What is the role of albumin in managing peritonitis?

Role of Albumin in Managing Peritonitis

Albumin administration significantly reduces mortality and kidney impairment in patients with spontaneous bacterial peritonitis (SBP) and should be administered alongside antibiotics at a dose of 1.5 g/kg on day 1 and 1.0 g/kg on day 3. 1

Albumin in Spontaneous Bacterial Peritonitis

Evidence for Mortality and Renal Function Benefits

• Albumin administration in SBP reduces the rate of kidney impairment (OR, 0.21; 95% CI, 0.11-0.42) and mortality (OR, 0.34; 95% CI, 0.19-0.60) when combined with antibiotics compared to antibiotics alone 1
• The largest randomized trial showed significantly lower rates of kidney impairment (10% vs 33%; P = .002) and in-hospital mortality (10% vs 29%; P = .01) in patients treated with albumin plus antibiotics versus antibiotics alone 1
• A meta-analysis demonstrated that albumin plus antibiotics improved survival at 3 months (OR = 0.66; 95% CI 0.45–0.96, P = 0.03) compared to standard antibiotic therapy alone 1

Dosing Recommendations

• The recommended dosing regimen for SBP is 1.5 g/kg body weight within 6 hours of diagnosis, followed by 1.0 g/kg on day 3 1, 2
• This dosing strategy is particularly important for high-risk patients with baseline serum creatinine >1 mg/dL, blood urea nitrogen >30 mg/dL, or total bilirubin >4 mg/dL 1, 2, 3
• Implementation of albumin order sets restricted to high-risk SBP patients has been shown to significantly reduce the incidence of acute kidney injury and mortality 3

Mechanism of Action

• Albumin improves systemic hemodynamics in SBP through multiple mechanisms 4, 5:
  • Expansion of central blood volume (increase in cardiopulmonary pressures)
  • Increase in systolic volume and systemic vascular resistance
  • Improvement in cardiac function due to increased filling
  • Decrease in the degree of arterial vasodilation
  • Potential effects on endothelial function

Albumin in Other Types of Peritonitis

Secondary Peritonitis

• For patients with severe sepsis due to secondary peritonitis, albumin administration may reduce 28-day mortality in patients with baseline serum albumin ≤20 g/L 6
• No significant mortality benefit has been observed in patients with baseline serum albumin >20 g/L 6

Peritoneal Dialysis-Associated Peritonitis

• Low serum albumin levels at the start of continuous ambulatory peritoneal dialysis (CAPD) correlate significantly with the development of peritonitis 7
• Hypoalbuminemia can serve as a warning sign for peritonitis risk in CAPD patients 7

Potential Adverse Effects and Precautions

• Albumin administration can cause fluid overload and pulmonary edema, particularly in patients with cirrhosis 1, 2
• Higher rates of circulatory overload have been observed in patients receiving albumin compared to crystalloids 1
• Albumin infusion should be done slowly to prevent potential cardiac overload, especially in patients with preexisting cardiomyopathy 1
• The risk-benefit profile should be carefully considered, with attention to the patient's volume status and cardiovascular function 1

Clinical Implementation

• Albumin should be administered within 6 hours of SBP diagnosis for optimal outcomes 3
• For patients with cirrhosis and SBP, albumin should always be given alongside appropriate antibiotic therapy 1
• The International Collaboration for Transfusion Medicine Guidelines conditionally recommends the use of albumin for patients with spontaneous bacterial peritonitis 1
• Careful assessment of the patient's volume status, cardiovascular status, and degree of kidney impairment before albumin infusion is advised 1