When and why is albumin (human albumin) administered to patients with cirrhosis and significant ascites prior to ascitic tapping, and in which cases can it be omitted?

Albumin Administration for Ascitic Tapping in Cirrhosis

Direct Answer

Albumin should be administered at 8 grams per liter of ascites removed when performing large-volume paracentesis (>5 liters), but can be safely omitted when removing ≤5 liters of ascitic fluid. 1, 2, 3

---

When to Give Albumin: The 5-Liter Threshold

Volume >5 Liters Removed

• Administer 8 g of albumin per liter of ascites drained using 20% or 25% albumin solution after paracentesis completion 1, 2
• This dosing prevents post-paracentesis circulatory dysfunction (PICD), which occurs in up to 70-80% of patients without volume expansion versus only 18.5% with albumin 1, 3, 4
• Without albumin after large-volume paracentesis, acute kidney injury develops in 21% of patients; with albumin, the rate approaches 0% 4

Volume ≤5 Liters Removed

• Albumin replacement is not routinely required based on a single small study showing safety without albumin for volumes <5 liters 1, 2
• The International Ascites Club recommends synthetic plasma expanders if used at all for <5 liter removals, though this is based on consensus rather than strong evidence 1
• The risk of PICD is sufficiently low at these volumes that routine albumin administration is not cost-effective 2

---

Why We Give Albumin: Pathophysiology

Hemodynamic Protection

• Large-volume paracentesis causes marked reduction in intra-abdominal and inferior vena cava pressure, leading to decreased right atrial pressure and increased cardiac output initially 1, 3
• Without volume expansion, pulmonary capillary wedge pressure continues to fall, resulting in effective hypovolemia and activation of the renin-angiotensin-aldosterone system 1, 3
• Albumin prevents PICD by maintaining effective circulating volume and reducing renin-angiotensin-aldosterone activation 1, 5

Clinical Outcomes

• Albumin reduces PICD by 60% (OR 0.40,95% CI 0.27-0.58) compared to no treatment 5
• Albumin reduces hyponatremia by 42-50% (8% incidence with albumin vs 17% with other expanders) 1, 2, 5
• The severity of PICD correlates inversely with patient survival, making prevention clinically important 1, 3
• Albumin administration decreases liver-related complications within 30 days post-paracentesis and is more cost-effective than alternative plasma expanders despite higher initial costs 1, 3

---

When NOT to Give Albumin

Uncomplicated Ascites Without Paracentesis

• Albumin should not be used in hospitalized or outpatient cirrhotic patients with uncomplicated ascites not undergoing paracentesis 1
• Standard therapy is sodium restriction plus diuretics (spironolactone with or without furosemide) 1
• Multiple studies show albumin does not enhance diuretic response in routine ascites management and is not cost-effective 1

Chronic Hypoproteinemic States

• Do not use albumin as nutritional protein replacement in chronic cirrhosis, malabsorption, protein-losing enteropathies, or malnutrition 6
• In chronic nephrosis, infused albumin is promptly excreted with no relief of edema or effect on underlying renal lesion 6

Non-SBP Infections

• Albumin is not indicated for cirrhotic patients with infections other than spontaneous bacterial peritonitis (SBP) unless associated with acute kidney injury 1
• Three RCTs and meta-analysis showed albumin does not reduce AKI or mortality in non-SBP infections and was associated with more pulmonary edema 1

---

Alternative Plasma Expanders: Why Albumin is Preferred

Comparative Efficacy

• Albumin is superior to dextran-70, polygeline (haemaccel/gelofusine), and hydroxyethyl starch in preventing PICD 1, 3
• Artificial plasma expanders cause significantly greater activation of renin-angiotensin-aldosterone system compared to albumin 1, 3
• When compared directly, albumin reduces PICD significantly (OR 0.34,95% CI 0.22-0.52) versus other colloid expanders 5

Safety Concerns

• Most alternative plasma expanders have safety concerns or are contraindicated, making albumin the preferred choice when volume expansion is needed 2, 4

---

Special Considerations and Dosing Nuances

Reduced Dosing Evidence

• One pilot study suggested half-dose albumin (4 g/L instead of 8 g/L) may be effective in preventing PICD with similar rates of hyponatremia and renal impairment 7
• However, standard guideline-recommended dosing remains 8 g/L as the half-dose study was small, unblinded, and requires confirmation 1, 2, 7

High-Risk Patients

• Consider albumin at 8 g/L even for volumes <5 liters if the patient has acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury 4

Patients with ESRD on Hemodialysis

• Use the same volume-based guidelines (8 g/L for >5 L removed) but with heightened vigilance for fluid overload 4
• Monitor closely for dyspnea, hypoxia, and pulmonary edema during and after albumin infusion 4
• Do not withhold albumin entirely due to ESRD status—hemodynamic benefits outweigh fluid overload risks when managed appropriately 4

---

Common Pitfalls to Avoid

Administration Errors

• Administer albumin slowly after paracentesis completion to avoid cardiac overload, especially in patients with latent cirrhotic cardiomyopathy 3, 4
• Use 20% or 25% albumin solution to minimize volume load 2, 3

Inappropriate Withholding

• Failure to administer albumin after LVP >5 L leads to PICD with impaired renal function and electrolyte disturbances 3
• Do not substitute artificial plasma expanders—they are inferior and potentially harmful 2, 4

Volume Limits

• Limiting paracentesis volume to <8 L per session may help preserve renal function and improve survival, though complete drainage is generally safer than repeated smaller-volume procedures when albumin is given 1, 3