plasma substitutes


Summary: Any liquid used to replace blood plasma, usually a saline solution, often with serum albumins, dextrans or other preparations. These substances do not enhance the oxygen- carrying capacity of blood, but merely replace the volume. They are also used to treat dehydration.

Top Publications

  1. Boldt J, Suttner S. Plasma substitutes. Minerva Anestesiol. 2005;71:741-58 pubmed
    ..because aside of the natural colloid albumin several non-protein (synthetic) colloids are available as plasma substitutes (e.g. dextrans, gelatins, hydroxyethyl starch [HES] solutions)...
  2. Schramko A, Suojaranta Ylinen R, Kuitunen A, Kukkonen S, Niemi T. Rapidly degradable hydroxyethyl starch solutions impair blood coagulation after cardiac surgery: a prospective randomized trial. Anesth Analg. 2009;108:30-6 pubmed publisher
    ..In this clinical setting, human albumin does not impair hemostasis. ..
  3. Choi Y, Shim J, Hong S, Kim J, Kwak Y. Comparing the effects of 5% albumin and 6% hydroxyethyl starch 130/0.4 on coagulation and inflammatory response when used as priming solutions for cardiopulmonary bypass. Minerva Anestesiol. 2010;76:584-91 pubmed
    ..The two substances showed similar effects on coagulation variables, blood loss and pro-inflammatory activities in adult patients undergoing mitral valvular heart surgery. ..
  4. James M, Michell W, Joubert I, Nicol A, Navsaria P, Gillespie R. Resuscitation with hydroxyethyl starch improves renal function and lactate clearance in penetrating trauma in a randomized controlled study: the FIRST trial (Fluids in Resuscitation of Severe Trauma). Br J Anaesth. 2011;107:693-702 pubmed publisher
    ..In penetrating trauma, HES provided significantly better lactate clearance and less renal injury than saline. No firm conclusions could be drawn for blunt trauma. ISRCTN 42061860. ..
  5. Hartog C, Reuter D, Loesche W, Hofmann M, Reinhart K. Influence of hydroxyethyl starch (HES) 130/0.4 on hemostasis as measured by viscoelastic device analysis: a systematic review. Intensive Care Med. 2011;37:1725-37 pubmed publisher
    ..HES 130/0.4 administration results in a weaker and smaller clot. Until results from well-designed clinical trials are available, safer fluids should be chosen for patients with impaired coagulation. ..
  6. Shi X, Zou Z, He X, Xu H, Yuan H, Liu H. Hydroxyethyl starch for cardiovascular surgery: a systematic review of randomized controlled trials. Eur J Clin Pharmacol. 2011;67:767-82 pubmed publisher
    ..As the third generation of HES preparations, HES 130 kD showed a trend toward lower blood loss and transfusion rates and is a suitable choice for cardiovascular surgery. ..
  7. Bailey A, McNaull P, Jooste E, Tuchman J. Perioperative crystalloid and colloid fluid management in children: where are we and how did we get here?. Anesth Analg. 2010;110:375-90 pubmed publisher
    ..We discuss the origins of perioperative fluid management in children, review the current options for crystalloid fluid management, and present information on colloid use in pediatric patients. ..
  8. Simon T, Schuerholz T, Hüter L, Sasse M, Heyder F, Pfister W, et al. Impairment of renal function using hyperoncotic colloids in a two hit model of shock: a prospective randomized study. Crit Care. 2012;16:R16 pubmed publisher
    ..Despite similar maintenance of macrocirculation 6% hydroxyethylstarch 130/0.42 and Ringer's acetate significantly preserve renal function and attenuate tubular damage better than 10% hydroxyethylstarch 200/0.5 in saline. ..
  9. Shao L, Wang B, Wang S, Mu F, Gu K. Comparison of 7.2% hypertonic saline - 6% hydroxyethyl starch solution and 6% hydroxyethyl starch solution after the induction of anesthesia in patients undergoing elective neurosurgical procedures. Clinics (Sao Paulo). 2013;68:323-8 pubmed
    ..Moreover, HS-HES improved the dural tension scores and provided satisfactory brain relaxation. Our results indicate that HS-HES may represent a new avenue for volume therapy during elective neurosurgical procedures. ..

