Christian J. WIEDERMANN
Eurasian Journal of Critical Care - 2026;8(2):61-70
Background: The use of hyperoncotic (25%) albumin in sepsis resuscitation remains controversial because of concerns about nephrotoxicity, particularly in patients with pre-existing renal impairment. This study examined whether early administration of 25% albumin in addition to crystalloids increases the risk of acute kidney injury or worsens short-term hemodynamic outcomes compared with crystalloids alone. Materials and Methods: A retrospective cohort study was performed using a large, publicly available intensive care database. Adult patients with sepsis who received crystalloids alone or crystalloids plus 25% albumin within the first 24 hours of intensive care admission were identified; patients receiving 5% albumin were excluded. Propensity score matching was performed by 1:1 nearest-neighbor matching without replacement, applying a caliper of 0.2 standard deviations of the logit of the propensity score, with demographics, laboratory values, organ-dysfunction sub-scores, and comorbidities as covariates; balance was assessed by standardized mean differences. The primary outcome was acute kidney injury, defined by standardized consensus criteria. Secondary outcomes were renal replacement therapy, intensive care length of stay, and vasopressor-free days. Results: Among 15,882 patients, 587 matched pairs were analyzed. The incidence of acute kidney injury was similar between groups (albumin, 59.5% versus control, 55.4%; p = 0.175), as was the need for renal replacement therapy (23.9% versus 27.8%; p = 0.142). Intensive care length of stay and vasopressor-free days did not differ. Despite higher lactate levels, greater hepatic and coagulation dysfunction, and modestly worse baseline renal function in the albumin group, renal outcomes were comparable, and the renal safety profile was consistent across strata of baseline kidney function. Fluid exposure was lower in the albumin group, which received less crystalloid and a less positive net fluid balance. Conclusions: Early administration of 25% albumin with crystalloids was not associated with worse short-term renal or hemodynamic outcomes. These findings support clinical equipoise and suggest that cautious use of 25% albumin in selected patients confers no additional renal risk.
