Albumin for bacterial infections other than spontaneous bacterial peritonitis in cirrhosis. A randomized, controlled study

Background & Aims

Treatment with albumin in patients with cirrhosis and spontaneous bacterial peritonitis (SBP) prevents renal failure and improves survival. Whether albumin has similar beneficial effects in patients with infections other than SBP is unknown.

Methods

One hundred and ten patients with cirrhosis hospitalized for infections other than SBP were randomly assigned to receive antibiotics plus albumin (1.5 g/kg bw at diagnosis and 1 g/kg bw at day 3) (albumin group; n = 56) or antibiotics alone (control group; n = 54). The primary end point was survival at 3 months. Secondary end points were effects on renal and circulatory function.

Results

The renal function, as evaluated by differences in changes in serum creatinine and estimated glomerular filtration rate between the two groups, improved in patients treated with albumin. The circulatory function improved significantly in patients treated with albumin, but not in those from the control group. There was a trend for a lower frequency of type 1 hepatorenal syndrome in the albumin group compared to the control group (1 vs. 4 patients, respectively; p = n.s.). Probability of survival at 3 months was not significantly different among the two groups. However, when adjusted for factors with independent prognostic value, treatment with albumin was an independent predictive factor of survival.

Conclusions

As compared with standard antibiotic therapy alone, treatment with albumin together with antibiotics has beneficial effects on the renal and circulatory function and shows a potential survival benefit. Further studies with large sample sizes should be performed to confirm these findings.

Introduction

Bacterial infections are very common in advanced cirrhosis and represent a major cause of hospitalizations and death [1], [2], [3], [4]. The occurrence of renal failure is one of the main complications of spontaneous bacterial peritonitis (SBP) and a major prognostic factor [5], [6], [7], [8], [9], [10]. Renal failure is also common in patients with infections other than SBP and its occurrence is associated with an increased risk of death [11], [12], [13].

In patients with SBP, renal failure is related to an impairment of the circulatory function, which is characterized by a marked increase in the activity of vasoconstrictor systems due to both a reduction in systemic vascular resistance and a decrease in cardiac output [14], [15]. The reduction in systemic vascular resistance is likely related to endothelial dysfunction caused by a massive release of inflammatory mediators [5], [6], [15], [16], [17]. The decrease in cardiac output is possibly related to the worsening of a preexisting cirrhotic cardiomyopathy, together with a sepsis-related impairment of cardiac function. In patients with infections other than SBP, renal failure also appears to be related to impairment of circulatory function, yet only limited information is available [7], [12].

In patients with SBP, the administration of albumin prevents the deleterious effects on circulatory function and the development of renal failure, and improves survival [15], [18], [19]. The beneficial effects of albumin are likely related to its capacity to increase intravascular volume, improve endothelial dysfunction, and/or other biological properties [15], [18], [20], [21], [22]. Guidelines recommend the administration of albumin to patients with SBP [23], [24], [25], [26]. It is unknown whether albumin is also effective in preventing circulatory and renal failure and improving outcome in patients with bacterial infections other than SBP. The current study was designed to address this question.