Is albumin infusion necessary before ascitic tap in a patient with HCV-related cirrhosis and portal hypertension?

Albumin Infusion Before Ascitic Tap in HCV Cirrhosis

Albumin should be infused AFTER—not before—large-volume paracentesis (>5 liters) at a dose of 8 g per liter of ascites removed, using 20% or 25% albumin solution. 1, 2

Timing of Albumin Administration

• Albumin is administered after the paracentesis is completed, not before or during the procedure. 1, 2, 3
• The rationale is to prevent post-paracentesis circulatory dysfunction (PPCD), which manifests as renal impairment, hyponatremia, and activation of the renin-angiotensin-aldosterone system after fluid removal. 1, 2
• Pre-procedural albumin infusion is not indicated and provides no benefit—the hemodynamic changes occur after ascites removal, not during needle insertion. 1

Volume-Based Algorithm for Albumin Replacement

For Paracentesis >5 Liters:

• Mandatory albumin replacement at 8 g per liter of ascites removed (strong recommendation, high-quality evidence). 1, 2, 4
• Example: If 8 liters removed, give 64 g albumin (approximately 256 mL of 25% albumin solution). 2, 4
• This reduces PPCD by 61%, hyponatremia by 42%, and mortality by 36% compared to alternative plasma expanders. 3

For Paracentesis <5 Liters:

• Albumin replacement is generally not required for routine cases. 1, 2, 4
• Consider albumin (8 g/L) in high-risk patients even with <5 liters removed if they have: 1, 2
  • Acute-on-chronic liver failure (ACLF)
  • High baseline risk of acute kidney injury
  • Concurrent spontaneous bacterial peritonitis (use different dosing protocol—see below)

Special Circumstances Requiring Different Protocols

If Concurrent TIPS Procedure:

• Albumin infusion should be considered for all patients undergoing concurrent paracentesis during TIPS creation, especially if >5 liters removed, to prevent paracentesis-induced circulatory dysfunction and acute kidney injury. 1
• Large-volume paracentesis with albumin may be performed within 24 hours prior to or concomitantly during TIPS. 1

If Concurrent Spontaneous Bacterial Peritonitis:

• Use a completely different dosing regimen: 1.5 g albumin/kg within 6 hours of SBP diagnosis, followed by 1 g/kg on day 3 (based on estimated dry weight). 1, 2
• This protocol reduces renal dysfunction by 72% and mortality by 47% in SBP patients. 1
• If large-volume paracentesis is also needed in an SBP patient, proceed with the SBP albumin protocol, not the standard post-paracentesis dosing. 1

Critical Pitfalls to Avoid

• Do not give albumin before the tap—this wastes resources and provides no hemodynamic benefit, as circulatory dysfunction occurs after fluid removal, not before. 1, 2
• Do not withhold paracentesis due to coagulopathy—routine measurement of PT/INR and platelet count before paracentesis is not recommended, and blood product infusion is unnecessary even with significant coagulopathy. 1, 3
• Do not use normal saline or crystalloids as albumin substitutes—artificial plasma expanders are inferior to albumin, with higher rates of PPCD (34-38% vs 18.5%) and greater activation of the renin-angiotensin-aldosterone system. 1, 3
• Do not artificially slow the drainage rate—complete drainage over 1-4 hours is safe and does not cause hemodynamic collapse, even with volumes >10 liters. 3
• Do not leave the drain in overnight—complete the procedure in a single session. 3

Practical Procedure Details

• Use ultrasound guidance when available to reduce adverse events. 1, 3
• Complete drainage to dryness is preferred over serial smaller procedures—this minimizes repeated needle insertions and reduces overall PPCD risk. 3
• Typical drainage rate is 2-9 liters per hour, with total procedure time of 1-4 hours. 3
• Monitor for fluid overload during albumin infusion, particularly in patients with baseline cardiac dysfunction or those receiving high cumulative albumin doses (>87.5 g may increase risk of pulmonary edema). 1