Albumin Infusion Rate After Large-Volume Paracentesis
Administer 8 g of albumin per liter of ascites removed (for volumes >5 L) as a post-procedure infusion over 1–2 hours, not during the tap itself. 1
Dosing Protocol
- Mandatory dose: 8 g albumin per liter when >5 L is removed 1, 2
- Practical formulation: 100 mL of 20% albumin per 3 liters of ascites drained 1, 3
- Example calculation: For 8 L removed = 64 g total = 320 mL of 20% albumin or 256 mL of 25% albumin 1
Timing and Infusion Rate
- Timing: Infuse albumin after paracentesis completion, never during the procedure 1, 2
- Infusion rate: Deliver over 1–2 hours to avoid volume overload, particularly in patients with cirrhotic cardiomyopathy 1
- Formulation: Use hyperoncotic solutions (20% or 25% albumin); 5% albumin is inadequate 1, 3
Paracentesis Drainage Rate (Separate from Albumin Infusion)
- Drainage speed: Remove ascites at approximately 2–9 liters per hour, completing the entire tap within 1–4 hours 1
- No artificial slowing: Historical concerns about rapid drainage causing circulatory collapse are unfounded—removing >10 L over 2–4 hours produces minimal blood pressure changes (<8 mmHg decrease) 1
Evidence Supporting This Protocol
Guideline consensus from the American Association for the Study of Liver Diseases, European Association for the Study of the Liver, and British Society of Gastroenterology uniformly endorses 6–8 g/L (with 8 g/L as the mandatory standard) for volumes >5 L 1, 2. This recommendation carries the highest strength of evidence across international hepatology societies.
Clinical outcomes without adequate albumin:
- Renal impairment occurs in 21% of patients without albumin versus 0% with proper replacement 1
- Post-paracentesis circulatory dysfunction (PICD) develops in up to 80% without volume expansion but only 18.5% with albumin 1
- Albumin reduces PICD by 61%, hyponatremia by 42%, and mortality by 36% compared to alternative expanders 1
Special Considerations for Volumes <5 L
- Standard cases: Albumin is not mandatory for <5 L; synthetic plasma expanders (150–200 mL gelofusine or Haemaccel) are acceptable alternatives 1, 2
- High-risk patients: Consider albumin at 8 g/L even for <5 L in acute-on-chronic liver failure or high acute kidney injury risk 1, 2, 4
A 2020 randomized trial in ACLF patients demonstrated that PICD occurs even with modest-volume paracentesis (<5 L), with 70% developing PICD without albumin versus 30% with albumin (P=0.001) 4. This supports albumin use in high-risk populations regardless of volume.
Dose-Reduction Evidence (Controversial)
One 2011 pilot study (n=70) suggested that half-dose albumin (4 g/L) may be non-inferior to standard dosing (8 g/L), showing similar rates of PICD (14% vs 20%, P=NS) and renal impairment (0% in both groups) 5. However, this single unblinded pilot study has not been incorporated into any major guideline, and all current international hepatology societies continue to mandate 8 g/L for volumes >5 L 1, 2. A 2020 retrospective study using reduced doses (6.5 g/L vs 8.3 g/L) showed no difference in adverse outcomes but lacked the power to detect clinically meaningful differences 6.
Clinical recommendation: Adhere to the guideline-endorsed 8 g/L dose until larger randomized trials definitively establish non-inferiority of lower doses 1, 2.
Common Pitfalls to Avoid
- Do not confuse with SBP dosing: Spontaneous bacterial peritonitis requires weight-based dosing (1.5 g/kg within 6 hours, then 1.0 g/kg on day 3), which is entirely different from volume-based paracentesis dosing 1, 3
- Do not infuse during the tap: Albumin must be given after drainage is complete 1, 2
- Do not use normal saline: Saline aggravates sodium retention and ascites; only albumin or synthetic colloids are appropriate 1
- Do not artificially slow drainage: Complete the paracentesis rapidly (1–4 hours total) without concern for hemodynamic instability 1