More Information


  1. Schramko A, Suojaranta Ylinen R, Kuitunen A, Raivio P, Kukkonen S, Niemi T. Hydroxyethylstarch and gelatin solutions impair blood coagulation after cardiac surgery: a prospective randomized trial. Br J Anaesth. 2010;104:691-7 pubmed publisher
    ..Chest tube drainage was comparable between all groups. Even a small dose of HES 130/0.4 or gelatin impaired clot strength after cardiac surgery in a dose-dependent fashion, but neither colloid increased blood loss. ..
  2. Trof R, Sukul S, Twisk J, Girbes A, Groeneveld A. Greater cardiac response of colloid than saline fluid loading in septic and non-septic critically ill patients with clinical hypovolaemia. Intensive Care Med. 2010;36:697-701 pubmed publisher
  3. Brinkman A, Romijn J, van Barneveld L, Greuters S, Veerhoek D, Vonk A, et al. Profound effects of cardiopulmonary bypass priming solutions on the fibrin part of clot formation: an ex vivo evaluation using rotation thromboelastometry. J Cardiothorac Vasc Anesth. 2010;24:422-6 pubmed publisher
    ..These results suggest that the composition of priming solutions may distinctly affect blood clot formation, in particular with respect to the fibrinogen component in hemostasis. ..
  4. Sumpelmann R, Witt L, Brütt M, Osterkorn D, Koppert W, Osthaus W. Changes in acid-base, electrolyte and hemoglobin concentrations during infusion of hydroxyethyl starch 130/0.42/6 : 1 in normal saline or in balanced electrolyte solution in children. Paediatr Anaesth. 2010;20:100-4 pubmed publisher
    ..01). No serious adverse drug reactions were observed. Infusion related iatrogenic acid-base and electrolyte alterations can be minimized by using hydroxyethyl starch in a balanced electrolyte solution instead of normal saline. ..
  5. Van der Linden P, James M, Mythen M, Weiskopf R. Safety of modern starches used during surgery. Anesth Analg. 2013;116:35-48 pubmed publisher
    ..73 [95% confidence interval = 0.61-0.87], P = 0.0005), or increased mortality (odds ratio for HES mortality = 0.51 [0.24-1.05], P = 0.079). ..
  6. Bellmann R, Feistritzer C, Wiedermann C. Effect of molecular weight and substitution on tissue uptake of hydroxyethyl starch: a meta-analysis of clinical studies. Clin Pharmacokinet. 2012;51:225-36 pubmed publisher
    ..001 and p?<?0.001, respectively). This meta-analysis did not support the hypothesis that lower molecular weight and substitution decrease tissue uptake of HES. Further clinical studies of HES tissue uptake are needed. ..
  7. Boldt J. Modern rapidly degradable hydroxyethyl starches: current concepts. Anesth Analg. 2009;108:1574-82 pubmed publisher
    ..Modern HES preparations are dissolved in balanced, plasma-adapted solutions that no longer contain unphysiological amounts of sodium and chloride and are thus suitable for correcting hypovolemia. ..
  8. Barros J, do Nascimento P, Marinello J, Braz L, Carvalho L, Vane L, et al. The effects of 6% hydroxyethyl starch-hypertonic saline in resuscitation of dogs with hemorrhagic shock. Anesth Analg. 2011;112:395-404 pubmed publisher
  9. Khwannimit B, Bhurayanontachai R. Prediction of fluid responsiveness in septic shock patients: comparing stroke volume variation by FloTrac/Vigileo and automated pulse pressure variation. Eur J Anaesthesiol. 2012;29:64-9 pubmed publisher
  10. Gattas D, Dan A, Myburgh J, Billot L, Lo S, Finfer S. Fluid resuscitation with 6% hydroxyethyl starch (130/0.4) in acutely ill patients: an updated systematic review and meta-analysis. Anesth Analg. 2012;114:159-69 pubmed publisher
    ..4. This same conclusion is reached with or without the retracted studies. Given the widespread use of 6% HES 130/0.4, high-quality trials reporting a large number of events are urgently required. ..
  11. Azoubel G, Nascimento B, Ferri M, Rizoli S. Operating room use of hypertonic solutions: a clinical review. Clinics (Sao Paulo). 2008;63:833-40 pubmed
    ..Examining the immunomodulatory effects of hypertonic solutions should also be a priority in future studies. ..
