From the Guidelines
Albumin infusion at the time of large-volume paracentesis (LVP) of >5 L is recommended to mitigate the risk of postparacentesis circulatory dysfunction (PPCD). The use of albumin in patients undergoing LVP is crucial to prevent a further reduction of effective arterial blood volume, which may precipitate PPCD, as stated in the 2021 practice guidance by the American Association for the Study of Liver Diseases 1.
Key Points
- The recommended dose of albumin replacement is 6-8 g for every liter of ascites removed, based on expert opinion, as there has not been a dose-response study on albumin use with LVP 1.
- Albumin infusion is particularly important if more than 5 L of ascites are removed to prevent the development of PPCD, as paracenteses of a smaller volume are not associated with significant hemodynamic changes, and albumin infusion may not be required 1.
- The clinical manifestations of PPCD include renal impairment, including hepatorenal syndrome, dilutional hyponatremia, hepatic encephalopathy, and death, highlighting the importance of albumin administration in large-volume paracentesis 1.
Administration Details
- The typical concentration used is 25% albumin solution (25 g per 100 mL), with administration occurring during or immediately after the procedure.
- Patients should be monitored for signs of circulatory dysfunction after paracentesis, including hypotension, tachycardia, and decreased urine output, regardless of whether albumin is administered.
- For smaller volume paracentesis (less than 5 liters), albumin replacement is usually unnecessary unless the patient has severe hypoalbuminemia or is hemodynamically unstable.
From the Research
Albumin Administration After Paracentesis
- The use of albumin after large volume paracentesis (LVP) has been shown to reduce paracentesis-induced circulatory dysfunction (PICD) 2, 3, 4, 5.
- A meta-analysis of randomized trials found that albumin infusion reduced the incidence of PICD and hyponatremia, and lowered mortality compared to alternative treatments 3.
- A systematic review and meta-analysis found that albumin use reduced the odds of PICD by 60% and lowered the incidence of hyponatremia, but did not reduce overall mortality, readmission rate, recurrence of ascites, or hepatic encephalopathy 4.
- Another study found that albumin use in cirrhotic patients with infection was associated with a significant reduction in mortality and renal impairment 5.
Dosage and Administration
- A study found that standardizing albumin doses based on the amount of ascitic fluid removed during LVP resulted in a significant reduction in the amount of albumin given, with no difference in adverse effects 2.
- The study used albumin doses of 25g (5-6 L removed), 50g (7-10 L), and 75g (>10 L) 2.
Clinical Outcomes
- Albumin use has been shown to improve renal function in critically ill cirrhotic patients with tense ascites and hepatorenal syndrome 6.
- Paracentesis with parameter-guided fluid substitution and maintenance of central blood volume may improve renal function and is safe in the treatment of ICU patients with hepato-renal failure 6.
- However, albumin use did not reduce the overall mortality, readmission rate, recurrence of ascites, hepatic encephalopathy, or GI bleeding in some studies 4, 5.