Renal Failure Risk Is Key in Albumin for Spontaneous Bacterial Peritonitis

SAN DIEGO – Cirrhotics with spontaneous bacterial peritonitis probably need albumin only if their total bilirubin is above 4 mg/dL and/or their blood urea nitrogen (BUN) is above 30 mg/dL, according to transplant hepatologist Dr. James Burton.

Supplementation expands plasma volume to attenuate the splanchnic and systemic vasodilation associated with spontaneous bacterial peritonitis (SBP), increasing blood flow to the kidneys and preserving renal function, said Dr. Burton, medical director of liver transplantation at the University of Colorado Hospital, Aurora.

But it seems to be needed only when SBP patients are at high risk for renal failure, according to two studies.

The first randomized 63 cirrhotic SBP patients to cefotaxime alone and 63 to cefotaxime plus albumin, 1.5 g/kg on day 1 and 1.0 g/kg on day 3. The regimen wiped out the infection in most patients. Renal impairment and mortality were significantly lower in the albumin group, but only patients with total baseline bilirubins above 4 mg/dL and/or BUNs greater than 30 mg/dL benefited from albumin, Dr. Burton said (N. Engl. J. Med. 1999;341:403-9).

A follow-up 28-subject study limited albumin supplementation, again 1.5 g/kg on day 1 and 1.0 g/kg on day 3, to SBP patients with similar parameters or creatinines above 1 mg/dL. It was the right choice; none of the 15 patients with lower baseline values developed renal impairment, Dr. Burton said (Gut 2007;56:597-9).

He noted that it’s possible for patients to have SBP without obvious symptoms, so "if you’re sick enough to have cirrhosis and be in the hospital, you need a needle in your abdomen to rule out" the condition.

In general, cirrhotics have low levels of albumin, which is responsible for about 80% of plasma’s oncotic pressure. Also, what they have "may not work as well" to transport fatty acids, hormones, and enzymes, and drugs.

Outpatient supplementation for cirrhotics not only seems to reduce the need for paracentesis, but also makes patients feel better. "I am a believer because my patients tell me it works. Some of my patients refer to it as ‘nectar of the gods.’ This is more than just the oncotic things. I also think they are transporting hormones, carrying drugs, and other stuff better. So I am a big believer," Dr. Burton said.

He opts for 25% albumin instead of 5%, to reduce fluid load and also because "there is a lot of sodium in 5% albumin. Obviously, these patients need to have their sodium restricted," he said.

When paracentesis is needed, "studies suggest you can probably [remove] 4-6 liters without giving albumin." Even so, "we often give albumin during paracentesis," he said.

Dr. Burton said he has no relevant financial disclosures.

SAN DIEGO – Cirrhotics with spontaneous bacterial peritonitis probably need albumin only if their total bilirubin is above 4 mg/dL and/or their blood urea nitrogen (BUN) is above 30 mg/dL, according to transplant hepatologist Dr. James Burton.

Supplementation expands plasma volume to attenuate the splanchnic and systemic vasodilation associated with spontaneous bacterial peritonitis (SBP), increasing blood flow to the kidneys and preserving renal function, said Dr. Burton, medical director of liver transplantation at the University of Colorado Hospital, Aurora.

But it seems to be needed only when SBP patients are at high risk for renal failure, according to two studies.

The first randomized 63 cirrhotic SBP patients to cefotaxime alone and 63 to cefotaxime plus albumin, 1.5 g/kg on day 1 and 1.0 g/kg on day 3. The regimen wiped out the infection in most patients. Renal impairment and mortality were significantly lower in the albumin group, but only patients with total baseline bilirubins above 4 mg/dL and/or BUNs greater than 30 mg/dL benefited from albumin, Dr. Burton said (N. Engl. J. Med. 1999;341:403-9).

