For a cirrhotic patient undergoing large‑volume paracentesis (≥5 L), when should albumin be administered and what dose is recommended?

Albumin Infusion Timing for Large-Volume Paracentesis in Cirrhosis

Albumin should be administered immediately after completing the paracentesis procedure, not during it, infused slowly over 1–2 hours at a dose of 8 g per liter of ascites removed when ≥5 L is drained. 1, 2

Dosing Protocol

• For paracentesis removing ≥5 L of ascitic fluid, administer 8 g of albumin per liter removed (e.g., 40 g for 5 L, 80 g for 10 L). 1, 2
• Use 20% or 25% hyperoncotic albumin solutions; 5% albumin is inadequate for preventing post-paracentesis circulatory dysfunction (PICD). 2, 3
• Calculate the dose solely on volume of ascites removed, not on patient body weight. 2

Timing and Administration

• Infuse albumin after the paracentesis is completed, not during the procedure. 1, 2, 3
• Deliver the dose over 1–2 hours to avoid volume overload, particularly in patients with cirrhotic cardiomyopathy. 2, 3
• Complete the paracentesis itself rapidly in a single session (1–4 hours), draining to dryness. 2

Evidence Supporting Post-Procedure Timing

The 2024 American Gastroenterological Association guidelines explicitly state that albumin should be given "at the time of" large-volume paracentesis, with supporting evidence clarifying this means immediately after completion. 1 Multiple hepatology societies converge on post-procedure administration because albumin's oncotic effect is most beneficial when given after fluid removal to counteract the circulatory dysfunction that develops in the hours following paracentesis. 2, 3

Clinical Rationale

• Without albumin, PICD occurs in 70–80% of patients versus ≈18% when the recommended 8 g/L dose is given. 2, 3
• Renal impairment develops in ≈21% of patients without albumin versus 0% with proper replacement. 2, 4
• Post-procedure administration prevents the marked activation of renin-angiotensin-aldosterone system, hyponatremia, and electrolyte disturbances that characterize PICD. 2, 4

Common Pitfalls to Avoid

• Do not infuse albumin during the paracentesis—this timing is ineffective at preventing PICD. 2, 3
• Do not use synthetic colloids (dextran-70, polygeline, hydroxyethyl starch) as substitutes; they cause greater RAAS activation, higher hyponatremia rates (17% vs 8%), and worse outcomes. 2, 3
• Do not underdose albumin (e.g., 4 g/L)—while one small pilot study suggested potential equivalence 5, all major guidelines continue to endorse 8 g/L as the standard. 1, 2, 3
• Do not infuse rapidly—rapid administration can precipitate cardiac overload in patients with underlying cirrhotic cardiomyopathy. 2, 3

Post-Paracentesis Management

• Restart diuretics within 1–2 days after the procedure (spironolactone 100–400 mg plus furosemide 40–160 mg in a 100:40 ratio) to prevent rapid ascites re-accumulation, which occurs in ≈93% without diuretics versus ≈18% with early reinitiation. 2, 3
• Monitor serum sodium daily—hyponatremia develops in 17% of inadequately replaced patients versus 8% with proper albumin dosing. 2, 3
• Watch for rising serum creatinine >0.3 mg/dL from baseline, which suggests evolving hepatorenal syndrome. 3

Special Considerations for Smaller Volumes

• For paracentesis <5 L, albumin at 8 g/L may be considered (but is not mandatory) in high-risk patients with acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury. 1, 2
• In uncomplicated cases with <5 L removed, albumin is not required. 1, 2