What is the recommended intravenous albumin dose per liter of ascitic fluid removed during large‑volume paracentesis in a cirrhotic patient?

Albumin Dosing for Large-Volume Paracentesis

Administer 6–8 grams of intravenous albumin per liter of ascitic fluid removed when the total volume exceeds 5 liters. 1

Standard Dosing Protocol

For paracentesis >5 liters, the mandatory dose is 8 g albumin per liter of ascites drained. 1, 2

Practical Calculation Examples

• For 10 liters removed: Administer 80 grams of albumin (320 mL of 25% albumin or 400 mL of 20% albumin) 3
• For 5 liters removed: Administer 40 grams of albumin (160 mL of 25% albumin or 200 mL of 20% albumin) 3
• For <5 liters removed: Albumin is generally not required unless the patient has acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury 1, 2

Administration Details

• Timing: Infuse albumin after paracentesis is completed, not during the procedure 3, 2
• Formulation: Use 20% or 25% albumin solution—5% albumin is inadequate for this indication 3, 4
• Infusion rate: Deliver over 1–2 hours to avoid volume overload, particularly in patients with cirrhotic cardiomyopathy 3

Clinical Rationale: Prevention of Post-Paracentesis Circulatory Dysfunction

Albumin replacement prevents post-paracentesis circulatory dysfunction (PPCD), which occurs in up to 80% of patients without volume expansion but only 18.5% with albumin. 3

Consequences of Inadequate Albumin Replacement

Without albumin, large-volume paracentesis causes: 1, 5

• Renal impairment in 21% of patients (versus 0% with albumin) 1
• Marked elevation of plasma renin activity and aldosterone concentration 1, 5
• Dilutional hyponatremia 2, 5
• Increased risk of hepatorenal syndrome 4, 2
• Higher mortality (36% reduction with albumin versus alternative expanders) 3

Hemodynamic Changes Without Albumin

Paracentesis without albumin replacement causes: 5

• Decreased cardiac output, central venous pressure, and pulmonary capillary wedge pressure 5
• Decreased plasma atrial natriuretic peptide 5
• These circulatory disturbances appear within 24 hours and are accompanied by renal impairment or hyponatremia in 20% of patients 5

Evidence Hierarchy: Guideline Consensus

All major hepatology societies converge on the 6–8 g/L dosing standard: 1, 3

• American Gastroenterological Association (2024): 8 g/L for >5 L paracentesis 1
• Korean Association for the Study of the Liver (2018): 6–8 g/L (Grade A1 recommendation) 1
• European Association for the Study of the Liver: 6–8 g/L for >5 L 3

This represents the highest level of guideline consensus across international societies. 1, 3

Special Populations Requiring Albumin Even for <5 Liters

Consider albumin replacement at 8 g/L even for volumes <5 liters in: 1, 3, 2

• Patients with acute-on-chronic liver failure (ACLF) 1
• Patients at high risk of post-paracentesis acute kidney injury 1, 2

Historical Validation: Complete Drainage is Safe

Total paracentesis (mean 10.7 L removed over 60 minutes) with albumin 6–8 g/L is safe and effective, with no renal impairment when albumin is administered. 6

• The landmark 1990 study demonstrated that complete ascites mobilization in a single session with albumin replacement did not impair renal function, glomerular filtration rate, or plasma volume 6
• This established that there is no absolute upper volume limit for single-session paracentesis when albumin is given appropriately 3, 6

Critical Pitfalls to Avoid

Underdosing Albumin

• Do not reduce albumin dose below 6 g/L—this is associated with significantly higher rates of PPCD and renal complications 1, 5
• If underdosing occurs, administer the remaining albumin promptly within hours 3

Using Inferior Volume Expanders

• Albumin is superior to synthetic colloids (dextran-70, polygeline, hydroxyethyl starch) in preventing PPCD 3, 4
• Alternative expanders show PPCD rates of 34.4–37.8% versus 18.5% with albumin 3

Withholding Paracentesis Due to Coagulopathy

• Do not delay paracentesis for INR or platelet correction—routine blood product infusion is not needed even with INR up to 8.7 or platelets as low as 19×10³/μL 3

Confusing SBP Dosing with Paracentesis Dosing

• Spontaneous bacterial peritonitis requires different dosing: 1.5 g/kg within 6 hours of diagnosis, then 1.0 g/kg on day 3 1, 4, 2
• This is a weight-based regimen, unlike paracentesis dosing which is volume-based 3

Post-Procedure Monitoring

Monitor for PPCD over the subsequent 6 days: 3

• Daily serum creatinine—acute kidney injury is a recognized complication of inadequate replacement 3
• Daily serum sodium—hyponatremia may develop with under-replacement 3
• Plasma renin activity—look for >50% rise from baseline as an early PPCD marker 3