Is there still a need for albumin infusions to treat patients with liver disease?

Is there still a need for albumin infusions to treat patients with liver disease? The course of patients with cirrhosis is frequently complicated by derangement of body fluid homeostasis which results in accumulation of large amounts of extracellular fluid in the peritoneal cavity and interstitial tissue. 1 Investigations performed in the 1940s proposed that the formation of ascites and oedema was related to an imbalance in Starling's equilibrium in splanchnic and sys-temic capillaries caused by increased hydrostatic pressure due to portal hypertension and reduced oncotic pressure because of the low serum albumin levels characteristic of cirrhosis, which would favour the passage of fluid from the intravascular compartment to the interstitial tissue. 2–4 Later studies showed that patients with cirrhosis and ascites have marked circulatory dysfunction, characterised mainly by low systemic vascular resistance and arterial pressure, abnormal distribution of blood volume, with reduced central blood volume, and marked stimulation of vasoconstric-tor and antinatriuretic systems (that is, the renin-angiotensin-aldosterone system and sympathetic nervous system). 5 6 In some patients this circulatory dysfunction is so intense that renal perfusion is greatly reduced leading to severe impairment of renal function, a condition known as hepatorenal syndrome. 7 Considering all of these factors it is not surprising that albumin infusions have been used for many years in the management of patients with cirrhosis and ascites in an attempt to reduce the formation of ascites and/or improve circulatory and renal function. 8 In the current decade the use of albumin in cirrhosis has regained attention because of the demonstration that patients with large ascites can be treated safely with large volume paracentesis associated with albumin infusions. 9 While some of these indications for albumin infusions are supported by the results of randomised studies, others are based on clinical experience and have not been proved in prospective investigations. Therefore, the use of albumin infusions in patients with cirrhosis is controversial. Recently, this debate has been fostered by the high cost and limited availability of albumin and the results of a meta-analysis showing that albumin administration may increase mortality in critically ill patients. 10 This article will review the use of albumin infusions in the management of patients with cirrhosis and ascites on the basis of the current knowledge of the pathogenesis of ascites and renal dysfunction in cirrhosis. The information given does not apply to the clinical situation of patients with cirrhosis and dehydration because of excessive …