Correspondence

Intravenous Albumin in Patients with Cirrhosis and Spontaneous Bacterial Peritonitis

N Engl J Med 1999; 341:1773-1774December 2, 1999

Article

To the Editor:

Patients in whom sepsis develops, particularly those who also have cirrhosis, are prone to the development of renal failure secondary to peripheral vasodilatation and subsequent renal arterial vasoconstriction. Sort et al. (Aug. 5 issue)1 reported on the effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. They found that in such patients, inadequate fluid resuscitation may result in further deterioration in renal function. This is not a new concept in medicine.

In their study, central venous pressure was measured in only 15 patients, yet renal impairment developed in 27. Seven patients with tense ascites underwent partial paracentesis, yet three of these patients did not receive albumin-replacement therapy — a practice known to precipitate renal failure and one that is contrary to the previous recommendation of this group.2 No details are given with regard to the fluid management of the group that received cefotaxime alone, other than the evidence that they had intravascular volume depletion, as reflected by the elevated plasma renin activity. Details of vasoconstrictor therapy are also not provided. Before one can recommend 20 percent albumin as the fluid-replacement therapy of choice — and this recommendation may be appropriate — one must demonstrate that the control group received standard medical treatment, and Sort et al. do not provide this information.

David Patch, M.D.
Andrew Burroughs, M.D.
Royal Free Hospital National Health Service Trust, London NW3 2QG, United Kingdom

2 References

1. 1

   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;341:403-409
   Full Text | Web of Science | Medline

2. 2

   Gines P, Tito L, Arroyo V, et al. Randomized comparative study of therapeutic paracentesis with and without intravenous albumin in cirrhosis. Gastroenterology 1988;94:1493-1502
   Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Patch and Burroughs hypothesize that the beneficial effect of albumin on renal function and mortality in our study was due to the fact that patients in the group given cefotaxime and albumin received adequate fluid therapy, whereas patients in the group given cefotaxime alone had intravascular volume depletion as a consequence of an inappropriately low level of administration of fluids. Intravascular volume depletion would have caused renal hypoperfusion, with subsequent renal failure and increased mortality.

To date, there are no data to support the concept that spontaneous bacterial peritonitis itself is associated with a reduction in plasma volume, unless patients have diarrhea or ileus or have had excessive diuresis during the preceding days. We specifically looked for all these conditions. Patients with these associated conditions were excluded from the study, as stated in the Methods section, and were treated with antibiotics and plasma expansion. Therefore, the participants had no signs or symptoms and no clinical history of conditions associated with real hypovolemia. The increase in plasma renin activity in our patients reflects a reduced effective arterial blood volume, which is a widely recognized characteristic of advanced cirrhosis with ascites.1 This reduced effective arterial blood volume indicates the existence of a severely dilated vascular tree and not a reduction in plasma volume, which is, in fact, increased in patients with cirrhosis and ascites. Finally, all patients received standard medical care during their hospitalization, including adequate administration of intravenous fluids. Special attention was paid to the administration of intravenous fluids in the case of patients who were not able to take fluids orally.

For all these reasons, it is extremely unlikely that the higher incidence of renal impairment and mortality observed in the group given cefotaxime alone was due to an inappropriately low level of administration of fluids. In fact, the incidence of renal impairment and the mortality rate in the group given cefotaxime alone are similar to those reported in most series,2 whereas the incidence of renal impairment and the mortality rate in the albumin group are the lowest we are aware of in a series of patients with cirrhosis and spontaneous bacterial peritonitis.

Pau Sort, M.D.
Pere Ginès, M.D.
Vicente Arroyo, M.D.
Hospital Clínic de Barcelona, 8036 Barcelona, Spain

2 References

1. 1

   Arroyo V, Ginès G, Jiménez W, Rodès J. Renal dysfunction in cirrhosis. In: Bircher J, Benhamou JP, McIntyre N, Rizzetto M, Rodès J, eds. Oxford textbook of clinical hepatology. New York: Oxford University Press, 1999:733-61.
   

2. 2

   Rimola A, Navasa M. Infections in liver disease. In: Bircher J, Benhamou JP, McIntyre N, Rizzetto M, Rodès J, eds. Oxford textbook of clinical hepatology. New York: Oxford University Press, 1999:1861-74.
   

Citing Articles (5)

Citing Articles

1. 1

   Juan M Canabal, David J Kramer. (2008) Management of sepsis in patients with liver failure. Current Opinion in Critical Care 14:2, 189-197
   CrossRef

2. 2

   Florence Wong. (2007) Drug Insight: the role of albumin in the management of chronic liver disease. Nature Clinical Practice Gastroenterology & Hepatology 4:1, 43-51
   CrossRef

3. 3

   G. Marx. (2005) Fluid therapy in sepsis with capillary leakage. European Journal of Anaesthesiology 20:6, 429
   CrossRef

4. 4

   A.K Burroughs. (2003) Is the use of albumin of value in cirrhosis?. Digestive and Liver Disease 35:9, 664-667
   CrossRef

5. 5

   G. Marx. (2003) Fluid therapy in sepsis with capillary leakage. European Journal of Anaesthesiology 20:6, 429-442
   CrossRef