A follow-up 28-subject study limited albumin supplementation, again 1.5 g/kg on day 1 and 1.0 g/kg on day 3, to SBP patients with similar parameters or creatinines above 1 mg/dL. It was the right choice; none of the 15 patients with lower baseline values developed renal impairment, Dr. Burton said (Gut 2007;56:597-9).

He noted that it’s possible for patients to have SBP without obvious symptoms, so "if you’re sick enough to have cirrhosis and be in the hospital, you need a needle in your abdomen to rule out" the condition.

In general, cirrhotics have low levels of albumin, which is responsible for about 80% of plasma’s oncotic pressure. Also, what they have "may not work as well" to transport fatty acids, hormones, and enzymes, and drugs.

Outpatient supplementation for cirrhotics not only seems to reduce the need for paracentesis, but also makes patients feel better. "I am a believer because my patients tell me it works. Some of my patients refer to it as ‘nectar of the gods.’ This is more than just the oncotic things. I also think they are transporting hormones, carrying drugs, and other stuff better. So I am a big believer," Dr. Burton said.

He opts for 25% albumin instead of 5%, to reduce fluid load and also because "there is a lot of sodium in 5% albumin. Obviously, these patients need to have their sodium restricted," he said.

When paracentesis is needed, "studies suggest you can probably [remove] 4-6 liters without giving albumin." Even so, "we often give albumin during paracentesis," he said.

Dr. Burton said he has no relevant financial disclosures.

SAN DIEGO – Cirrhotics with spontaneous bacterial peritonitis probably need albumin only if their total bilirubin is above 4 mg/dL and/or their blood urea nitrogen (BUN) is above 30 mg/dL, according to transplant hepatologist Dr. James Burton.

Supplementation expands plasma volume to attenuate the splanchnic and systemic vasodilation associated with spontaneous bacterial peritonitis (SBP), increasing blood flow to the kidneys and preserving renal function, said Dr. Burton, medical director of liver transplantation at the University of Colorado Hospital, Aurora.

But it seems to be needed only when SBP patients are at high risk for renal failure, according to two studies.

The first randomized 63 cirrhotic SBP patients to cefotaxime alone and 63 to cefotaxime plus albumin, 1.5 g/kg on day 1 and 1.0 g/kg on day 3. The regimen wiped out the infection in most patients. Renal impairment and mortality were significantly lower in the albumin group, but only patients with total baseline bilirubins above 4 mg/dL and/or BUNs greater than 30 mg/dL benefited from albumin, Dr. Burton said (N. Engl. J. Med. 1999;341:403-9).

A follow-up 28-subject study limited albumin supplementation, again 1.5 g/kg on day 1 and 1.0 g/kg on day 3, to SBP patients with similar parameters or creatinines above 1 mg/dL. It was the right choice; none of the 15 patients with lower baseline values developed renal impairment, Dr. Burton said (Gut 2007;56:597-9).

He noted that it’s possible for patients to have SBP without obvious symptoms, so "if you’re sick enough to have cirrhosis and be in the hospital, you need a needle in your abdomen to rule out" the condition.

In general, cirrhotics have low levels of albumin, which is responsible for about 80% of plasma’s oncotic pressure. Also, what they have "may not work as well" to transport fatty acids, hormones, and enzymes, and drugs.

Outpatient supplementation for cirrhotics not only seems to reduce the need for paracentesis, but also makes patients feel better. "I am a believer because my patients tell me it works. Some of my patients refer to it as ‘nectar of the gods.’ This is more than just the oncotic things. I also think they are transporting hormones, carrying drugs, and other stuff better. So I am a big believer," Dr. Burton said.

He opts for 25% albumin instead of 5%, to reduce fluid load and also because "there is a lot of sodium in 5% albumin. Obviously, these patients need to have their sodium restricted," he said.

When paracentesis is needed, "studies suggest you can probably [remove] 4-6 liters without giving albumin." Even so, "we often give albumin during paracentesis," he said.

Dr. Burton said he has no relevant financial disclosures.