Albumin Administration for Paracentesis
Direct Recommendation
Albumin should be administered after large-volume paracentesis (>5 liters) at a dose of 8 grams per liter of ascitic fluid removed using 20-25% albumin solution to prevent paracentesis-induced circulatory dysfunction, reduce mortality, and prevent renal impairment. 1
Volume-Based Algorithm for Albumin Use
For Paracentesis >5 Liters (Mandatory Albumin)
- Administer 8 g albumin per liter of ascitic fluid removed after paracentesis completion 1
- Use 20% or 25% albumin solution (e.g., 100 mL of 20% albumin per 3 liters removed) 2, 3
- Infuse albumin after paracentesis is completed, not during the procedure 1, 2
- This reduces paracentesis-induced circulatory dysfunction by 61%, hyponatremia by 42%, and mortality by 36% compared to alternative volume expanders 1
For Paracentesis <5 Liters (Albumin Generally Not Required)
- Albumin is not mandatory for volumes <5 liters in uncomplicated cirrhosis 1
- Exception: Consider albumin at 8 g/L even for <5 L in high-risk patients with acute-on-chronic liver failure or elevated baseline creatinine 4, 3
- In acute-on-chronic liver failure, even modest-volume paracentesis (<5 L) causes paracentesis-induced circulatory dysfunction in 70% without albumin versus 30% with albumin 4
Clinical Rationale and Evidence Strength
Why Albumin is Superior
The most recent high-quality guidelines consistently demonstrate albumin's superiority over alternative plasma expanders 1:
- Paracentesis-induced circulatory dysfunction occurs 1.98 times more frequently with non-albumin expanders (RR 1.98,95% CI 1.31-2.99) 1
- Alternative plasma expanders (dextran, gelatin, hydroxyethyl starch) are either unavailable, carry significant risks (prion transmission with polygeline, allergic reactions with dextran, renal impairment with hydroxyethyl starch), or have been restricted by regulatory agencies 1
- Albumin reduces renal impairment, hyponatremia, and recurrent ascites more effectively than alternatives 1
Mortality Benefit
Meta-analysis of 17 randomized studies (1,225 patients) showed albumin reduced mortality by 36% (OR 0.64,95% CI 0.41-0.98) compared to alternative treatments 1. This mortality benefit persists even when excluding studies with unsuitable controls 1.
Dosing Considerations and Cost-Effectiveness
Standard vs. Lower Dose Debate
While the standard dose remains 8 g/L 1, emerging evidence suggests potential flexibility:
- A pilot study (70 patients, MELD 16-17) showed half-dose albumin (4 g/L) was equally effective as standard dose (8 g/L) in preventing paracentesis-induced circulatory dysfunction (14% vs 20%, p=NS) 5
- A retrospective review (935 patients) demonstrated reduced albumin use (6.5 g/L vs 8.3 g/L) with standardized protocols showed no increase in renal impairment, hyponatremia, or hypotension 6
- However, these studies were small, unblinded, and included only low-severity cirrhosis patients 1, 5
Current recommendation remains 8 g/L until larger trials confirm safety of lower doses, particularly since paracentesis-induced circulatory dysfunction risk increases substantially when >8 liters are removed 1, 3.
Critical Safety Monitoring
Infusion Rate and Cardiac Overload
- Infuse albumin slowly to prevent circulatory overload, particularly in patients with preexisting cirrhomyopathy 1
- Monitor for signs of pulmonary edema, which is the primary safety concern with albumin administration 1, 2
- Fluid overload has been reported in prospective studies, particularly when excessive doses (>87.5 g) are used 1
Procedure Technique
- Complete drainage in a single session over 1-4 hours as rapidly as possible 1, 3
- Use ultrasound guidance when available to reduce adverse events 1, 3
- Do not leave drain in overnight 1, 3
Common Pitfalls to Avoid
Do Not Use Albumin For:
- Routine treatment of hypoalbuminemia alone in cirrhosis—serum albumin concentration does not reflect albumin function in liver disease 2
- Chronic nephrosis—infused albumin is promptly excreted with no relief of edema 7
- Protein nutrition in chronic cirrhosis, malabsorption, or malnutrition 7
- Routine volume replacement in critically ill patients without specific indications 1, 2, 8
Do Not Withhold Paracentesis Due To:
- Coagulopathy or thrombocytopenia—routine correction of INR or platelet count is not recommended, even with INR up to 8.7 or platelets as low as 19×10³/μL 3
- Concerns about rapid drainage—historical concerns about circulatory collapse from rapid removal have been disproven 3
Do Not Artificially Limit Volume:
- There is no absolute upper limit for single-session paracentesis as long as albumin is administered appropriately 3
- Complete drainage to dryness is preferred over serial smaller procedures 1, 3
- The risk of paracentesis-induced circulatory dysfunction increases when >8 liters are removed, but this is managed with appropriate albumin dosing, not volume restriction 1, 3
Special Clinical Scenario: Spontaneous Bacterial Peritonitis
If paracentesis is performed in the context of spontaneous bacterial peritonitis, use a different albumin dosing regimen 1: