Volume Expansion for Paracentesis in Cirrhotic Ascites
Albumin is the plasma expander of choice for large-volume paracentesis (>5 liters), administered at 8 g per liter of ascites removed, given after the procedure is completed. 1, 2
Volume-Based Algorithm for Fluid Replacement
For Paracentesis >5 Liters
- Albumin is mandatory at a dose of 6-8 g per liter of ascites removed (typically 100 mL of 20% or 25% albumin solution per 3 liters removed) 1, 2, 3
- Infuse albumin after paracentesis is completed, not during the procedure 1, 2
- This prevents post-paracentesis circulatory dysfunction (PICD), which occurs in up to 80% of patients without volume expansion but only 18.5% with albumin 2
For Paracentesis <5 Liters
- Albumin replacement is not routinely necessary for volumes under 5 liters 1
- Consider albumin even for smaller volumes in high-risk patients with acute-on-chronic liver failure, hypotension, renal insufficiency, or electrolyte abnormalities 2, 3
- The International Ascites Club recommends synthetic plasma expanders for <5 liters based on consensus, though this is not strongly evidence-based 1
Why Albumin Over Alternative Plasma Expanders
Albumin is clinically superior to synthetic alternatives (dextran-70, haemaccel, gelofusine) despite their theoretical efficacy 1:
- Albumin reduces PICD by 60% compared to other colloid volume expanders (OR 0.40,95% CI 0.27-0.58) 4
- Albumin prevents hyponatremia more effectively: 8% incidence versus 17% with synthetic expanders 1
- Synthetic expanders cause significantly greater activation of the renin-angiotensin-aldosterone system 1, 5
- Albumin administration decreases liver-related complications and reduces 30-day hospital costs by more than 50% compared to artificial plasma expanders 1
Critical Complications Prevented by Albumin
Failure to provide volume expansion leads to serious morbidity and mortality 1:
- Renal impairment and hepatorenal syndrome 1, 2
- Severe hyponatremia (significant fall in serum sodium) 1
- Marked activation of renin-angiotensin-aldosterone system 1
- Post-paracentesis circulatory dysfunction correlates inversely with patient survival 1
Practical Administration Details
Timing and Technique
- Complete the paracentesis in a single session, draining to dryness over 1-4 hours 2, 6
- Use 20% or 25% albumin solution administered after (not during) the procedure 1, 2
- Insert needle in left lower quadrant (preferred) using Z-track technique 1, 6
Common Pitfalls to Avoid
- Do not withhold albumin due to cost concerns—the reduction in complications and shorter hospitalization makes it cost-effective 1
- Do not use crystalloids alone for volume expansion in large-volume paracentesis, as they do not prevent PICD 1
- Do not delay albumin administration—give it promptly after completing paracentesis 1, 2
- Do not artificially limit paracentesis volume out of concern for hemodynamic instability when albumin is available—complete drainage is safe and more effective 2, 6
Evidence Quality Note
The guideline recommendations are based on multiple randomized controlled trials showing significantly higher rates of renal impairment and electrolyte disturbances without albumin replacement 1. While individual trials comparing albumin to synthetic expanders were relatively small and underpowered, pooled analysis consistently demonstrates albumin's superiority 1. The FDA labeling supports albumin use for ascites removal in cirrhosis to prevent hypovolemic shock 7.