Albumin Dosing in Spontaneous Bacterial Peritonitis
No, you should not give additional albumin before day 3 in cirrhotic patients with SBP—the established protocol is 1.5 g/kg at diagnosis (day 1) and 1.0 g/kg on day 3, and this two-dose regimen should not be modified. 1, 2, 3
Standard Albumin Protocol for SBP
The evidence-based regimen is fixed and should be followed precisely:
- Day 1 (within 6 hours of diagnosis): Administer 1.5 g/kg of IV albumin 2, 3
- Day 3: Administer 1.0 g/kg of IV albumin 1, 2, 3
- This protocol is combined with appropriate antibiotic therapy (typically ceftriaxone or cefotaxime) 1, 4
Why This Specific Timing Matters
The landmark randomized controlled trial that established this regimen demonstrated that this two-dose schedule significantly reduces:
- Acute kidney injury: 10% vs 33% (with antibiotics alone) 1, 3
- In-hospital mortality: 10% vs 29% (with antibiotics alone) 1, 3
- Three-month mortality: 22% vs 41% (with antibiotics alone) 4
The mechanism involves improving systemic hemodynamics through increased cardiac filling and decreased arterial vasodilation, with peak effects observed when albumin is given at these specific intervals 5. The day 3 dose specifically addresses the ongoing inflammatory response and prevents late deterioration of renal function that can occur even after infection resolution 1.
Patients Who Benefit Most
Target this protocol specifically for patients with:
These high-risk patients are most likely to develop hepatorenal syndrome and derive maximum benefit from the standard two-dose regimen 1, 3.
Critical Safety Considerations
Do not exceed the standard dosing protocol because:
- Doses exceeding 87.5-100 g are associated with worse outcomes due to fluid overload 2, 6
- Albumin infusion must be given slowly to prevent cardiac overload, particularly in patients with cirrhotic cardiomyopathy 1, 6
- Adverse effects include pulmonary edema, fluid overload, hypotension/tachycardia, and respiratory complications 1, 3
Evidence Supporting Lower Doses (But Not Additional Doses)
One small study showed that even 10 g/day for days 1-3 reduced renal dysfunction (7% vs 20%) and mortality (27% vs 40%), suggesting the standard protocol may be more than adequate 1. Another study using continuous albumin infusion (50 cc of 20% albumin daily for 3 days) showed benefit through reduction of TNF-alpha and nitric oxide levels 7. However, these alternative regimens do not support giving additional albumin before day 3—they simply demonstrate that the standard protocol is effective and should not be exceeded.
Common Pitfall to Avoid
Do not use albumin for infections other than SBP. Three RCTs and a meta-analysis demonstrated that albumin in non-SBP infections (pneumonia, urinary tract infections, etc.) does not reduce AKI or mortality and was associated with more pulmonary edema 1. The beneficial effects are specific to SBP due to the unique pathophysiology involving peritoneal inflammation and systemic vasodilation 5.