What is the recommended dose of albumin (Human Albumin) in Spontaneous Bacterial Peritonitis (SBP)?

Albumin Dosing in Spontaneous Bacterial Peritonitis (SBP)

The recommended dose of albumin in spontaneous bacterial peritonitis is 1.5 g/kg at diagnosis (day 1) followed by 1 g/kg on day 3, administered intravenously. 1

Evidence-Based Rationale

The administration of albumin in SBP is crucial for preventing hepatorenal syndrome (HRS) and reducing mortality. This recommendation is supported by high-quality evidence from multiple guidelines and clinical trials.

Mechanism and Benefits

• SBP can precipitate deterioration of circulatory function leading to hepatorenal syndrome, which occurs in approximately 30% of patients treated with antibiotics alone 1
• Albumin administration significantly:
  • Decreases the incidence of type 1 HRS (from 30% to 10%)
  • Reduces mortality (from 29% to 10%) compared with antibiotic therapy alone 1
  • Improves systemic hemodynamics through both cardiac function enhancement and decreased arterial vasodilation 2

Dosing Protocol

• Initial dose: 1.5 g/kg body weight at diagnosis (day 1)
• Follow-up dose: 1 g/kg body weight on day 3 1
• Albumin should be administered intravenously along with appropriate antibiotic therapy

Patient Selection

While all patients with SBP benefit from albumin administration, those with the following baseline parameters derive particular benefit:

• Serum bilirubin ≥4 mg/dL (68 μmol/L)
• Serum creatinine ≥1 mg/dL (88 μmol/L) 1
• Blood urea nitrogen >30 mg/dL 3

Implementation Considerations

Timing

• Albumin should be administered as soon as possible after SBP diagnosis, ideally within 6 hours 3
• The effectiveness of albumin is time-sensitive; delays may reduce its protective effect on renal function

Administration Rate

• Infuse albumin slowly to prevent potential cardiac overload, particularly in patients with pre-existing cardiomyopathy 1
• Consider administering over 4-6 hours, especially in patients at risk for volume overload

Monitoring

• Monitor for signs of volume overload during administration
• Assess renal function parameters (creatinine, urine output) during treatment
• Consider a follow-up paracentesis after 48 hours of treatment to confirm resolution of SBP 1

Special Considerations

Tolerability Concerns

• Some patients, particularly those with smaller body habitus, may not tolerate the standard dose when administered over a short period 4
• In patients who develop respiratory distress during infusion, consider:
  • Slowing the infusion rate
  • Temporarily stopping the infusion
  • Using a reduced dose regimen in selected cases (though standard dosing is preferred when tolerated) 4

Alternative Dosing

While the standard dosing regimen is strongly recommended based on the highest quality evidence, some studies have explored lower doses:

• A small study showed that 10 g/day from days 1-3 still provided benefit with lower renal dysfunction rates (7% vs 20%) 1
• Another study used 30 g/day on days 1 and 3 (regardless of weight) with favorable outcomes 5

However, these alternative regimens have not been validated in large randomized controlled trials and should be considered only when standard dosing cannot be tolerated.

Conclusion

The evidence strongly supports the use of albumin at a dose of 1.5 g/kg on day 1 and 1 g/kg on day 3 in all patients with SBP. This intervention significantly reduces the risk of renal impairment and mortality, with the greatest benefit observed in patients with elevated bilirubin or baseline renal dysfunction.