From the Guidelines
Intravenous albumin should be administered after large-volume paracentesis (removal of more than 5 liters of ascitic fluid) to prevent post-paracentesis circulatory dysfunction, with a recommended dose of 6-8 grams of albumin per liter of ascitic fluid removed, as supported by the most recent and highest quality study 1. The administration of albumin helps maintain effective circulating volume by increasing oncotic pressure and preventing the rapid fluid shifts that can occur after large-volume paracentesis. This prevents complications such as hypotension, hepatorenal syndrome, and increased mortality. Some key points to consider include:
- The use of albumin is particularly important if more than 5 L of ascites are removed to prevent the development of post-paracentesis circulatory dysfunction (PPCD) 1.
- Paracenteses of a smaller volume are not associated with significant hemodynamic changes, and albumin infusion may not be required 1.
- Although there has not been a dose-response study on albumin use with LVP, the administration of 6-8 g of albumin per liter of ascites removed has been shown to be effective 1.
- Albumin administration is crucial to prevent a further reduction of effective arterial blood volume, which may precipitate postparacentesis circulatory dysfunction (PPCD) 1.
- The clinical manifestations of PPCD include renal impairment, including HRS, dilutional hyponatremia, hepatic encephalopathy, and death 1. For smaller volume paracentesis (less than 5 liters), albumin replacement is generally not necessary unless the patient has severe hypoalbuminemia or renal dysfunction. Patients with advanced cirrhosis are particularly vulnerable to these hemodynamic changes due to their baseline splanchnic vasodilation and relative hypovolemia. While albumin administration adds cost to the procedure, its benefits in preventing serious complications outweigh this consideration in high-risk patients undergoing large-volume paracentesis. Other studies have also shown that albumin is more effective than other plasma expanders in preventing PPCD 1. However, the most recent and highest quality study 1 provides the strongest evidence for the use of albumin in this setting.
From the Research
Albumin Administration After Paracentesis
- The use of albumin after paracentesis has been studied in several research papers 2, 3, 4, 5, 6.
- Albumin is used to prevent paracentesis-induced circulatory dysfunction (PICD), which can occur after large-volume paracentesis in patients with cirrhosis and ascites 2, 4, 5.
- The efficacy of albumin in preventing PICD has been compared to other treatments, such as midodrine, a vasoconstrictor 2, 4, 6.
- Studies have shown that albumin is effective in preventing PICD, but its use can be costly 2, 3, 4.
- The optimal dose of albumin for preventing PICD is unclear, but standardized dosing regimens have been proposed 3.
- The use of albumin has been associated with improved outcomes, including reduced rates of hyponatremia, renal impairment, and hypotension 3, 5.
Comparison with Midodrine
- Midodrine has been compared to albumin as a treatment for preventing PICD 2, 4, 6.
- Studies have shown that midodrine is not as effective as albumin in preventing PICD, particularly in patients with hepatocellular carcinoma (HCC) 4.
- However, one study found that midodrine was as effective as albumin in preventing PICD in patients with acute-on-chronic liver failure (ACLF) undergoing paracentesis of less than 5 liters 6.
- Midodrine has been found to be more cost-effective than albumin 6.
Predictors of PICD
- The incidence of PICD has been found to be higher in patients with massive hepatic ascites, and the type of plasma expander used (e.g. dextran vs. albumin) has been identified as a predictor of PICD 5.
- Younger age has also been identified as a predictor of PICD 5.
- Left ventricular diastolic function has been found to be altered in cirrhosis with tense ascites, but this was not affected by large-volume paracentesis and did not reflect the occurrence of PICD 5.