Should albumin be administered for every pleural fluid removal?

From the Guidelines

No, albumin should not be given for every pleural fluid removal. The decision to administer albumin should be based on specific clinical circumstances rather than as a standard practice. According to the most recent and highest quality study, albumin administration may be considered in cases of large-volume thoracentesis (typically >1.5 liters) where there is concern for re-expansion pulmonary edema or in patients with significant hypoalbuminemia 1.

Key Considerations

• The body can typically compensate for the protein loss associated with standard thoracentesis.
• Routine albumin administration has not been shown to improve outcomes in most patients undergoing pleural fluid removal and represents an unnecessary expense with potential risks.
• If albumin is deemed necessary, the typical dose is 25g of 25% albumin administered intravenously, but this should be determined based on the patient's clinical status, amount of fluid removed, and baseline albumin levels.

Clinical Context

In contrast to ascites removal, where albumin infusion is recommended to mitigate the risk of postparacentesis circulatory dysfunction (PPCD) when more than 5 L of fluid is removed 1, the guidelines for pleural fluid removal do not support routine albumin administration. The risk of re-expansion pulmonary edema and the patient's underlying clinical condition should guide the decision to administer albumin.

Albumin Administration

The study on ascites removal provides guidance on albumin administration, recommending 6-8 g of albumin per liter of ascites removed 1. However, this does not directly apply to pleural fluid removal, and the decision to administer albumin should be based on the specific clinical circumstances of the patient undergoing thoracentesis.

From the FDA Drug Label

Removal of ascitic fluid from a patient with cirrhosis may cause changes in cardiovascular function and even result in hypovolemic shock. In such circumstances, the use of an albumin infusion may be required to support the blood volume.

The use of albumin infusion may be required to support blood volume in cases where removal of fluid (such as ascitic or pleural fluid) may cause hypovolemic shock.

• Albumin administration is not explicitly required for every pleural fluid removal.
• The decision to administer albumin should be based on the patient's individual needs and hemodynamic response. 2

From the Research

Albumin Administration in Pleural Fluid Removal

• The administration of albumin in pleural fluid removal is a topic of interest in medical research, with studies investigating its effects on patient outcomes 3, 4, 5.
• A study published in the Journal of Pharmacy Practice in 2020 found that standardizing the use of albumin in large volume paracentesis reduced the amount of albumin used per liter of fluid removed, without significant differences in patient outcomes such as hyponatremia, renal impairment, and hypotension 3.
• Another study published in Chest in 1999 investigated the frequency of unexplained pleural effusions in patients with normal and low plasma oncotic pressures, and found that hypoalbuminemia was an uncommon cause of pleural effusion 4.
• A review article published in Deutsches Arzteblatt International in 2019 discussed the etiology, diagnosis, and treatment of pleural effusion in adults, and highlighted the importance of precise differential diagnostic categorization in determining treatment and prognosis 6.
• A narrative review published in the European Journal of Heart Failure in 2025 discussed the association between hypoalbuminemia and poor outcomes in heart failure patients, and suggested that albumin supplementation or nutritional support may be beneficial in improving clinical outcomes, although further research is needed 5.

Key Findings

• The use of albumin in pleural fluid removal may not be necessary in all cases, and its administration should be guided by individual patient needs and outcomes 3, 4.
• Hypoalbuminemia is an uncommon cause of pleural effusion, and other potential causes should be carefully evaluated in patients with low serum albumin levels 4.
• The treatment of pleural effusion should be determined after meticulous differential diagnosis, and may involve a range of therapeutic options including pleurodesis, thoracoscopy, and video-assisted thoracoscopy 6.
• Further research is needed to fully understand the role of albumin in the natural history of heart failure and other cardiovascular diseases, and to determine the potential benefits of albumin supplementation or nutritional support in improving clinical outcomes 5.