Should albumin be given for every fluid removed?

From the Guidelines

Albumin should not be given for every fluid removed, but rather in specific clinical scenarios such as large volume paracentesis (>5 liters) where it may be given at 6-8g per liter of ascites removed to prevent post-paracentesis circulatory dysfunction. The use of albumin is crucial in preventing 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 hepatorenal syndrome, dilutional hyponatremia, hepatic encephalopathy, and death.

Key Points to Consider

• Albumin administration is only indicated in specific clinical scenarios, not as a routine replacement for all fluid losses.
• Albumin is primarily indicated in situations like large volume paracentesis (>5 liters) where it may be given at 6-8g per liter of ascites removed to prevent post-paracentesis circulatory dysfunction.
• It's also considered in certain patients with spontaneous bacterial peritonitis, hepatorenal syndrome, or severe hypoalbuminemia with edema unresponsive to diuretics.
• For most routine fluid losses, crystalloids like normal saline or lactated Ringer's solution are the appropriate first-line replacement.
• Albumin is a blood product derived from human plasma, making it expensive and a limited resource, and it carries risks including allergic reactions and theoretical infection transmission.

Evidence-Based Recommendations

The most recent and highest quality study, published in 2021 by the American Association for the Study of Liver Diseases, recommends albumin infusion at the time of large volume paracentesis (>5 L) to mitigate the risk of PPCD 1. The recommended dose of albumin replacement is 6-8 g for every liter of ascites removed. Another study published in 2024 suggests that intravenous albumin is recommended to prevent paracentesis-induced circulatory dysfunction in patients with cirrhosis and ascites undergoing large-volume paracentesis (> 5 L) 1.

Clinical Considerations

In clinical practice, the decision to use albumin should be based on the individual patient's needs and the underlying pathophysiology of their condition. The rationale for selective albumin use relates to its oncotic properties that help maintain intravascular volume in specific pathological states, but this benefit doesn't extend to most routine fluid losses where the underlying pathophysiology doesn't warrant albumin's unique properties.

From the Research

Albumin Administration in Fluid Removal

• The use of albumin in patients undergoing fluid removal, such as paracentesis, has been investigated in several studies 2, 3, 4, 5, 6.
• These studies suggest that albumin administration can help reduce paracentesis-induced circulatory dysfunction and improve patient outcomes 4, 5.
• The amount of albumin to be administered is often standardized based on the volume of fluid removed, with typical doses ranging from 25g to 75g depending on the volume of ascitic fluid removed 4.
• The use of albumin in patients with cirrhosis and infection has been shown to reduce mortality and renal impairment 5.

Benefits of Albumin Administration

• Albumin administration can help correct hypoalbuminemia and raise colloid osmotic pressure, limiting edema formation and potentially improving endothelial function 2.
• The use of hyperoncotic human albumin solution can facilitate restrictive fluid therapy and the effectiveness of deresuscitative measures 2.
• Albumin administration has been shown to reduce the risk of paracentesis-induced circulatory dysfunction and improve patient outcomes in patients undergoing paracentesis 4, 5.

Guidelines for Albumin Administration

• The amount of albumin to be administered should be standardized based on the volume of fluid removed, with typical doses ranging from 25g to 75g depending on the volume of ascitic fluid removed 4.
• The use of albumin in patients with cirrhosis and infection should be considered to reduce mortality and renal impairment 5.
• Albumin administration should be guided by the patient's individual needs and medical condition, and should be used in conjunction with other treatments such as diuretics and vasoconstrictors as needed 6.