In a cirrhotic patient with spontaneous bacterial peritonitis and rising serum creatinine, should intravenous albumin be administered?

Intravenous Albumin in SBP with Rising Creatinine

Yes, intravenous albumin is strongly recommended for cirrhotic patients with spontaneous bacterial peritonitis who have rising serum creatinine or baseline creatinine ≥1 mg/dL. 1

Evidence-Based Dosing Protocol

The standard albumin regimen that has proven mortality benefit is:

• 1.5 g/kg body weight at the time of SBP diagnosis
• 1.0 g/kg on day 3 1, 2

This specific dosing reduced hospital mortality from 29% to 10% and decreased hepatorenal syndrome incidence from 30% to 10% in the landmark randomized controlled trial. 1, 2

Patient Selection Criteria

Albumin is particularly critical when patients meet ANY of these high-risk criteria:

• Serum creatinine ≥1 mg/dL (88 μmol/L) at SBP diagnosis 1
• Serum bilirubin ≥4 mg/dL (68 μmol/L) 1
• Rising creatinine during SBP treatment 1, 3

For patients with bilirubin <4 mg/dL AND creatinine <1 mg/dL, the benefit is less clear since hepatorenal syndrome rates are very low (0-7%) even without albumin. 1 However, the 2024 international albumin guidelines note that all patients with SBP should receive albumin as a conditional recommendation, though they raise concerns about the rigid dosing protocol and potential fluid overload. 1

Mechanism and Rationale

Albumin works by:

• Expanding effective arterial blood volume 2
• Reducing plasma renin activity (patients treated with antibiotics alone had significantly higher renin levels) 2
• Preventing the circulatory dysfunction that precipitates hepatorenal syndrome 1

The mortality benefit persists at 3 months (22% vs 41% mortality with vs without albumin). 2

Critical Implementation Points

Administer albumin immediately upon SBP diagnosis alongside antibiotics—do not delay. 1 The combination therapy must start together, as albumin prevents the renal impairment that develops during infection treatment. 2

Discontinue diuretics when SBP is diagnosed in any patient with rising creatinine. 1, 4 In cirrhotic patients specifically, both diuretics AND beta-blockers should be stopped. 4

Monitor volume status carefully during albumin infusion. The 2024 guidelines express concern that the 1.5 g/kg + 1.0 g/kg protocol (which can exceed 200g total albumin in larger patients) may cause fluid overload, particularly in patients with cardiovascular compromise. 1 Assess cardiovascular status, jugular venous pressure, and lung examination before each dose. 1

Alternative Approaches (Emerging Evidence)

A 2016 randomized trial found that terlipressin alone or low-dose albumin plus terlipressin achieved similar outcomes to standard-dose albumin in high-risk SBP patients (those with bilirubin >4 or creatinine >1). 5 However, this represents a single study and has not been incorporated into major guidelines. The established standard remains full-dose albumin. 1

Common Pitfalls to Avoid

Do not use crystalloids or hydroxyethyl starch as substitutes for albumin in SBP. Albumin improves circulatory function in SBP patients while equivalent doses of hydroxyethyl starch show no such benefit. 1

Do not assume albumin is beneficial for all cirrhotic infections. When albumin was studied in cirrhotic patients with extraperitoneal infections (non-SBP bacterial infections), it showed no benefit and raised concerns for harm. 1 Albumin's proven benefit is specific to SBP. 1

Renal impairment after SBP carries extremely poor prognosis: mortality reaches 100% with progressive renal dysfunction, 58% with steady dysfunction, versus only 3% with transient or no dysfunction. 3 This underscores why preventing renal impairment with albumin is critical. 3

Monitoring Protocol

• Measure serum creatinine every 2-4 days during hospitalization 4
• Perform repeat paracentesis at 48 hours to confirm infection resolution (PMN count <250/mm³) 1, 6
• If creatinine continues rising despite albumin and antibiotics after 48 hours, consider hepatorenal syndrome and initiate vasoconstrictors (terlipressin or norepinephrine) 1, 4