  12. Ertmer C, Wulf H, Van Aken H, Friederich P, Mahl C, Bepperling F, et al. Efficacy and safety of 10% HES 130/0.4 versus 10% HES 200/0.5 for plasma volume expansion in cardiac surgery patients. Minerva Med. 2012;103:111-22 pubmed
    ..5 for volume therapy in patients undergoing cardiovascular surgery. Postoperative coagulation and renal function, as measured by standard laboratory tests, were similar among groups. ..
  13. Sumpelmann R, Kretz F, Luntzer R, de Leeuw T, Mixa V, Gabler R, et al. Hydroxyethyl starch 130/0.42/6:1 for perioperative plasma volume replacement in 1130 children: results of an European prospective multicenter observational postauthorization safety study (PASS). Paediatr Anaesth. 2012;22:371-8 pubmed publisher
    ..Caution should be exercised in patients with renal function disturbances and those with an increased bleeding risk. ..
  14. Nielsen V. Colloids decrease clot propagation and strength: role of factor XIII-fibrin polymer and thrombin-fibrinogen interactions. Acta Anaesthesiol Scand. 2005;49:1163-71 pubmed
    ..Investigation to determine if clinical enhancement of FXIII activity and/or FI concentration (e.g. fresh-frozen plasma, cryoprecipitate) can attenuate colloid-mediated decreases in hemostasis is warranted. ..
  15. James M, Latoo M, Mythen M, Mutch M, Michaelis C, Roche A, et al. Plasma volume changes associated with two hydroxyethyl starch colloids following acute hypovolaemia in volunteers. Anaesthesia. 2004;59:738-42 pubmed
    ..The large molecular weight starch (Hextend) provided a less well-sustained volume expansion effect than the smaller one (Voluven) ..
  16. Reuter D, Kirchner A, Felbinger T, Weis F, Kilger E, Lamm P, et al. Usefulness of left ventricular stroke volume variation to assess fluid responsiveness in patients with reduced cardiac function. Crit Care Med. 2003;31:1399-404 pubmed
  17. Marx G, Pedder S, Smith L, Swaraj S, Grime S, Stockdale H, et al. Attenuation of capillary leakage by hydroxyethyl starch (130/0.42) in a porcine model of septic shock. Crit Care Med. 2006;34:3005-10 pubmed
    ..Systemic oxygenation was not significantly altered in either group. In this porcine septic shock model, HES 130/0.42 attenuated capillary leakage significantly more effectively than HES 200/0.5. ..
  18. Su F, Wang Z, Cai Y, Rogiers P, Vincent J. Fluid resuscitation in severe sepsis and septic shock: albumin, hydroxyethyl starch, gelatin or ringer's lactate-does it really make a difference?. Shock. 2007;27:520-6 pubmed
    ..v. fluid did not affect outcome. ..
  19. Ickx B, Bepperling F, Melot C, Schulman C, Van der Linden P. Plasma substitution effects of a new hydroxyethyl starch HES 130/0.4 compared with HES 200/0.5 during and after extended acute normovolaemic haemodilution. Br J Anaesth. 2003;91:196-202 pubmed
    ..This study demonstrates a good immediate and medium-term plasma volume substitution effect of HES 130 compared with HES 200. HES 130 could represent a suitable synthetic colloid for plasma volume substitution during extensive ANH. ..
  20. Wettstein R, Cabrales P, Erni D, Tsai A, Winslow R, Intaglietta M. Resuscitation from hemorrhagic shock with MalPEG-albumin: comparison with MalPEG-hemoglobin. Shock. 2004;22:351-7 pubmed
    ..7 cP (vs. 2.5 cP for MalPEG-Hb). The present results show that both solutions are efficacious plasma expanders and that the hemoglobin-based solution provides improved oxygen distribution and tissue Po2 in the hamster chamber model. ..
  21. Drobin D, Hahn R. Kinetics of isotonic and hypertonic plasma volume expanders. Anesthesiology. 2002;96:1371-80 pubmed
    ..Kinetic analysis and simulation is a useful tool for the study of such differences. ..
  22. Felfernig M, Franz A, BRAUNLICH P, Fohringer C, Kozek Langenecker S. The effects of hydroxyethyl starch solutions on thromboelastography in preoperative male patients. Acta Anaesthesiol Scand. 2003;47:70-3 pubmed
    ..7/4.6 compromises TEG parameters more than the other solutions tested, whereas HES 130/0.4/9 has the smallest effect. Further outcome-related studies are needed in order to assess the clinical relevance of our findings. ..
