Does the evidence support a survival benefit of albumin infusion in patients with cirrhosis undergoing large-volume paracentesis?

Ascites is a major complication of cirrhosis and is associated with poor prognosis [1]. Large-volume paracentesis (LVP) has become first-line treatment for patients with tense (grade 3) or refractory ascites. However, LVP markedly influences systemic hemodynamics and, in the absence of concomitant plasma volume expansion, >70% of patients undergoing LVP may develop paracentesis-induced circulatory dysfunction (PICD). This is associated with ascites recurrence, hepatic encephalopathy, hepatorenal syndrome, hyponatremia, and reduced survival. Human albumin is a physiological plasma expander used for LVP and can significantly reduce incidence of PICD. Albumin was also shown to be favorable versus alternative treatments (such as plasma expanders or vasoconstrictors) in minimizing PICD, hyponatremia, and mortality among patients with cirrhosis and ascites undergoing LVP in a meta-analysis conducted by our group in 2012. However, these results have been questioned by a recent meta-analysis investigating the effect of albumin on morbidity, performed by Kütting et al. [7]. Here, we critically analyze the evidence from Kütting et al. and other recent metaanalyses assessing use of albumin in LVP.