What are the indications for albumin in patients with Spontaneous Bacterial Peritonitis (SBP)?

Indications for Albumin in Patients with Spontaneous Bacterial Peritonitis (SBP)

All patients who develop SBP should be treated with broad spectrum antibiotics and intravenous albumin at a dose of 1.5 g/kg at diagnosis and 1 g/kg on day 3 to decrease the frequency of hepatorenal syndrome and improve survival. 1

Primary Indication: Prevention of Renal Dysfunction and Mortality

• IV albumin administration in SBP significantly decreases the incidence of type 1 hepatorenal syndrome (from 30% to 10%) and reduces mortality (from 29% to 10%) compared with antibiotic treatment alone 1
• The recommended dosing regimen is 1.5 g/kg body weight at diagnosis (within 6 hours), followed by 1 g/kg on day 3 1, 2
• This combination therapy has been established as a Level A1 recommendation (highest evidence level) by clinical practice guidelines 1

Patient Selection: Who Benefits Most

• Albumin administration is particularly effective in high-risk patients with:

  • Baseline serum bilirubin ≥68 μmol/L (4 mg/dL) 1, 2
  • Baseline serum creatinine ≥88 μmol/L (1 mg/dL) 1, 2
  • Blood urea nitrogen >30 mg/dL 1, 3

• The benefit is less clear in patients with both:

  • Baseline serum bilirubin <68 μmol/L (4 mg/dL) AND
  • Baseline serum creatinine <88 μmol/L (1 mg/dL) 1

Mechanism of Benefit

• SBP without septic shock may precipitate deterioration of circulatory function leading to:

  • Severe hepatic insufficiency
  • Hepatic encephalopathy
  • Type 1 hepatorenal syndrome 1

• Albumin improves circulatory function in patients with SBP, while equivalent doses of hydroxyethyl starch do not provide the same beneficial effect 1

Implementation Considerations

• Albumin should be administered within 6 hours of SBP diagnosis for maximum benefit 1, 3
• A standardized albumin order set restricted to high-risk SBP patients has been shown to significantly reduce the incidence of acute kidney injury and mortality 3
• Response to therapy should be monitored with a repeat paracentesis after 48 hours of antibiotic treatment to assess resolution (decrease in ascitic neutrophil count to <250/mm³) 1

Potential Complications and Pitfalls

• Potential adverse effects of albumin administration include:

  • Fluid overload and pulmonary edema (particularly in the sickest patients) 2, 4
  • Hypotension/tachycardia, nausea/vomiting, rigors, pyrexia, and rash/pruritus 2

• Some patients, particularly those with more severe disease, may not tolerate the standard albumin dose infused over short periods (6 hours) 5

• In patients at risk for fluid overload, consider:

  • Monitoring for signs of respiratory distress during infusion 5
  • Potentially using a slower infusion rate in high-risk patients 5

Alternative Approaches Under Investigation

• Lower albumin doses (0.75 g/kg at diagnosis and 0.5 g/kg 48 hours later) may be considered in patients who cannot tolerate standard dosing due to circulatory overload 5
• Terlipressin or low-dose albumin plus terlipressin could potentially be used as therapeutic alternatives to standard-dose albumin in high-risk SBP patients, though more research is needed 6

Important Distinction

• While albumin is beneficial in SBP, its efficacy in cirrhotic patients with infections other than SBP is less clear - studies show it may delay onset of renal failure but does not improve renal function or survival at 3 months in these other infections 4