  23. Jacob M, Chappell D, Conzen P, Wilkes M, Becker B, Rehm M. Small-volume resuscitation with hyperoncotic albumin: a systematic review of randomized clinical trials. Crit Care. 2008;12:R34 pubmed publisher
    ..Small-volume resuscitation can rapidly correct hypovolemia. Hyperoncotic albumin solutions, long in clinical use, are suitable for small-volume resuscitation; however, their clinical benefits remain uncertain...
  24. Lehmann G, Marx G, Forster H. Bioequivalence comparison between hydroxyethyl starch 130/0.42/6 : 1 and hydroxyethyl starch 130/0.4/9 : 1. Drugs R D. 2007;8:229-40 pubmed
    ..Being equivalent with pentastarch and HES 130/0.4/9 : 1 in terms of colloid osmotic and haemodilution effect, HES 130/0.42/6 : 1 shows the fastest clearance from the circulation. ..
  25. Kasper S, Meinert P, Kampe S, Görg C, Geisen C, Mehlhorn U, et al. Large-dose hydroxyethyl starch 130/0.4 does not increase blood loss and transfusion requirements in coronary artery bypass surgery compared with hydroxyethyl starch 200/0.5 at recommended doses. Anesthesiology. 2003;99:42-7 pubmed
    ..Six percent HES 130/0.4 at a median dose of 49 ml/kg did not increase blood loss and transfusion requirements in coronary artery bypass surgery compared with 6% HES 200/0.5 at a median dose of 33 ml/kg. ..
  26. Sander O, Reinhart K, Meier Hellmann A. Equivalence of hydroxyethyl starch HES 130/0. 4 and HES 200/0. 5 for perioperative volume replacement in major gynaecological surgery. Acta Anaesthesiol Scand. 2003;47:1151-8 pubmed
    ..4 solution and a standard HES 200/0.5 solution for perioperative volume replacement. Moreover, both HES preparations were equally well-tolerated and safe. ..
  27. Molter G, Soltesz S, Larsen R, Baumann Noss S, Biedler A, Silomon M. [Haemodynamic effects following preoperative hypervolemic haemodilution with hypertonic hyperoncotic colloid solutions in coronary artery bypass graft surgery]. Anaesthesist. 2003;52:905-18 pubmed
  28. Assaly R, Azizi M, Kennedy D, Amauro C, Zaher A, Houts F, et al. Plasma expansion by polyethylene-glycol-modified albumin. Clin Sci (Lond). 2004;107:263-72 pubmed
    ..Based on these data, PEG-Alb appears to be retained within blood vessels in models of capillary leak. PEG-Alb may ultimately be effective in the clinical treatment of shock associated with capillary leak. ..
  29. Margarson M, Soni N. Changes in serum albumin concentration and volume expanding effects following a bolus of albumin 20% in septic patients. Br J Anaesth. 2004;92:821-6 pubmed
    ..After giving albumin, serum albumin concentrations decrease significantly faster in septic patients than in healthy controls. ..
  30. Woessner R, Grauer M, Dieterich H, Bepperling F, Baus D, Kahles T, et al. Influence of a long-term, high-dose volume therapy with 6% hydroxyethyl starch 130/0.4 or crystalloid solution on hemodynamics, rheology and hemostasis in patients with acute ischemic stroke. Results of a randomized, placebo-controlled, double-blind . Pathophysiol Haemost Thromb. 2003;33:121-6 pubmed
    ..In our study with patients suffering from acute ischemic stroke, continuous infusion (1 ml/min) of HES 130/0.4 or crystalloid solution did not differ regarding safety or hemodynamic efficacy. ..
  31. Van der Linden P, De Hert S, Deraedt D, Cromheecke S, De Decker K, De Paep R, et al. Hydroxyethyl starch 130/0.4 versus modified fluid gelatin for volume expansion in cardiac surgery patients: the effects on perioperative bleeding and transfusion needs. Anesth Analg. 2005;101:629-34, table of contents pubmed
    ..In the conditions of the present study, HES 130/0.4 up to 50 mL/kg is a valuable alternative to modified fluid gelatin for plasma volume expansion during and after cardiac surgery. ..
  32. Lv R, Zhou W, Zhang L, Xu J. Effects of hydroxyethyl starch on hepatic production of cytokines and activation of transcription factors in lipopolysaccharide-administered rats. Acta Anaesthesiol Scand. 2005;49:635-42 pubmed
    Hydroxyethyl starch (HES) is one of the most frequently used plasma substitutes. Some studies have indicated that HES may have anti-inflammatory effects...
