In a cirrhotic patient undergoing therapeutic paracentesis with removal of >5 L of ascitic fluid, is routine normal‑saline replacement necessary?

Normal Saline is NOT Appropriate for Volume Replacement After Large-Volume Paracentesis

For cirrhotic patients undergoing therapeutic paracentesis with removal of >5 L of ascitic fluid, albumin replacement at 8 g per liter removed is mandatory—normal saline is explicitly contraindicated because it worsens salt retention and exacerbates ascites. 1, 2

Why Normal Saline Fails in This Context

• Normal saline contains 154 mmol/L of sodium and will worsen fluid overload and ascites in cirrhotic patients who already have impaired sodium excretion. 2
• The British Society of Gastroenterology explicitly recommends against normal saline in ascites management due to these mechanisms. 2
• The FDA drug label for sodium chloride IV warns that in cirrhosis, "the kidney fails to eliminate sufficient sodium," resulting in retention of both salt and water, and that "repeated paracentesis for removal of ascitic fluid" can cause marked salt depletion—but this refers to the loss of sodium with ascites removal, not a rationale to replace it with saline. 3

The Evidence-Based Standard: Albumin Replacement

Albumin at 8 g per liter of ascites removed (when >5 L is drained) is the mandatory standard endorsed by all major hepatology societies. 1, 4

Dosing Protocol

• Administer 8 g of albumin per liter of ascitic fluid removed after completing the paracentesis. 1, 4
• For a 5-liter paracentesis, this equals 40 g of albumin, delivered as 200 mL of 20% albumin or 160 mL of 25% albumin. 4
• Infuse albumin after (not during) the procedure, over 1–2 hours to avoid volume overload. 4

Clinical Outcomes Without Albumin

• Renal impairment occurs in approximately 21% of patients undergoing large-volume paracentesis without albumin, compared with 0% when albumin is administered. 1, 2
• Failure to give albumin leads to post-paracentesis circulatory dysfunction (PICD) with marked activation of the renin-angiotensin-aldosterone system, hyponatremia, and electrolyte disturbances. 1
• The severity of PICD correlates inversely with patient survival. 1

What About Volumes <5 Liters?

• For paracentesis <5 L, albumin replacement is not mandatory in uncomplicated cases, though synthetic plasma expanders (150–200 mL of gelofusine or Haemaccel) are acceptable alternatives. 1, 4
• However, albumin at 8 g/L should be considered even for <5 L in patients with acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury. 4, 2
• One small study (n=12) suggested that a single <5 L paracentesis without albumin was safe, but the International Ascites Club notes this was based on consensus rather than robust evidence. 1, 5

Alternative Plasma Expanders: Inferior to Albumin

• Dextran 70 and polygeline (gelofusine/Haemaccel) have been studied as alternatives to albumin. 1, 6
• While these synthetic expanders can prevent hyponatremia and renal impairment, they are associated with significantly greater activation of renin-angiotensin-aldosterone compared to albumin. 1
• Pooled data show albumin is more effective in preventing hyponatremia (8% vs. 17% for other expanders). 1
• One cost-analysis study from 1995 found dextran 70 had similar biochemical outcomes to albumin at lower cost ($20.80 vs. $266 USD), but this predates modern evidence showing albumin's superiority in reducing liver-related complications and hospital costs. 1, 6

Common Pitfalls to Avoid

• Do not use normal saline as a volume expander after large-volume paracentesis—it will worsen ascites and sodium retention. 2
• Do not underdose albumin—giving less than 6 g/L is associated with significantly increased PICD and renal complications. 4
• Do not artificially slow the drainage rate out of concern for hemodynamic instability—studies show that removing >10 liters over 2–4 hours causes only minimal blood pressure changes (<8 mm Hg decrease). 1, 4
• Do not withhold paracentesis due to coagulopathy—routine correction of INR or platelet count is not recommended, even with INR up to 8.7 or platelets as low as 19×10³/μL. 4

Post-Paracentesis Management

• After large-volume paracentesis, diuretic therapy is required to prevent re-accumulation of ascites. 1, 4
• Initiate or resume spironolactone 100–400 mg/day combined with furosemide 40–160 mg/day in a 100:40 mg ratio to maintain normokalemia. 4
• Advise a dietary sodium limit of 88 mmol/day (≈2 g of sodium or 5.2 g of salt). 4

The Only Exception: Severe Hyponatremia with Renal Dysfunction

• If a cirrhotic patient presents with severe hyponatremia (Na <125 mmol/L) **and** renal dysfunction (creatinine >150 μmol/L or rising), volume expansion with albumin or colloids is preferred, but if crystalloids must be used, normal saline (154 mmol/L sodium) is acceptable despite worsening salt retention—the priority in this specific scenario is preventing irreversible renal failure over managing ascites. 2
• This is the only clinical context where normal saline might be considered, and even then, albumin remains superior. 2