The administration of albumin improves circulatory function, prevents hepatorenal syndrome, and reduces hospital mortality in patients with cirrhosis and spontaneous bacterial peritonitis. This randomized unblinded pilot study compared the effect of albumin (10 patients) and the synthetic plasma expander hydroxyethyl starch 200/0.5 (10 patients) on the systemic hemodynamics of patients with spontaneous bacterial peritonitis. Baseline measurements were performed within 12 hours after diagnosis of infection. Patients then received 2 doses of the volume expander (1.5 g/kg body weight after baseline measurements and 1 g/kg body weight on day 3). Measurements were repeated after infection resolution. Treatment with albumin was associated with a significant increase in arterial pressure and a suppression of plasma renin activity, indicating an improvement in circulatory function. This occurred in the setting of a significant expansion of central blood volume (increase in cardiopulmonary pressures and atrial natriuretic factor) and an increase in systolic volume and systemic vascular resistance. In contrast, no significant changes were observed in these parameters in patients treated with hydroxyethyl starch. Von Willebrand-related antigen plasma levels significantly decreased in patients treated with albumin but not in those treated with hydroxyethyl starch. Serum nitrates and nitrites increased in patients treated with hydroxyethyl starch but not in those treated with albumin. These data suggest an effect of albumin on endothelial function. In conclusion, albumin but not hydroxyethyl starch improves systemic hemodynamics in patients with spontaneous bacterial peritonitis. This effect is due not only to volume expansion but also to an action on the peripheral arterial circulation. (HEPATOLOGY 2005;42:627-634.) See Editorial on Page 533 P atients with cirrhosis and spontaneous bacterial peritonitis (SBP) frequently develop a severe impairment in circulatory function, the pathogenesis of which is not well understood. Initial studies suggested that it was due to an accentuation of the arterial vasodila-tion, already present in patients with decompensated cirrhosis, related to a cytokine-mediated release of endothelial vasodilators, mainly nitric oxide (NO). However, recent investigations suggest that a decrease in cardiac output could also be involved. [1][2][3] In approximately one third of the patients, this abnormality leads to type 1 hepatorenal syndrome, which is associated with high hos-