Cirrhosis Table

In patients with cirrhosis who are hypoalbuminemic, protein binding is decreased with consequent effects on volume of distribution and clearance. Bioavailability is normal, though the rate of absorption is slowed. Overall, unless renal function is compromised, diuretic delivery into urine is normal (Tables 2 and 3); as such, resistance is pharmacodynamic in nature. The possible mechanisms for such resistance include increased solute reabsorption at the proximal or distal tubule and/or alterations in the receptor for loop diuretics.

A few studies have shown that some patients with severe cirrhosis have impaired delivery of diuretic into urine, presumably due to mild decreases in renal function. In such patients larger doses will attain adequate amounts of diuretic in the urine. Even including such patients, however, there seems little rationale for administering single intravenous doses of furosemide greater than 40 mg (or the equivalent dose of other agents or formulations).

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