From the Guidelines
Albumin should be administered after large-volume paracentesis (removal of more than 5 liters of ascitic fluid) at a dose of 8 grams of albumin per liter of ascitic fluid removed, as recommended by the most recent guidelines 1.
Key Points
- The dose of albumin is based on the volume of ascitic fluid removed, with 8 grams of albumin per liter of ascites removed being the recommended dose 1.
- Albumin should be administered as a 20% or 25% solution intravenously immediately after the procedure or within 6 hours of completion.
- For paracentesis with less than 5 liters removed, albumin replacement is generally not necessary unless the patient has severe hypoalbuminemia or renal dysfunction.
- The purpose of albumin administration is to prevent post-paracentesis circulatory dysfunction, which can lead to rapid reaccumulation of ascites, hepatorenal syndrome, and increased mortality.
Rationale
The use of albumin after large-volume paracentesis is supported by several studies, including a 2021 systematic review and meta-analysis that found a decreased incidence of post-paracentesis-induced circulatory dysfunction in patients treated with albumin compared with an alternative plasma expander 1.
Administration
Patients should be monitored for signs of volume overload during administration, particularly those with cardiac issues. The albumin should be infused at a rate that prevents volume overload, and patients should be closely monitored for signs of circulatory dysfunction.
Evidence
The evidence for the use of albumin after large-volume paracentesis is based on several studies, including a 2024 systematic review and meta-analysis that found no difference in mortality or kidney impairment between patients treated with albumin and those treated with an alternative plasma expander 1. However, the most recent guidelines recommend the use of albumin as the preferred plasma expander when paracentesis is undertaken 1.
From the Research
Albumin Dosage Post Paracentesis
- The amount of albumin to be given post paracentesis depends on the volume of ascitic fluid removed.
- According to the study 2, albumin doses were standardized to 25 g for 5-6 L removed, 50 g for 7-10 L, and 75 g for more than 10 L.
- The study 2 also found that patients who received a standardized dose of albumin had a lower amount of albumin used per liter removed compared to those who did not receive a standardized dose (6.5 g/L vs 8.3 g/L).
- Other studies 3, 4, 5 have shown that albumin reduces the incidence of paracentesis-induced circulatory dysfunction and hyponatremia, but the optimal dosage is not clearly established.
Comparison with Other Plasma Expanders
- The study 6 found no evidence of a difference in effect between plasma expansion versus no plasma expansion on mortality, renal impairment, and other liver-related complications.
- The same study 6 also found no evidence of a difference in effect between experimental plasma expanders versus albumin on mortality, serious adverse events, renal impairment, and other liver-related complications.
- However, the certainty of the evidence was rated as very low due to the small number of trials and high risk of bias.
Clinical Implications
- The use of albumin post paracentesis may reduce the risk of paracentesis-induced circulatory dysfunction and hyponatremia.
- The optimal dosage of albumin is not clearly established, but a standardized dose based on the volume of ascitic fluid removed may be effective.
- Further studies are needed to determine the benefits and harms of plasma expanders, including albumin, in patients with cirrhosis and large ascites undergoing paracentesis.