Human Albumin Injection in Spontaneous Bacterial Peritonitis (SBP)

UptoDate: Spontaneous bacterial peritonitis in adults: Treatment and prophylaxis

Renal failure develops in 30 to 40 percent of patients with SBP and is a major cause of death. The risk may be decreased with an infusion of intravenous albumin (1.5 g per kg body weight within six hours of diagnosis and 1.0 g/kg body weight on day three). Albumin infusion should be given if the creatinine is >1 mg/dL (88 micromol/L), the blood urea nitrogen is >30 mg/dL (10.7 mmol/L), or the total bilirubin is >4 mg/dL (68 micromol/L). Once renal failure has developed, treatment with a combination of octreotide and midodrine may be helpful, in addition to infusion of 25 grams of 25 percent albumin daily, unless there is massive fluid overload.

The development of renal failure is associated with activation of the renin-angiotensin system and a decrease in effective arterial volume. Thus, it has been hypothesized that plasma volume expansion could attenuate the hemodynamic changes in patients with SBP, thereby preserving renal function and hence reduce mortality. A meta-analysis of four randomized trials (with a total of 288 patients) by Salerno et al. 2013 evaluated the impact of albumin infusion (in addition to antibiotics) on renal impairment and mortality in patients with SBP. Albumin infusion was associated with a significant decrease in the incidence of renal impairment (8 versus 31 percent) and a significant reduction in mortality (16 versus 35 percent).

EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis

A randomized, controlled study in patients with SBP treated with cefotaxime showed that albumin (1.5 g/kg body weight at diagnosis, followed by 1 g/kg on day 3) significantly decreased the incidence of type 1 HRS (from 30% to 10%) and reduced mortality from 29% to 10% compared with cefotaxime alone.

Treatment with albumin was particularly effective in patients with baseline serum bilirubin ≥68 mcmol/L (4 mg/dl) or serum creatinine ≥88 mcmol/L (1 mg/dl). It is unclear whether intravenous albumin is useful in patients with baseline bilirubin <68 mcmol/L and creatinine <88 mcmol/L, as the incidence of type 1 HRS was very low in the two treatment groups (7% without albumin and 0% with albumin).

It is not known whether crystalloids or artificial colloids could replace albumin in the prevention of HRS in patients with SBP. Albumin improves circulatory function in patients with SBP while equivalent doses of hydroxyethyl starch have no such beneficial effect.

Therefore, the EASL guidelines summarises that:

• ·         Hepatorenal syndrome (HRS) occurs in approximately 30% of patients with SBP treated with antibiotics alone, and is associated with a poor survival.
• ·         The administration of albumin (1.5 g/kg at diagnosis and 1g/kg on day 3) decreases the frequency of HRS and improves survival (Level A1).
• ·         It is unclear whether albumin is useful in the subgroup of patients with baseline serum bilirubin <68 mcmol/L and creatinine <88 mcmol/L (Level B2).
• ·         Until more information is available, we recommend that all patients who develop SBP should be treated with broad spectrum antibiotics and intravenous albumin (Level A2).

Guideline	Recommended Dosages of Human Albumin Injection for SBP
UptoDate [Accessed 19 August 2019]	1.5 g/kg body weight within six hours of diagnosis and 1.0 g/kg body weight on day three
Clinical Guidelines for Human Albumin Use (NHS Scotland 2016)	Day 1: 1.5g HAS / kg given over a 6 hour period: Day 3: 1g HAS / kg given over 3 hours (high risk of mortality defined as: urea ≥11 mmol/L and/or bilirubin ≥ 68 mcmol/L)
Guidelines for Intravenous Albumin Administration at Stanford Health Care (Stanford Health Care 2017)	1.5 g/kg within 6-hours of detection (day 1) and 1 g/kg on day 3 *
Albumin – Adult – Inpatient Clinical Practice Guideline (University of Wisconsin Hospitals 2018)	Dose: 1.5 g/kg on day 1, followed by 1 g/kg on day 3. Maximum daily dose: 100 g (400 mL) *
EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis 2010	1.5 g/kg at diagnosis and 1g/kg on day 3
Evidence-based Guidelines for the Use of Albumin Products (Japan Society of Transfusion Medicine and Cell Therapy 2017)	1.5 g per kilogram of body weight within 6 hours after diagnosis, followed by 1 g per kilogram of body weight on day 3 of illness
Guideline for the use of human albumin solution (Guy’s and St. Thomas’ 2015)	Day 1 and 2: 1.5g/kg Day 3 onwards: 1g/kg until significant improvement in the patients clinical condition

*Use 25%.

References:

1. UptoDate: Spontaneous bacterial peritonitis in adults: Treatment and prophylaxis  [Accessed 19 August 2019]
2. NHS Services Scotland: National Plasma Products Expert Advisory Group. Clinical Guidelines for Human Albumin Use.
3. Weinacker A & Ang H. Guidelines for Intravenous Albumin Administration at Stanford Health Care. 2017. Stanford Health Care.
4. Retter et al. Guideline for the use of human albumin solution (HAS). 2015. Guy’s and St. Thomas’ NHS Foundation Trust.
5. Fish et al.  Albumin – Adult – Inpatient Clinical Practice Guideline. 2018.  University of Wisconsin Hospitals and Clinics Authority
6. European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. Journal of Hepatology 2010 vol. 53 j 397–417.