My patient with spontaneous bacterial peritonitis (SBP) is requiring IV albumin. Does IV albumin do anything other than expand the plasma volume?

FA Manian MD, MPH, , , ,

Yes! Besides expanding the circulatory plasma volume by raising the oncotic pressure, albumin appears to have a vasoconstricting effects by binding to endotoxins, nitric oxide (NO), bilirubin and fatty acids1,2.

Splanchnic vasodilatation, a feature of decompensated cirrhosis (eg ascites, bleeding varices, hepatorenal syndrome, and hepatic encephalopathy), is accentuated by superimposed infections through cytokine-mediated release of endothelial vasodilators3.  By binding to potential vasodilators such as bile acids, endotoxins and NO, albumin may also help restore endothelial function and act as a vasoconstrictor.  

In a cool study involving patients with SBP randomized to either albumin or hydroxyethyl starch (HS, a synthetic volume expander), the albumin (not HS) group had a significant increase in mean arterial pressure, right atrial pressure, pulmonary artery pressure,  systolic volume, left ventricular stroke work, and systemic vascular resistance3.

Albumin may also have an immune-modulating activity in patients with cirrhosis or acute liver decompensation by binding to prostaglandin E-2 (PGE-2), generated as a result of inflammatory reaction in the liver and bacterial translocation4.  PGE-2 is a suppressor of macrophage cytokine secretion and bacterial killing.  By binding to PGE-2, albumin can reverse this immunosuppression by reducing the availability of serum PGE-2.

References

  1. Baraldi O, Valenini C, Donati G, et al. Hepatorenal syndrome: update on diagnosis and treatment 2015;4:511-20. https://www.ncbi.nlm.nih.gov/pubmed/26558188
  2. Angeli P, Volpin R, Piovan D, et al. Acute effects of the oral administration of midodrine, an α-adrenergic agonist, on renal hemodynamics and renal function in cirrhotic patients with ascites. Hepatology 1998;28:937-43. https://www.ncbi.nlm.nih.gov/pubmed/9755229
  3. Fernandez J, Monteagudo J, Bargallo X, et al. A randomized unblended pilot study comparing albumin versus hydroxyethyl starch in spontaneous bacterial peritonitis. Hepatology 2005;42:627-634. https://www.ncbi.nlm.nih.gov/pubmed/16108036
  4. Gleeson, MW, Dickson RC. Albumin gains immune boosting credibility. Clin Transl 2015;6:e86;doi:10.1038/ctg.2015.11. http://www.nature.com/ctg/journal/v6/n4/full/ctg201511a.html
My patient with spontaneous bacterial peritonitis (SBP) is requiring IV albumin. Does IV albumin do anything other than expand the plasma volume?

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