From the Guidelines
For a 5-liter paracentesis, the recommended albumin replacement is 40 grams of intravenous albumin, as 8 grams of albumin per liter of ascites removed is advised. The standard dosing is based on the most recent and highest quality study, which suggests that albumin infusion at the time of large-volume paracentesis (>5 L) is recommended to mitigate the risk of post-paracentesis circulatory dysfunction (PPCD) 1. This complication occurs because removing large volumes of ascitic fluid can cause rapid fluid shifts, reducing effective arterial blood volume and potentially leading to hypotension, renal impairment, and electrolyte abnormalities. Albumin helps maintain oncotic pressure and vascular volume, mitigating these risks.
Key Points
- The recommended dose of albumin replacement is 8 grams of albumin per liter of ascites removed, as stated in the guidelines on the management of ascites in cirrhosis 1.
- For paracentesis volumes less than 5 liters, albumin replacement is generally not required unless the patient has severe hypoalbuminemia or renal dysfunction.
- The use of albumin is crucial to prevent a further reduction of effective arterial blood volume, which may precipitate postparacentesis circulatory dysfunction (PPCD), as noted in the diagnosis, evaluation, and management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: 2021 practice guidance by the American Association for the Study of Liver Diseases 1.
Administration
- The albumin should be given during or immediately after the procedure to prevent post-paracentesis circulatory dysfunction.
- The administration of 8 grams of albumin per liter of ascites removed has been shown to be effective in preventing PPCD, as stated in the guidelines on the management of ascites in cirrhosis 1.
From the Research
Albumin Dosage for 5 Liter Paracentesis
- The optimal dosage of albumin for a 5-liter paracentesis is not explicitly stated in the provided studies, but we can look at the dosages used in similar procedures:
- A study from 2020 2 standardized albumin doses to 25 g for 5-6 L removed, 50 g for 7-10 L, and 75 g for more than 10 L.
- Another study from 2016 3 used 6-8 g of albumin per liter of ascites drained, with a mean of 9 ± 3 g of albumin given per liter of ascites drained for a mean of 6.8 ± 1.8 L of ascites removed.
- Based on these studies, a possible dosage for a 5-liter paracentesis could be around 25-40 g of albumin, but this should be determined by a healthcare professional based on individual patient needs and circumstances.
Rationale for Albumin Use
- Albumin is used to prevent paracentesis-induced circulatory dysfunction (PICD) and to maintain blood volume during large-volume paracentesis:
- A systematic review and meta-analysis from 2021 4 found that albumin use reduced the odds of PICD by 60% and lowered the incidence of hyponatremia.
- A study from 2016 3 found that albumin infusion did not significantly impact long-term renal function or cirrhosis-related complications, but may prevent PICD.
Risks Associated with Paracentesis
- Paracentesis exceeding three liters increases the risks of acute kidney injury (AKI) even in cirrhotic patients with albumin infused refractory ascites:
- A study from 2025 5 found that paracentesis ≥3 L is an independent risk factor for AKI, and that higher MELD scores and older age are risk factors for overall complications.
- Patients with post-paracentesis complications had significantly poorer 28-day survival rates:
- The same study from 2025 5 found that patients with post-paracentesis complications had poorer short-term survival rates.