When is albumin infusion recommended for patients with ascites?

Albumin Infusion for Ascites in Cirrhosis

Albumin infusion is mandatory after large-volume paracentesis (>5 L) at a dose of 8 g per liter of ascites removed, and should also be given in spontaneous bacterial peritonitis (SBP) with renal impairment at 1.5 g/kg within 6 hours followed by 1 g/kg on day 3. 1

Post-Paracentesis Albumin Administration

For Large-Volume Paracentesis (>5 L)

• Albumin (20% or 25% solution) must be infused after paracentesis of >5 L is completed at 8 g albumin per liter of ascites removed. 1 This is a high-quality, strong recommendation based on robust evidence.

• The albumin should be given after the paracentesis is complete, not during the procedure. 1, 2

• For example, if 8 L of ascites is removed, approximately 64 g of albumin should be administered (typically 256 mL of 25% albumin solution). 1

• This prevents post-paracentesis circulatory dysfunction (PPCD), which occurs in up to 80% of patients without volume expansion but only 18.5% with albumin. 2

For Moderate-Volume Paracentesis (<5 L)

• Albumin is generally not required for paracentesis <5 L in uncomplicated cases, as smaller volumes are not associated with significant hemodynamic changes. 1, 3

• However, albumin at 8 g/L should be considered for volumes <5 L in high-risk patients: those with acute-on-chronic liver failure (ACLF) or high risk of post-paracentesis acute kidney injury. 1, 3

• Recent evidence suggests that renal and sodium derangements may begin after draining as little as 3 L, suggesting the 5 L threshold may need re-evaluation. 4

Clinical Benefits of Albumin

Albumin is superior to all alternative plasma expanders (dextran, gelatin, hydroxyethyl starch, hypertonic saline) for preventing complications: 1, 5

• Reduces odds of PPCD by 61% (OR 0.39,95% CI 0.27-0.55) 1, 5
• Reduces hyponatremia by 42% (OR 0.58,95% CI 0.39-0.87) 1, 5
• Reduces mortality by 36% (OR 0.64,95% CI 0.41-0.98) 1, 5

Important Caveats

• The risk of PPCD increases when >8 L of fluid is evacuated in a single session, though complete drainage is still recommended with appropriate albumin dosing. 1, 2

• Some institutions use lower doses (6 g/L instead of 8 g/L) with acceptable outcomes, but the standard recommendation remains 8 g/L. 1, 6

• A pilot study suggested 4 g/L might be adequate in low-severity cirrhosis (MELD 16-17), but this requires further validation before routine adoption. 1

Albumin for Spontaneous Bacterial Peritonitis (SBP)

In patients with SBP and elevated or rising serum creatinine, albumin should be infused at 1.5 g/kg within 6 hours of diagnosis, followed by 1 g/kg on day 3. 1

• This regimen reduces renal impairment (10% vs 33%, p=0.002) and mortality (22% vs 41%, p=0.03) compared to antibiotics alone. 1

• This is a different dosing protocol than post-paracentesis albumin and should not be confused. 3

Long-Term Albumin Use

There is insufficient evidence to recommend routine long-term albumin infusions for refractory ascites outside the setting of large-volume paracentesis. 1

• While some observational data suggest weekly albumin (20 g twice weekly) may reduce hospitalizations and mortality in refractory ascites, randomized controlled trials are needed before this can be recommended. 1

Practical Administration Details

Dosing Calculations

• 25% albumin solution contains 25 g per 100 mL. 3
• For 6 L removed: 48 g albumin = 192 mL of 25% albumin 3
• For 8 L removed: 64 g albumin = 256 mL of 25% albumin 1, 3

Procedure Considerations

• Ultrasound guidance should be used when available to reduce adverse events. 1, 2

• Routine measurement of PT/INR and platelet count before paracentesis is not recommended, and blood product infusion is not routinely needed even with coagulopathy. 1, 2

• Complete drainage can be performed safely over 1-4 hours without artificial slowing of the drainage rate. 2

Common Pitfalls to Avoid

• Do not withhold albumin due to cost concerns—alternative plasma expanders are inferior and associated with worse outcomes. 1, 7, 5

• Do not give albumin during the paracentesis—it should be administered after completion. 1, 2

• Do not artificially limit paracentesis volume out of concern for hemodynamic instability when appropriate albumin is given. 2

• Do not use the post-paracentesis albumin dose (8 g/L) for SBP—SBP requires the weight-based protocol (1.5 g/kg then 1 g/kg). 1, 3