Albumin Dosing in Spontaneous Bacterial Peritonitis

Standard Two‑Dose Regimen

In adults with cirrhosis and spontaneous bacterial peritonitis (SBP), give 1.5 g/kg intravenous albumin within 6 hours of diagnosis (Day 1) followed by 1.0 g/kg on Day 3; this fixed schedule should not be altered. 1
The albumin regimen is administered together with standard anti‑pseudomonal antibiotics (e.g., ceftriaxone or cefotaxime). 2

In a landmark randomized controlled trial, the two‑dose schedule reduced the incidence of acute kidney injury from 33 % (antibiotics alone) to 10 % (albumin + antibiotics). High‑quality evidence (Level A). 1
The same trial showed a decrease in in‑hospital mortality from 29 % to 10 % with the albumin protocol. High‑quality evidence (Level A). 1
The Day 3 dose specifically mitigates the ongoing inflammatory response and prevents late‑onset renal deterioration even after the infection has been cleared. Moderate evidence (Level B). 1

Patients with elevated bilirubin (approximately >4 mg/dL), baseline creatinine >1.0 mg/dL, or blood urea nitrogen >30 mg/dL experience the most pronounced protection against hepatorenal syndrome and should be prioritized for the standard two‑dose regimen. Moderate evidence (Level B). 1

Albumin should be infused slowly to avoid cardiac overload, particularly in individuals with cirrhotic cardiomyopathy. Moderate evidence (Level B). 2
Recognized adverse effects of the protocol include pulmonary edema, fluid overload, hypotension or tachycardia, and other respiratory complications. Moderate evidence (Level B). 1

A small study demonstrated that a reduced dose of 10 g/day for days 1–3 lowered renal dysfunction (7 % vs 20 %) and mortality (27 % vs 40 %) compared with no albumin, indicating that the standard regimen is already sufficient and that higher or additional doses provide no extra benefit. Low‑to‑moderate evidence (Level C). 1

Three randomized trials and a meta‑analysis found that albumin administered for non‑SBP infections (e.g., pneumonia, urinary tract infection) did not reduce acute kidney injury or mortality and was linked to a higher rate of pulmonary edema; therefore, albumin should be reserved for SBP only. High‑quality evidence (Level A). 1

The American Association for the Study of Liver Diseases recommends albumin administration during large-volume paracentesis (>5L) at a dose of 6-8 g/L of ascites removed to prevent post-paracentesis circulatory dysfunction 3, 4, 5
For paracentesis <5L, the risk of developing circulatory dysfunction is low, though some guidelines still recommend albumin administration 6
It's preferable to limit ascites removal to <8L during a single paracentesis procedure to reduce complications 6

The European Association for the Study of the Liver recommends IV albumin (1.5 g/kg on day 1 and 1 g/kg on day 3) should be administered with antibiotics in patients with SBP 7, 8
This combination significantly reduces the incidence of acute kidney injury (10% vs 33%) and mortality (10% vs 29%) compared to antibiotics alone 7, 9
Patients with serum bilirubin >4 mg/dL and baseline kidney dysfunction are most likely to benefit from albumin administration 7, 8

Albumin administration can cause fluid overload, pulmonary edema, hypotension/tachycardia, nausea/vomiting, rigors, pyrexia, and rash/pruritus 5, 7
These adverse events are generally dose-dependent but can occur even with lower doses 7

Treatment of underlying inflammation with appropriate medications is recommended 5
Surgical intervention when indicated is also recommended 4