Albumin and Furosemide Administration Protocol for Ascites Management

Albumin Dosing Guidelines

For large volume paracentesis (>5 L), administer 20% or 25% albumin solution at a dose of 8 g albumin/L of ascites removed after the procedure is completed 1, 2
For paracentesis <5 L, albumin (20% or 25% solution) can be considered at the same dose (8 g/L) in patients with acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury 1
In spontaneous bacterial peritonitis (SBP), administer albumin 1.5 g/kg within 6 hours of diagnosis, followed by 1 g/kg on day 3, particularly in patients with increased serum creatinine or rising creatinine 1, 2, 4

For cirrhosis with ascites, start with oral furosemide 40 mg combined with spironolactone 100 mg as a single morning dose 1, 3
Doses can be increased simultaneously every 3-5 days if weight loss and natriuresis are inadequate, up to a maximum of 160 mg/day of furosemide and 400 mg/day of spironolactone 1, 3
Oral administration is preferred in cirrhotic patients due to good bioavailability and to avoid acute reductions in glomerular filtration rate associated with IV administration 3

Administer albumin and furosemide separately, using different infusion sites 5
Complete the albumin infusion first, followed by furosemide administration 5
Monitor electrolytes, kidney function, and hemodynamic parameters closely during treatment 5

Discontinue diuretics if severe hyponatremia, acute kidney injury, worsening hepatic encephalopathy, or incapacitating muscle cramps develop 5
In patients with refractory ascites, consider transjugular intrahepatic portosystemic shunt (TIPSS) rather than escalating diuretic doses 1
Do not use albumin in patients with cirrhosis and infections other than SBP, as it does not reduce the risk of acute kidney injury or mortality and may cause pulmonary edema 4

Monitor for adverse events, as nearly half of patients require diuretic discontinuation or dose reduction 1
Check electrolytes regularly, particularly sodium and potassium 3
Assess kidney function through urine output and serum creatinine 3
Evaluate fluid status through weight, blood pressure, and clinical examination 3

Avoid simultaneous administration of albumin and furosemide in the same infusion, as this may reduce efficacy 5
Do not administer furosemide in patients with marked hypovolemia, as it could worsen hypovolemia and promote thrombosis 3, 6
Avoid high doses of furosemide (>6 mg/kg/day) for periods longer than 1 week due to risk of ototoxicity 6