Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis

Background In patients with cirrhosis and spontaneous bacterial peritonitis , renal function frequently becomes impaired. This impairment is probably r elated to a reduction in effective arterial blood volume and is associated with a high mortality rate. We conducted a study to determine whether plasm a volume expansion with intravenous albumin prevents renal impairment and r educes mortality in these patients. Methods We randomly assigned 126 patients with cirrhosis and spontaneous ba cterial peritonitis to treatment with intravenous cefotaxime (63 patients) or cefotaxime and intravenous albumin (63 patients). Cefotaxime was given d aily in doses that varied according to the serum creatinine level, and albu min was given at a dose of 1.5 g per kilogram of body weight at the time of diagnosis, followed by 1 g per kilogram on day 3. Renal impairment was def ined as nonreversible deterioration of renal function during hospitalizatio n. Results The infection resolved in 59 patients in the cefotaxime group (94 p ercent) and 62 in the cefotaxime-plus-albumin group (98 percent) (P=0.36). Renal impairment developed in 21 patients in the cefotaxime group (33 perce nt) and 6 in the cefotaxime-plus-albumin group (10 percent) (P=0.002). Eigh teen patients (29 percent) in the cefotaxime group died in the hospital, as compared with 6(10 percent) in the cefotaxime-plus-albumin group (P=0.01); at three months, the mortality rates were 41 percent (a total of 26 deaths ) and 22 percent (a total of 14 deaths), respectively (P=0.03). Patients tr eated with cefotaxime had higher levels of plasma renin activity than those treated with cefotaxime and albumin; patients with renal impairment had th e highest values. Conclusions In patients with cirrhosis and spontaneous bacterial peritoniti s, treatment with intravenous albumin in addition to an antibiotic reduces the incidence of renal impairment and death in comparison with treatment wi th an antibiotic alone. (N Engl J Med 1999;341:403-9.) (C) 1999, Massachuse tts Medical Society.