What is the recommended dose of albumin (Albumin) for the treatment of Spontaneous Bacterial Peritonitis (SBP)?

Albumin Dosing for Spontaneous Bacterial Peritonitis

Administer intravenous albumin at 1.5 g/kg body weight at diagnosis (within 6 hours) followed by 1 g/kg on day 3 in patients with SBP. 1

Standard Dosing Regimen

The established albumin protocol for SBP treatment is:

• Day 1: 1.5 g/kg body weight administered within 6 hours of diagnosis 1, 2, 3
• Day 3: 1 g/kg body weight 1

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

Risk Stratification for Albumin Administration

All patients with SBP should receive albumin according to current EASL guidelines, though the benefit is most pronounced in high-risk patients. 1

High-Risk Patients (Greatest Benefit)

Albumin is particularly effective in 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 3

Lower-Risk Patients (Uncertain Benefit)

For patients with bilirubin <4 mg/dL AND creatinine <1 mg/dL, the benefit is less clear, as the incidence of hepatorenal syndrome was very low in both treatment groups (7% without albumin vs 0% with albumin). 1 However, EASL guidelines still recommend albumin for all SBP patients until more data becomes available. 1

Clinical Outcomes

The combination of albumin plus antibiotics demonstrates:

• Reduced mortality: 22% vs 41% at 3 months compared to antibiotics alone 1
• Prevention of acute kidney injury: 10% vs 33% incidence 1, 2, 3
• Improved circulatory function: Albumin increases arterial pressure, suppresses plasma renin activity, and expands central blood volume 4

Important Caveats and Practical Considerations

Timing is Critical

• Albumin should be administered within 6 hours of SBP diagnosis for optimal benefit 2, 3
• Implementation of order sets has improved timely administration from 24.59% to 40.74% of cases 3

Infusion Rate and Tolerability

• Standard infusion over 6 hours may not be tolerated in all populations, particularly in patients with underlying cirrhotic cardiomyopathy 5
• In one study, 100% of patients receiving standard dose over 6 hours developed symptomatic circulatory overload 5
• Consider slower infusion rates to prevent fluid overload, pulmonary edema, and cardiac complications 2, 5

Alternative Plasma Expanders Are Inferior

• Hydroxyethyl starch does NOT provide the same hemodynamic benefits as albumin and should not be used as a substitute 1, 4
• Crystalloids have not been adequately studied for this indication 1
• Albumin has unique effects on endothelial function beyond simple volume expansion 4

Lower Dose Considerations

• Some centers use reduced doses (30 g/day on days 1 and 3, or 0.75 g/kg and 0.5 g/kg) with acceptable outcomes 6, 5
• However, guideline-recommended standard dosing remains the evidence-based approach 1
• Lower doses may be considered in resource-limited settings or patients at high risk for volume overload, but this represents a deviation from established guidelines 6

Common Pitfalls to Avoid

• Do not withhold albumin based solely on cost considerations - the mortality benefit is substantial 1, 3
• Do not use quinolones as antibiotics if the patient is already on quinolone prophylaxis - resistance is common 1
• Do not assume all plasma expanders are equivalent - only albumin has proven mortality benefit 1, 4
• Do not delay albumin administration - early treatment (within 6 hours) is associated with better outcomes 2, 3