Albumin Requirement for Paracentesis
Albumin infusion is required when removing more than 5 liters of ascitic fluid during paracentesis, administered at a dose of 6-8 grams per liter of ascites removed. 1, 2, 3
Volume Threshold for Albumin Administration
For paracentesis >5 liters: Albumin replacement is mandatory at 8 g per liter of ascites removed to prevent paracentesis-induced circulatory dysfunction (PICD). 1, 2
For paracentesis <5 liters: Albumin replacement is generally not required in standard cirrhotic patients, though it should be considered in high-risk populations including those with acute-on-chronic liver failure or elevated risk of post-paracentesis acute kidney injury. 2, 4
Evidence Supporting the 5-Liter Threshold
The 5-liter cutoff is based on robust evidence showing that PICD occurs in approximately 70% of patients who undergo large-volume paracentesis without plasma expansion. 1 When albumin is administered at 8 g/L of ascites removed, the odds of developing PICD are reduced by 61% (OR = 0.39,95% CI 0.27–0.55), hyponatremia by 42% (OR = 0.58,95% CI 0.39–0.87), and mortality by 36% (OR = 0.64,95% CI 0.41–0.98) compared to alternative volume expanders. 1
Dosing Protocol
Standard dose: 8 g of albumin per liter of ascites removed (equivalent to 100 mL of 20% albumin per 3 liters removed). 1, 2
Alternative lower dose: For patients with low-severity cirrhosis (mean MELD 16-17), a half dose of 4 g/L may be effective and safe, though this remains somewhat controversial and is based on limited pilot data. 1, 5
Timing: Albumin should be infused after paracentesis is completed, not during the procedure. 2
Special Considerations for High-Risk Patients
Recent evidence demonstrates that patients with acute-on-chronic liver failure develop PICD even with modest-volume paracentesis (<5 L). 4 In this population, PICD occurred in 70% of patients who did not receive albumin versus 30% who did receive albumin (P = 0.001), with associated increases in hepatic encephalopathy, hyponatremia, acute kidney injury, and in-hospital mortality. 4 Therefore, albumin should be strongly considered even for volumes <5 L in ACLF patients.
Volume Limitation Considerations
While there is no absolute upper limit for single-session paracentesis, the PICD risk increases substantially when more than 8 liters are evacuated. 1, 2 It is therefore preferable to limit ascites removal to less than 8 liters during a single procedure when possible, though complete drainage can be performed safely with appropriate albumin replacement. 2
Common Pitfalls to Avoid
Do not withhold albumin for volumes >5 L: The evidence clearly demonstrates worse outcomes without albumin replacement, including increased mortality. 1
Do not use alternative plasma expanders: Dextran-40, gelatin, and hydroxyethyl starch are inferior to albumin for preventing PICD, with significantly higher rates of circulatory dysfunction (RR 1.98,95% CI 1.31-2.99). 1, 6
Do not artificially restrict paracentesis volume out of concern for albumin cost: Standardized dosing protocols using 25 g (5-6 L removed), 50 g (7-10 L), or 75 g (>10 L) have been shown to reduce albumin utilization to approximately 6.5 g/L without increasing adverse outcomes. 7