What is the preferred intravenous fluid for volume expansion in a patient with chronic liver disease and jaundice?

Fluid of Choice in Chronic Liver Disease with Jaundice

For volume expansion in patients with chronic liver disease and jaundice, albumin is the preferred intravenous fluid, particularly in specific clinical scenarios including large-volume paracentesis (>5 L), spontaneous bacterial peritonitis, and hepatorenal syndrome.

Primary Recommendation: Albumin as First-Line Colloid

Albumin (20% or 25% solution) should be used over crystalloid for volume replacement in patients with decompensated chronic liver disease, based on its superior oncotic and non-oncotic properties that address the unique pathophysiology of cirrhosis 1. The 2023 Critical Care Medicine guidelines specifically recommend albumin over crystalloid for intraoperative volume replacement during liver transplantation, with the explicit warning that starches should not be used due to risk of coagulopathy and renal failure 1.

Evidence Supporting Albumin Superiority

• Meta-analyses using indirect evidence showed decreased mortality with albumin (47 fewer deaths per 1,000 patients; range: 95 fewer to 7 more) compared to crystalloids in surgical and critically ill patients 1
• Colloid administration with synthetic starches (tetrastarch, pentastarch, dextran, gelatin) increased the risk of renal replacement therapy without mortality benefit 1
• The 2024 AGA guidelines and 2021 Gut guidelines both endorse albumin as the volume expander of choice for large-volume paracentesis 1

When Crystalloids Are Appropriate

If crystalloid is necessary, use balanced (normochloremic) solutions over normal saline 1. The 2023 Critical Care Medicine guidelines recommend balanced crystalloid solution over hyperchloremic saline for peri-transplant fluid replacement in liver transplant recipients, though this is a conditional recommendation based on low-quality evidence 1.

Rationale for Balanced Crystalloids

• Indirect evidence from non-liver transplant populations showed that balanced crystalloid improved survival in sepsis patients compared to normal saline 1
• A 2017 Cochrane review of 18 RCTs (1,096 surgical patients) evaluated buffered versus non-buffered crystalloid, supporting the preference for balanced solutions 1

Specific Clinical Scenarios in CLD with Jaundice

Large-Volume Paracentesis (>5 L)

Administer 8 g of albumin per liter of ascites removed using 20% or 25% albumin solution, infused after the procedure is completed 1, 2. This is a strong recommendation across all major hepatology societies.

• Without albumin, post-paracentesis circulatory dysfunction (PICD) occurs in 70-80% of patients versus approximately 18% when albumin is given 2, 3
• Renal impairment develops in approximately 21% of patients without albumin versus 0% with proper albumin replacement 2, 3
• For paracentesis <5 L, albumin can be considered (but is not mandatory) in patients with acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury 1, 2

Spontaneous Bacterial Peritonitis

Give 1.5 g/kg albumin within 6 hours of SBP diagnosis, followed by 1.0 g/kg on day 3 1, 3. This regimen reduces renal impairment (approximately 10% vs 33%) and mortality (approximately 22% vs 41%) compared to antibiotics alone 3, 4.

Hepatorenal Syndrome

Albumin is the volume expander of choice in hospitalized patients with cirrhosis and ascites presenting with acute kidney injury 1. Albumin should be combined with vasoconstrictors (terlipressin, norepinephrine, or octreotide plus midodrine) for treatment of HRS-AKI 1.

Hypovolemic Hyponatremia

Hypovolemic hyponatremia during diuretic therapy should be managed by discontinuation of diuretics and expansion of plasma volume with normal saline 1. This is one of the few scenarios where crystalloid (specifically normal saline) is explicitly recommended over albumin in cirrhotic patients.

Critical Pitfalls to Avoid

Do Not Use Synthetic Colloids

Avoid hydroxyethyl starch, dextran, and gelatin solutions 1, 3. These synthetic plasma expanders are associated with:

• Greater activation of the renin-angiotensin-aldosterone system 1
• Higher rates of hyponatremia (17% vs 8% with albumin) 1
• Increased risk of renal replacement therapy 1
• Inferior prevention of PICD compared to albumin 1, 3

Do Not Use Albumin for Uncomplicated Ascites

Albumin should not be used in patients (hospitalized or not) with cirrhosis and uncomplicated ascites 1. The ATTIRE trial (777 patients) showed no benefit from daily albumin infusions targeting serum levels ≥3 g/dL, with significantly higher incidence of pulmonary edema and fluid overload in the albumin group 3.

Avoid Rapid Infusion

Infuse albumin slowly over 1-2 hours to avoid cardiac overload, especially in patients with cirrhotic cardiomyopathy 2, 3. Rapid albumin infusion can precipitate volume overload despite the patient's effective hypovolemia.

Use Correct Albumin Concentration

Use 20% or 25% hyperoncotic albumin solutions; 5% albumin is inadequate for preventing PICD and addressing oncotic deficits in cirrhosis 2, 3, 5.

Practical Algorithm for Fluid Selection

1. Identify the clinical scenario:

   • Large-volume paracentesis (>5 L) → Albumin 8 g/L removed 1, 2
   • SBP → Albumin 1.5 g/kg then 1.0 g/kg day 3 1
   • HRS-AKI → Albumin + vasoconstrictor 1
   • Hypovolemic hyponatremia → Normal saline 1
   • Uncomplicated ascites → No albumin 1

2. If albumin is not available or contraindicated:

   • Use balanced crystalloid (lactated Ringer's or Plasma-Lyte) over normal saline 1
   • Avoid all synthetic colloids 1

3. Monitor for complications:

   • Daily serum sodium and creatinine for 6 days post-paracentesis 2, 3
   • Watch for signs of volume overload during albumin infusion 3
   • Restart diuretics within 1-2 days after paracentesis to prevent ascites re-accumulation 2, 3