Should albumin be administered before or after paracentesis?

Albumin Administration for Paracentesis

Albumin should be administered AFTER paracentesis is completed, not before, at a dose of 8 g per liter of ascitic fluid removed for large-volume paracentesis (>5 L). 1, 2

Timing of Administration

The albumin infusion should be given at the end of the paracentesis procedure when the total volume of ascites removed is known and the increasing cardiac output begins to return to baseline. 1 This timing is critical because:

• The hemodynamic changes from paracentesis (reduced intra-abdominal pressure, decreased right atrial pressure) occur during and after fluid removal 2, 3
• Administering albumin after completion allows for accurate dosing based on actual volume removed 1
• Slow administration after the procedure helps avoid cardiac overload in patients with latent cirrhotic cardiomyopathy 1, 2

Dosing Algorithm

For large-volume paracentesis (>5 L):

• Administer 8 g of albumin per liter of ascitic fluid removed 1, 2
• Use 20% or 25% hyperoncotic albumin solution 1, 2
• Infuse slowly after paracentesis completion 1

For paracentesis <5 L:

• Albumin is generally not required as the risk of post-paracentesis circulatory dysfunction (PPCD) is low 1
• However, the 2010 EASL guidelines note that albumin should still be considered even for smaller volumes due to concerns about alternative plasma expanders 1

Evidence Supporting Post-Paracentesis Administration

The most recent 2024 International Collaboration for Transfusion Medicine Guidelines confirms that albumin prevents paracentesis-induced circulatory dysfunction (PICD), which is characterized by a rise in plasma renin activity occurring on the sixth day after paracentesis—not during the procedure itself. 1 This pathophysiology supports post-procedure administration.

Albumin reduces PICD by 61% compared to alternative treatments (OR 0.39,95% CI 0.27-0.55) when given after paracentesis. 4, 5 A landmark 1996 trial demonstrated that PPCD occurred in only 18.5% of patients receiving albumin versus 34.4% with dextran and 37.8% with polygeline. 6

Clinical Outcomes of Post-Paracentesis Albumin

Albumin administration after paracentesis improves critical outcomes:

• Reduces mortality (OR 0.64,95% CI 0.41-0.98) 5
• Decreases hyponatremia (8% vs 17% with other expanders) 2, 5
• Prevents renal impairment 2, 4
• Reduces liver-related complications within 30 days 1, 2
• Increases time to first readmission (3.5 vs 1.3 months without albumin) 6

Practical Implementation

1. Complete the paracentesis first under strict sterile conditions 1
2. Calculate total volume removed to determine albumin dose 1
3. Administer albumin slowly as 20-25% solution 1, 2
4. Monitor for volume overload, especially in patients with cardiac dysfunction 1, 2

Alternative Dosing Considerations

While 8 g/L is the guideline-recommended dose, emerging evidence suggests lower doses may be effective. A 2011 pilot study found that 4 g/L (half-dose) had similar efficacy to 8 g/L for preventing PPCD (14% vs 20%, p=NS). 7 A 2020 study using a standardized order set with doses of 25-75 g total (approximately 6.5 g/L) showed no difference in adverse outcomes compared to 8.3 g/L. 8 However, the 2024 guidelines maintain the 8 g/L recommendation as the evidence for lower doses remains limited. 1

Critical Pitfalls to Avoid

• Never administer albumin before knowing the total volume removed—accurate dosing requires completion of paracentesis 1
• Do not use alternative plasma expanders for >5 L paracentesis—they are significantly less effective and associated with worse outcomes 1, 6
• Avoid rapid infusion—can precipitate cardiac overload in cirrhotic cardiomyopathy 1, 2
• Do not skip albumin for >5 L paracentesis—PPCD is associated with shorter survival (9.3 vs 16.9 months) 6

Why Not Before?

There is no physiologic rationale or evidence supporting pre-paracentesis albumin administration. The circulatory dysfunction develops as a consequence of the hemodynamic changes that occur during and after ascites removal, not before. 2, 3 Pre-treatment would risk volume overload without addressing the actual pathophysiology of PPCD, which manifests days after the procedure. 1, 6