  33. Fenger Eriksen C, Anker Møller E, Heslop J, Ingerslev J, Sørensen B. Thrombelastographic whole blood clot formation after ex vivo addition of plasma substitutes: improvements of the induced coagulopathy with fibrinogen concentrate. Br J Anaesth. 2005;94:324-9 pubmed
    b>Plasma substitutes such as hydroxyethyl starch (HES) and various dextrans may compromise the haemostatic system, thereby causing potentially dangerous bleeding...
  34. Hoffmann J, Vollmar B, Laschke M, Inthorn D, Schildberg F, Menger M. Hydroxyethyl starch (130 kD), but not crystalloid volume support, improves microcirculation during normotensive endotoxemia. Anesthesiology. 2002;97:460-70 pubmed
    ..Thus, our study provides microhemodynamic and cellular mechanisms of HES 130 kD-mediated protection on microcirculation during endotoxemia, even when used in a clinically relevant posttreatment mode during normotensive conditions. ..
  35. . Preferences for colloid use in Scandinavian intensive care units. Acta Anaesthesiol Scand. 2008;52:750-8 pubmed publisher
    ..Most ICUs are ready to change colloid use if randomised trials in ICU patients show changes in mortality or renal function. ..
  36. Reuter D, Felbinger T, Schmidt C, Kilger E, Goedje O, Lamm P, et al. Stroke volume variations for assessment of cardiac responsiveness to volume loading in mechanically ventilated patients after cardiac surgery. Intensive Care Med. 2002;28:392-8 pubmed
    ..68, p<0.001). SVV may help to determine the preload condition of ventilated patients following cardiac surgery and to predict and continuously monitor effects of volume administered as part of their hemodynamic management. ..
  37. Jones S, Whitten C, Despotis G, Monk T. The influence of crystalloid and colloid replacement solutions in acute normovolemic hemodilution: a preliminary survey of hemostatic markers. Anesth Analg. 2003;96:363-8, table of contents pubmed
    ..The changes in factor VIII, activated partial thromboplastin time, and TEG measurements indicate that HES and DEX may attenuate the hypercoagulability related to surgery. ..
  38. Waitzinger J, Bepperling F, Pabst G, Opitz J. Hydroxyethyl starch (HES) [130/0.4], a new HES specification: pharmacokinetics and safety after multiple infusions of 10% solution in healthy volunteers. Drugs R D. 2003;4:149-57 pubmed
    ..4) solution, which exhibits a high renal excretion rate over 10 days. Local as well as systemic tolerability of 10 repeated doses was good. ..
  39. Avorn J, Patel M, Levin R, Winkelmayer W. Hetastarch and bleeding complications after coronary artery surgery. Chest. 2003;124:1437-42 pubmed
    ..57; 95% CI, 1.74 to 12.00). HES use in patients undergoing CABG surgery may be associated with a significant risk of postoperative bleeding. A double-blinded, randomized, controlled trial will be necessary to confirm this finding. ..
  40. Lelievre J, Berry A, Benoit Vical F. An alternative method for Plasmodium culture synchronization. Exp Parasitol. 2005;109:195-7 pubmed
    ..This method also avoids the use of techniques based on Percoll-glucose gradients. The Plasmion-based technique proved to be a good method and could become an alternative to Plasmagel. ..
  41. Persson J, Grände P. Plasma volume expansion and transcapillary fluid exchange in skeletal muscle of albumin, dextran, gelatin, hydroxyethyl starch, and saline after trauma in the cat. Crit Care Med. 2006;34:2456-62 pubmed
    ..Under such circumstances, for equal volumes, plasma expansion was better preserved with 6% dextran 70 than with 5% albumin, which was better than 3.5% gelatin, 6% hydroxyethyl starch 130/0.4, and saline. ..
  42. Dubniks M, Persson J, Grände P. Plasma volume expansion of 5% albumin, 4% gelatin, 6% HES 130/0.4, and normal saline under increased microvascular permeability in the rat. Intensive Care Med. 2007;33:293-9 pubmed
    ..Gelatin and HES were equally effective. All solutions showed a smaller plasma expanding effect than observed in a previous study with normal permeability. ..
