ALBUMIN VERSUS CRYSTALLOIDS IN PATIENTS WITH CIRRHOSIS AND SPONTANEOUS BACTERIAL PERITONITIS: A SYSTEMATIC REVIEW
DOI:
https://doi.org/10.56238/levv17n60-048Keywords:
Liver Cirrhosis, Peritonitis, Albumins, Acute Kidney InjuryAbstract
Introduction: Spontaneous bacterial peritonitis is a severe infectious complication of decompensated cirrhosis and is strongly associated with acute kidney injury, hepatorenal syndrome, short-term mortality, and prolonged hospitalization. Albumin has been proposed as a disease-specific adjunct to antibiotic therapy because it may improve effective arterial blood volume, renal perfusion, and systemic circulatory stability, whereas crystalloids provide less sustained intravascular expansion in the pathophysiological context of advanced cirrhosis.
Objective: The main objective of this systematic review was to evaluate the efficacy and safety of albumin compared with crystalloid-based or non-albumin supportive strategies in patients with cirrhosis and spontaneous bacterial peritonitis. Secondary objectives were to assess renal outcomes, mortality, dosing strategies, timing of administration, adherence to guideline-concordant therapy, and certainty of evidence.
Methods: PubMed, Scopus, Web of Science, Cochrane Library, LILACS, ClinicalTrials.gov, and the International Clinical Trials Registry Platform were searched for studies evaluating albumin, crystalloid-based supportive care, usual care, dosing strategies, timing, implementation, or clinical outcomes in cirrhosis with spontaneous bacterial peritonitis. Randomized trials, observational comparative studies, implementation studies, dosing studies, and meta-analyses were eligible. Risk of bias was assessed using RoB 2, ROBINS-I, and QUADAS-2 when applicable, and certainty of evidence was judged using the GRADE framework.
Results and Discussion: Ten studies were included in the final qualitative synthesis. The evidence consistently supported albumin-based therapy as an adjunct to antibiotics in high-risk spontaneous bacterial peritonitis, particularly for reducing renal dysfunction, hepatorenal syndrome, and short-term mortality. No contemporary randomized trial directly compared guideline-dose albumin with a standardized crystalloid-only strategy, making indirectness a major limitation. Recent evidence emphasized implementation quality, early administration, dosing optimization, and persistent underuse of guideline-concordant albumin therapy in real-world practice.
Conclusion: Albumin should remain the preferred adjunctive fluid strategy for patients with cirrhosis and spontaneous bacterial peritonitis who are at high risk of renal dysfunction or death, while crystalloids remain appropriate for immediate stabilization in shock or overt hypovolemia. Future trials should directly compare standard-dose, reduced-dose, capped-dose, and crystalloid-dominant approaches within clearly defined risk strata.
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