When should albumin be given during an ascitic tap in a patient with severe hypertension, ascites, and cirrhosis, who is at high risk of developing hepatorenal syndrome or has a history of spontaneous bacterial peritonitis?

When to Give Albumin in Ascitic Tap

Albumin should be administered at a dose of 6-8 g per liter of ascites removed when performing large-volume paracentesis (>5 liters) to prevent post-paracentesis circulatory dysfunction, which can lead to hepatorenal syndrome, renal failure, and death. 1, 2

Primary Indication: Large-Volume Paracentesis

For paracentesis removing >5 liters of ascites:

• Administer 6-8 g of albumin per liter of ascites drained 1, 2
• Use 20% or 25% albumin solution 1, 2
• Infuse albumin slowly after completing the paracentesis to avoid cardiac overload in patients with underlying cirrhotic cardiomyopathy 1
• This prevents post-paracentesis circulatory dysfunction (PPCD), which occurs in up to 70% of patients without albumin replacement and leads to rapid ascites reaccumulation, hepatorenal syndrome, dilutional hyponatremia, and shortened survival 1, 2

For paracentesis removing <5 liters:

• Albumin is generally not required for standard-risk patients 1, 3
• However, consider albumin (8 g/L) even with <5 liters in high-risk patients: those with acute-on-chronic liver failure, baseline renal dysfunction, severe hyponatremia, or high risk of post-paracentesis acute kidney injury 2, 3

Critical Context: Spontaneous Bacterial Peritonitis

In patients with spontaneous bacterial peritonitis (SBP), use a different albumin protocol entirely:

• Give 1.5 g/kg albumin within 6 hours of SBP diagnosis 1, 2
• Follow with 1.0 g/kg albumin on day 3 1, 2
• This regimen reduces hepatorenal syndrome incidence from 33% to 10% and mortality from 41% to 22% 1
• Prioritize this protocol in high-risk SBP patients: those with bilirubin >4 mg/dL or creatinine >1.0 mg/dL 1, 2

When NOT to Give Albumin

Do not use albumin in the following scenarios:

• Uncomplicated ascites managed with diuretics alone (no proven survival benefit and not cost-effective) 1, 2
• Non-SBP infections in cirrhotic patients (increases pulmonary edema risk without reducing acute kidney injury or mortality) 2
• Routine outpatient ascites management without paracentesis 1, 2

Practical Algorithm for Decision-Making

Step 1: Determine the procedure type

• If diagnostic tap only (small volume): No albumin needed 1, 3
• If therapeutic paracentesis: Proceed to Step 2

Step 2: Assess volume to be removed

• If >5 liters planned: Albumin mandatory at 6-8 g/L 1, 2
• If <5 liters planned: Proceed to Step 3

Step 3: Risk stratification for <5 liter paracentesis

• High-risk features present (acute-on-chronic liver failure, baseline creatinine >1.5 mg/dL, severe hyponatremia <125 mEq/L, prior hepatorenal syndrome): Give albumin 8 g/L 2, 3
• No high-risk features: Albumin not required 1, 3

Step 4: Check for concurrent SBP

• If SBP diagnosed: Use SBP-specific protocol (1.5 g/kg then 1.0 g/kg on day 3) instead of paracentesis dosing 1, 2

Evidence Quality and Nuances

The recommendation for albumin in large-volume paracentesis is supported by high-quality evidence showing significant reduction in adverse effects and mortality compared to alternative plasma expanders like dextran-70 or polygeline 1. Albumin is superior to synthetic colloids because it more effectively prevents PPCD when >5 liters are removed 1. While some older studies suggested equivalence of dextran-70 for <5 liter paracentesis, current guidelines uniformly recommend albumin due to concerns about synthetic colloid safety 1.

The 2024 AGA guidelines explicitly state that albumin should NOT be used routinely in hospitalized or outpatient cirrhotic patients with uncomplicated ascites, as recent trials (ATTIRE, MACHT) showed no survival benefit and potential harm including pulmonary edema 1, 4. This contrasts with one Italian trial (ANSWER) showing survival benefit with long-term albumin, but the weight of evidence and expert consensus favors restriction to specific indications 1, 4.

Common Pitfalls to Avoid

• Do not use normal saline as a substitute for albumin in large-volume paracentesis—it worsens salt retention and does not prevent PPCD 2
• Do not restrict paracentesis volume to avoid albumin use—removing <8 liters per session with appropriate albumin replacement is safer than multiple smaller procedures 1, 3
• Do not delay albumin infusion—administer after paracentesis completion but within the same clinical encounter 1
• Do not use the paracentesis albumin dose for SBP patients—the SBP protocol requires weight-based dosing at specific time points 1, 2