Albumin in Sepsis and Septic Shock: A Systematic Review and Meta-Analysis

Sepsis and septic shock remain leading causes of mortality in intensive care units (ICUs) worldwide, and the optimal resuscitation fluid continues to be debated. This systematic review and meta-analysis evaluated the effectiveness of human albumin solution compared with control fluids across four patient-centred outcomes in adults with sepsis or septic shock. A comprehensive search of MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Cumulative Index to Nursing and Allied Health Literature (CINAHL) was conducted from inception to March 2026. Both randomised controlled trials (RCTs) and observational studies were eligible for inclusion. Nine studies were included in this meta-analysis. Pooled analysis using random-effects models demonstrated that albumin administration was not associated with a statistically significant reduction in all-cause mortality (risk ratio (RR) 1.05, 95% confidence interval (CI) 0.86-1.28), renal replacement therapy (RRT) requirement (RR 1.23, 95% CI 0.70-2.15), or acute kidney injury (AKI) incidence (RR 1.09, 95% CI 0.85-1.40). The sole outcome demonstrating consistent and statistically significant benefit was cumulative fluid balance, which was significantly lower in albumin-treated patients (mean difference (MD) -0.79 L, 95% CI -1.16 to -0.41). Subgroup analysis suggested that the renal effect of albumin is concentration-dependent, with hyperoncotic preparations associated with greater RRT risk in patients with pre-existing renal impairment. Albumin use is associated with a lower short-term cumulative fluid balance with no additional benefits on RRT and AKI. However, adequately powered randomised trials stratified by albumin concentration are needed to provide definitive guidance.