute-on-chronic liver failure (ACLF) or those at high risk for post-paracentesis acute kidney injury 2, 5
• Saline is a valid alternative when less than 5-6 liters are removed 1, 6

Evidence for Reduced Dosing

While the standard remains 8 g/L, emerging evidence suggests potential flexibility:

• A 2011 pilot study in low-severity cirrhosis patients (mean MELD 16-17) showed that 4 g/L (half-dose) was non-inferior to 8 g/L for preventing PICD 1, 7
• However, this was a small, unblinded study and has not changed guideline recommendations 1
• The 2024 International Collaboration for Transfusion Medicine Guidelines noted uncertainty about the risk-benefit profile of lower doses given limited data 1

Until larger confirmatory studies are available, the standard 8 g/L dose should be used, particularly when more than 8 liters are removed, as PICD risk increases substantially at higher volumes 1, 2

Critical Clinical Considerations

Albumin superiority over alternatives:

• Albumin is superior to synthetic colloids (dextran, gelatin, hydroxyethyl starch) for preventing PICD 1, 8
• Non-albumin plasma expanders show PICD rates of 34-38% versus 18.5% with albumin 2, 8
• Without any plasma expansion, PICD occurs in 70-80% of cases 1, 2, 3

Special population - ACLF patients:

• ACLF patients develop PICD even with modest-volume paracentesis (<5 L) 5
• In ACLF, albumin at 8 g/L reduced PICD from 70% to 30% and decreased mortality from 62.5% to 27.5% 5
• Always use albumin in ACLF patients regardless of volume removed 2, 5

Common Pitfalls to Avoid

• Do not withhold albumin due to cost concerns when >5 liters are removed—the consequences of PICD (hepatorenal syndrome, hyponatremia, increased mortality) far outweigh albumin costs 1
• Do not use synthetic colloids as first-line alternatives to albumin for large volume paracentesis—they are inferior for preventing PICD and its complications 1, 8
• Do not administer albumin during the procedure—wait until paracentesis is completed 1, 3
• Do not artificially limit paracentesis volume out of concern for albumin costs—complete drainage in a single session with appropriate albumin replacement is safer and more effective than serial smaller procedures 2, 3