  43. Sakr Y, Payen D, Reinhart K, Sipmann F, Zavala E, Bewley J, et al. Effects of hydroxyethyl starch administration on renal function in critically ill patients. Br J Anaesth. 2007;98:216-24 pubmed
    ..The administration of HES had no influence on renal function or the need for RRT in the ICU. ..
  44. Gandhi S, Weiskopf R, Jungheinrich C, Koorn R, Miller D, Shangraw R, et al. Volume replacement therapy during major orthopedic surgery using Voluven (hydroxyethyl starch 130/0.4) or hetastarch. Anesthesiology. 2007;106:1120-7 pubmed
    ..4 (P=0.0487 and P=0.008, respectively). Voluven (HES 130/0.4) and hetastarch are equally efficacious plasma volume substitutes; however, HES 130/0.4 has a lesser effect on coagulation. ..
  45. Tiryakioglu O, Yildiz G, Vural H, Goncu T, Ozyazicioglu A, Yavuz S. Hydroxyethyl starch versus Ringer solution in cardiopulmonary bypass prime solutions (a randomized controlled trial). J Cardiothorac Surg. 2008;3:45 pubmed publisher
    ..001). HES 130-0.4 solution is an alternative colloidal solution which can be used as the prime solution or as a mixture with the crystalloids in cardio-pulmonary bypass applications. ..
  46. Palumbo D, Servillo G, D Amato L, Volpe M, Capogrosso G, De Robertis E, et al. The effects of hydroxyethyl starch solution in critically ill patients. Minerva Anestesiol. 2006;72:655-64 pubmed
    ..4 (Voluven) is an effective fluid for resuscitation of hypovolemic patients and represent an attractive alternative to albumin. ..
  47. Zander R, Boldt J, Engelmann L, Mertzlufft F, Sirtl C, Stuttmann R. [The design of the VISEP trial. Critical appraisal]. Anaesthesist. 2007;56:71-7 pubmed
    ..Thus, any further advance presentations and interpretations should be shelved in expectation of the authors' publication of all the data, in order to begin further discussions including the flaws in study design listed here. ..
  48. Verheij J, van Lingen A, Beishuizen A, Christiaans H, de Jong J, Girbes A, et al. Cardiac response is greater for colloid than saline fluid loading after cardiac or vascular surgery. Intensive Care Med. 2006;32:1030-8 pubmed
    ..To study the effects on volume expansion and myocardial function of colloids or crystalloids in the treatment of hypovolaemic hypotension after cardiac and major vascular surgery...
  49. Lehmann G, Asskali F, Boll M, Burmeister M, Marx G, Hilgers R, et al. HES 130/0.42 shows less alteration of pharmacokinetics than HES 200/0.5 when dosed repeatedly. Br J Anaesth. 2007;98:635-44 pubmed
    ..5. The improved reproducibility may improve drug safety, particularly as the accumulation of residual starch with HES 200/0.5 does not contribute to the colloid's volume effect, but may rather increase the risk of undesired reactions. ..
  50. Yap W, Young D, Pathi V. Effects of gelatine and medium molecular weight starch as priming fluid in cardiopulmonary bypass--a randomised controlled trial. Perfusion. 2007;22:57-61 pubmed
    ..The significant increase in intraocular pressure measurements in the Gelofusine group compared to the Voluven group support the hypothesis that Voluven maintains the plasma oncotic pressure better and reduces fluid shift. ..
  51. Arroyo V. Review article: albumin in the treatment of liver diseases--new features of a classical treatment. Aliment Pharmacol Ther. 2002;16 Suppl 5:1-5 pubmed
    ..Based on this capacity an albumin dialysis system (MARS) has recently been developed. The usefulness of this system in the management of patients with acute and chronic liver failure is, at present, under evaluation. ..
  52. Fernandez J, Monteagudo J, Bargallo X, Jimenez W, Bosch J, Arroyo V, et al. A randomized unblinded pilot study comparing albumin versus hydroxyethyl starch in spontaneous bacterial peritonitis. Hepatology. 2005;42:627-34 pubmed
    ..This effect is due not only to volume expansion but also to an action on the peripheral arterial circulation. ..
  53. Jalan R, Kapoor D. Reversal of diuretic-induced hepatic encephalopathy with infusion of albumin but not colloid. Clin Sci (Lond). 2004;106:467-74 pubmed
    ..These data support the notion that other factors, such as oxidative stress, act as adjuncts to ammonia in the pathogenesis of diuretic-induced HE and suggest a possible role for albumin infusion in its treatment. ..