What dose of albumin should be administered after a large-volume paracentesis in an 80‑kg adult?

Albumin Dosing for Large-Volume Paracentesis in an 80-kg Patient

For an 80-kg patient undergoing large-volume paracentesis (>5 L), administer 8 g of albumin per liter of ascitic fluid removed, infused after the procedure is completed. 1, 2

Calculation Independent of Body Weight

• Albumin dosing is based solely on the volume of ascites removed, not on patient body weight. 2
• For example, if 10 L of ascites is removed, the total albumin dose is 80 g (10 L × 8 g/L). 2
• This corresponds to approximately 320 mL of 25% albumin or 400 mL of 20% albumin. 2

Evidence Supporting the 8 g/L Standard

• Multiple international hepatology societies converge on 6–8 g/L, with 8 g/L representing the mandatory dose for volumes >5 L. 1, 2
• The American Gastroenterological Association (2024), Korean Association for the Study of the Liver (2018), and European Association for the Study of the Liver all endorse this dosing range. 2
• Post-paracentesis circulatory dysfunction (PICD) occurs in 18.5% of patients receiving albumin versus 34.4–37.8% with alternative plasma expanders (dextran-70, polygeline). 1
• Without any volume expansion, PICD develops in up to 80% of patients. 1

Administration Protocol

• Infuse albumin after paracentesis completion, not during the procedure. 2, 3
• Administer over 1–2 hours to avoid volume overload, particularly in patients with cirrhotic cardiomyopathy. 2
• Use 20% or 25% hyperoncotic albumin solutions; 5% albumin is inadequate for this indication. 2, 3

Clinical Outcomes Without Adequate Albumin

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

Special Considerations for Volumes <5 L

• For paracentesis removing <5 L, albumin at 8 g/L should be considered (but is not mandatory) in patients with acute-on-chronic liver failure or those at high risk of post-paracentesis acute kidney injury. 2
• In uncomplicated cases with <5 L removed, synthetic plasma expanders (150–200 mL of gelofusine or Haemaccel) are acceptable alternatives. 2

Common Pitfall: Underdosing

• A recent study found that reducing albumin to 6.5 g/L (versus the standard 8.3 g/L) showed no difference in adverse effects, but this was a small single-center study. 4
• The weight of guideline evidence strongly supports 8 g/L as the standard dose, particularly given the superior outcomes demonstrated in larger randomized trials. 1, 2, 5
• Underdosing below 6 g/L is associated with significantly increased post-paracentesis circulatory dysfunction and renal complications. 2

Practical Example for an 80-kg Patient

If 8 L of ascites is removed:

• Total albumin required: 64 g (8 L × 8 g/L)
• Using 25% albumin: 256 mL (64 g ÷ 0.25)
• Using 20% albumin: 320 mL (64 g ÷ 0.20)
• Infuse over 1–2 hours after paracentesis completion 2

Why 25% Albumin Is Preferred

• 25% albumin delivers approximately five-fold less sodium than 5% albumin, making it preferable when strict sodium restriction is required. 2, 3
• The hyperoncotic formulation achieves the same dose with markedly lower infusion volume. 2, 3

Post-Procedure Monitoring

• Monitor serum creatinine daily for 6 days; acute kidney injury is a recognized complication of inadequate albumin replacement. 2
• Check serum sodium daily; hyponatremia may develop with under-replacement. 2
• Measure plasma renin activity if available; a >50% rise from baseline indicates PICD. 1, 6