Contributor: Travis Barlock MD

Educational Pearls:

• There are three indications for IV albumin in the ED

• Spontaneous bacterial peritonitis (SBP)

• Patients with SBP develop renal failure from volume depletion

• Albumin repletes volume stores and reduces renal impairment

• Albumin binds inflammatory cytokines and expands plasma volume

• Reduced all-cause mortality if IV albumin is given with antibiotics

• Hepatorenal syndrome

• Cirrhosis of the liver causes the release of endogenous vasodilators

• The renin-angiotensin-aldosterone system (RAAS) fails systemically but maintains vasoconstriction at the kidneys, leading to decreased renal perfusion

• IV albumin expands plasma volume and prevents failure of the RAAS

• Large volume paracentesis

• Large-volume removal may lead to circulatory dysfunction

• IV albumin is associated with a reduced risk of paracentesis-associated circulatory dysfunction

• There are many other FDA-approved conditions for which to use exogenous albumin but the data are conflicted about the benefits on mortality

References

1. Arroyo V, Fernandez J. Pathophysiological basis of albumin use in cirrhosis. Ann Hepatol. 2011;10(SUPPL. 1):S6-S14. doi:10.1016/s1665-2681(19)31600-x

2. Bai Z, Wang L, Wang R, et al. Use of human albumin infusion in cirrhotic patients: a systematic review and meta-analysis of randomized controlled trials. Hepatol Int. 2022;16(6):1468-1483. doi:10.1007/s12072-022-10374-z

3. Batool S, Waheed MD, Vuthaluru K, et al. Efficacy of Intravenous Albumin for Spontaneous Bacterial Peritonitis Infection Among Patients With Cirrhosis: A Meta-Analysis of Randomized Control Trials. Cureus. 2022;14(12). doi:10.7759/cureus.33124

4. Kwok CS, Krupa L, Mahtani A, et al. Albumin reduces paracentesis-induced circulatory dysfunction and reduces death and renal impairment among patients with cirrhosis and infection: A systematic review and meta-analysis. Biomed Res Int. 2013;2013. doi:10.1155/2013/295153

5. Sort P, Navasa M, Arroyo V, et al. Effect of Intravenous Albumin on Renal Impairment and Mortality in Patients with Cirrhosis and Spontaneous Bacterial Peritonitis. N Engl J Med. 1999;341(6):403-409.

Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit