Albumin Dosing in Spontaneous Bacterial Peritonitis
Administer intravenous albumin at 1.5 g/kg body weight at the time of SBP diagnosis, followed by 1.0 g/kg on day 3, in combination with antibiotics. 1, 2
Standard Dosing Regimen
The established albumin protocol for SBP consists of:
- Day 1: 1.5 g/kg body weight administered within 6 hours of diagnosis 1, 2, 3
- Day 3: 1.0 g/kg body weight 1, 2
This regimen, when combined with antibiotics (typically cefotaxime), significantly reduces mortality from 29% to 10% and decreases the incidence of type 1 hepatorenal syndrome from 30% to 10% compared to antibiotics alone 1, 2, 3. The European Association for the Study of the Liver designates this as Level A1 evidence 1.
Patient Selection for Albumin Therapy
All patients with SBP should receive albumin according to current EASL guidelines 1. However, the benefit is most pronounced in high-risk patients with:
- Serum bilirubin ≥4 mg/dL (≥68 μmol/L) 1, 2
- Serum creatinine ≥1 mg/dL (≥88 μmol/L) 1, 2
- Blood urea nitrogen >30 mg/dL 4
The evidence for albumin benefit in patients with bilirubin <4 mg/dL and creatinine <1 mg/dL is less clear, as the incidence of hepatorenal syndrome was very low in both treatment groups (7% without albumin vs 0% with albumin) 1. Despite this uncertainty, EASL guidelines recommend albumin for all SBP patients until more definitive data emerges 1.
Clinical Outcomes with Standard Dosing
The landmark randomized controlled trial demonstrated that albumin plus cefotaxime:
- Reduced renal impairment from 33% to 10% 2, 3
- Decreased in-hospital mortality from 29% to 10% 2, 3
- Lowered 3-month mortality from 41% to 22% 3
Implementation of albumin order sets restricted to high-risk SBP patients has shown similar benefits, with AKI incidence decreasing from 63.93% to 33.33% and mortality from 36.07% to 7.41% 4.
Alternative Dosing Considerations
Lower albumin doses are not recommended based on current evidence. A 2023 randomized trial comparing standard dose (1.5 g/kg and 1 g/kg) versus reduced dose (0.75 g/kg and 0.5 g/kg) found that standard dosing infused over 6 hours was poorly tolerated in Indian patients, with 100% developing symptomatic circulatory overload in the standard dose group 5. However, this study's infusion protocol (6 hours) differs from typical clinical practice where albumin is often infused more slowly.
One retrospective study using a fixed low dose of 30 g on days 1 and 3 (regardless of weight) reported HRS in 18.3% of patients and 6-month survival of 81.8% 6. While these outcomes appear acceptable, they do not match the superior results achieved with weight-based standard dosing 3.
Administration Timing and Monitoring
- Initiate albumin within 6 hours of SBP diagnosis 1, 2, 4, 3
- Infuse slowly to prevent circulatory overload, particularly in patients with underlying cardiac dysfunction 1
- Monitor for adverse effects including fluid overload, pulmonary edema, hypotension, and tachycardia 2
- Consider limiting infusion duration beyond 6 hours if circulatory overload develops 5
Important Caveats
Hydroxyethyl starch and other synthetic colloids should not be substituted for albumin. Studies demonstrate that albumin improves circulatory function in SBP while equivalent doses of hydroxyethyl starch provide no such benefit 1. The role of crystalloids as albumin alternatives remains unknown and is not recommended 1.
The albumin regimen should be combined with appropriate broad-spectrum antibiotics (third-generation cephalosporins as first-line) 1. Albumin alone without antibiotics is insufficient treatment for SBP 1.