Why is albumin administered during ascitic fluid drainage?

From the Guidelines

Albumin should be administered during large-volume paracentesis (removal of ascitic fluid) to prevent post-paracentesis circulatory dysfunction (PPCD), with a recommended dose of 6-8 grams per liter of ascitic fluid removed when the volume exceeds 5 liters, as supported by the most recent and highest quality study 1.

Key Points

• The administration of albumin is crucial to prevent a further reduction of effective arterial blood volume, which may precipitate postparacentesis circulatory dysfunction (PPCD) 1.
• The risk of PPCD may increase with >8 L of fluid evacuated in one single session, making albumin infusion particularly important in these cases 1.
• Albumin helps maintain intravascular volume by drawing fluid from the interstitial space into the bloodstream, preventing hemodynamic complications associated with large-volume paracentesis 1.
• For smaller volume paracentesis (less than 5 liters), albumin administration is generally not necessary as the risk of PPCD is lower, although some guidelines suggest its use due to concerns about alternative plasma expanders 1.

Albumin Dosage

• The recommended dose of albumin replacement is 6-8 g for every liter of ascites removed, based on expert opinion and supported by recent studies 1.
• For example, if 8 liters are removed, approximately 50 grams of albumin (typically as 25% solution, 200mL) should be administered.

Clinical Implications

• Without albumin replacement, patients may experience increased activation of the renin-angiotensin system, renal impairment, and electrolyte disturbances 1.
• Albumin administration is particularly important in patients with cirrhosis who already have compromised cardiovascular function, as it helps prevent the development of PPCD and its associated complications 1.

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. We give albumin when ascitic fluid is drained to support the blood volume and prevent hypovolemic shock that may occur due to changes in cardiovascular function in patients with cirrhosis 2.

• The main goal is to maintain plasma volume and prevent complications associated with oncotic deficit.
• Albumin infusion is used to expand plasma volume and support the patient's hemodynamic response.

From the Research

Rationale for Albumin Administration in Ascitic Drain

• Albumin is commonly employed in cirrhotic patients in association with diuretics for the treatment of ascites due to its role in modulating the distribution of fluid between body compartments 3.
• The administration of albumin is effective in preventing circulatory dysfunctions after large-volume paracentesis and renal failure, as well as after Spontaneous Bacterial Peritonitis (SBP) 3.
• Albumin represents, associated with vasoconstrictors, the therapeutic gold standard for the hepatorenal-syndrome (HRS) 3.

Physiopathological Basis for Albumin Use

• The effectiveness of albumin administration in the treatment of ascites is due to its plasma volume expander property as well as its efficacy in restoring plasmatic oncotic pressure 3.
• Cirrhotic patients with ascites show an effective hypovolemia with peripheral arterial vasodilatation and increase in heart rate, despite hydrosaline retention 3.

Comparison with Alternative Treatments

• Albumin infusion reduces the incidence of postparacentesis circulatory dysfunction among patients with cirrhosis and tense ascites, as compared with no treatment or alternative treatments such as artificial colloids and vasoconstrictors 4.
• Albumin decreases the occurrence of hyponatremia and mortality compared to alternative treatments 4.
• Human albumin appears to be more effective in preventing liver-related complications than synthetic colloid in patients with cirrhosis and ascites, which may be associated with decreased hospital costs 5.

Clinical Practice Guidelines

• The removal of at least 5L of ascitic fluid is considered large-volume paracentesis, and albumin administration is recommended in this setting to prevent circulatory dysfunction 6.
• Nurses play a crucial role in monitoring patients undergoing paracentesis and administering treatment as directed by the medical team, including albumin infusion 6.