What is the recommended dose of albumin (human albumin) to administer after paracentesis in a patient with a history of cirrhosis or significant ascites removal?

Albumin Dosing After Paracentesis

Administer 8 grams of albumin per liter of ascitic fluid removed when paracentesis exceeds 5 liters, using 20% or 25% albumin solution. 1, 2, 3, 4

Volume Threshold: The 5-Liter Rule

• Albumin is indicated only when >5 liters of ascites are removed 1, 2, 3, 4
• For paracentesis removing <5 liters, the risk of post-paracentesis circulatory dysfunction (PICD) is low and albumin is generally not required 1, 2
• The European Association for the Study of the Liver still recommends albumin even for <5L removals due to safety concerns with alternative plasma expanders, though this is more conservative 1

Standard Dosing Protocol

• Give 8 g albumin per liter of ascites removed when volume exceeds 5 liters 1, 2, 3, 4
• Use 20% or 25% albumin solution to minimize volume load 2, 3
• Administer the albumin slowly after paracentesis is completed to avoid cardiac overload, particularly in patients with cirrhotic cardiomyopathy 3
• The FDA label confirms albumin infusion may be required to support blood volume after ascitic fluid removal in cirrhotic patients 5

Why This Matters: Clinical Outcomes

Without albumin, PICD develops in up to 70% of patients undergoing large-volume paracentesis, leading to serious complications:

• Albumin reduces PICD by 61% (OR=0.39,95% CI 0.27-0.55) compared to no treatment or alternative expanders 1, 2
• Mortality is reduced by 36% (OR=0.64,95% CI 0.41-0.98) with albumin administration 1, 2
• Hyponatremia risk decreases by 42% (OR=0.58,95% CI 0.39-0.87) 1, 2
• Albumin is superior to dextran-70 and polygeline, which cause PICD in 34-38% of patients versus 18.5% with albumin 6

Evidence on Lower Doses: Not Ready for Prime Time

• One small pilot study (n=70) suggested 4 g/L might be as effective as 8 g/L in low-severity cirrhosis (MELD 16-17) 1, 7
• A retrospective study showed reduced albumin dosing (6.5 g/L vs 8.3 g/L) had similar short-term outcomes 8
• However, these studies were underpowered, unblinded, and conducted in selected low-risk populations 1, 7
• The standard 8 g/L dose remains the guideline-recommended approach given the strong mortality benefit and the higher risk when >8L is removed 1, 2, 3, 4

Critical Pitfalls to Avoid

• Do not use alternative plasma expanders (dextran, polygeline, hydroxyethyl starch) as they are significantly less effective and associated with worse outcomes 1, 2, 6, 9
• Limit single-session paracentesis to <8 liters when possible, as PICD risk increases substantially beyond this volume 1, 3
• Avoid rapid albumin infusion in patients with potential cirrhotic cardiomyopathy to prevent volume overload 3
• Do not withhold albumin due to cost concerns - albumin is more cost-effective than alternatives due to fewer complications requiring readmission 3, 4

Special Circumstance: Spontaneous Bacterial Peritonitis

• Different dosing applies for SBP: 1.5 g/kg albumin within 6 hours of diagnosis, followed by 1 g/kg on day 3 4
• This SBP-specific regimen reduces renal dysfunction by 72% and mortality by 47% 4
• Do not confuse this with post-paracentesis dosing, which is volume-based (8 g/L removed) 1, 2, 3, 4