Sepsis Resüsitasyonunda %25 Albüminin Erken Kullanımı Kötüleşen Böbrek Sonuçlarıyla İlişkili Değildir: MIMIC-IV Veritabanına Dayalı, Eğilim Skoruyla Eşleştirilmiş Retrospektif Kohort Çalışması

Öz

Amaç: Sepsis resüsitasyonunda hiperonkotik (%25) albümin kullanımı, özellikle önceden böbrek yetmezliği olan hastalarda nefrotoksisite kaygıları nedeniyle tartışmalı olmaya devam etmektedir. Bu çalışmada, kristaloidlere ek olarak %25 albüminin erken uygulanmasının, yalnızca kristaloid uygulamasına kıyasla akut böbrek hasarı riskini artırıp artırmadığı veya kısa dönem hemodinamik sonuçları kötüleştirip kötüleştirmediği incelenmiştir. Gereç ve Yöntem: Geniş, kamuya açık bir yoğun bakım veritabanı kullanılarak retrospektif bir kohort çalışması yürütülmüştür. Yoğun bakıma kabulün ilk 24 saati içinde yalnızca kristaloid ya da kristaloidlere ek olarak %25 albümin alan sepsisli erişkin hastalar tanımlanmış; %5 albümin alan hastalar çalışma dışı bırakılmıştır. Demografik özellikler, laboratuvar değerleri, organ disfonksiyonu alt skorları ve komorbiditeler kullanılarak 1:1 eğilim skoru eşleştirmesi uygulanmıştır. Birincil sonlanım, standart konsensüs ölçütlerine göre tanımlanan akut böbrek hasarıydı. İkincil sonlanımlar renal replasman tedavisi, yoğun bakımda kalış süresi ve vazopresörsüz günlerdi. Bulgular: 15.882 hasta arasında 587 eşleştirilmiş çift analiz edilmiştir. Akut böbrek hasarı insidansı gruplar arasında benzerdi (albümin %60,3'e karşı kontrol %56,2; p = 0,174); renal replasman tedavisi gereksinimi de benzerdi (%23,9'a karşı %27,8; p = 0,142). Yoğun bakımda kalış süresi ve vazopresörsüz günler farklılık göstermedi. Albümin grubunda daha yüksek laktat düzeyleri ile daha belirgin hepatik ve koagülasyon disfonksiyonu bulunmasına rağmen, böbrek alt skorları ve komorbiditeler benzerdi. Sonuç: Kristaloidlerle birlikte %25 albüminin erken uygulanması, daha kötü kısa dönem böbrek veya hemodinamik sonuçlarla ilişkili bulunmamıştır. Bu bulgular klinik eşdeğerliği desteklemekte ve seçilmiş hastalarda %25 albüminin temkinli kullanımının ek bir böbrek riski getirmediğini düşündürmektedir.

Anahtar Kelimeler

• albümin
• akut böbrek hasarı
• sepsis
• sıvı resüsitasyonu
• eğilim skoru eşleştirmesi
• yoğun bakım

Destekleyen Kurum

Yoktur — bu araştırma; kamu, ticari veya kâr amacı gütmeyen sektörlerdeki herhangi bir finansman kuruluşundan özel bir hibe veya finansal destek almamıştır.

Etik Beyan

Bu çalışma, tamamen kimliksizleştirilmiş verilerden oluşan, kamuya açık bir veri kaynağı olan MIMIC-IV veritabanının ikincil bir analizidir. Veritabanının oluşturulması, Massachusetts Institute of Technology ve Beth Israel Deaconess Medical Center kurumsal değerlendirme kurulları tarafından bilgilendirilmiş onam muafiyetiyle onaylanmıştır. Bu ikincil analiz için ek bir etik kurul onayı gerekmemiş olup çalışma Helsinki Bildirgesi'ne uygun olarak yürütülmüştür.

Teşekkür

Yoktur. Bu makalenin hazırlanmasına yazar dışında katkıda bulunan kişi yoktur.

Early Use of 25% Albumin in Sepsis Resuscitation Is Not Associated with Worsened Renal Outcomes: A Propensity-Matched Retrospective Cohort Study of MIMIC-IV

Öz

Objective: 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 (1:1) was applied using demographics, laboratory values, organ-dysfunction sub-scores, and comorbidities. 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, 60.3% versus control, 56.2%; p = 0.174), 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 and greater hepatic and coagulation dysfunction in the albumin group, renal sub-scores and comorbidities were comparable. Conclusion: 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.

Anahtar Kelimeler

• Albumin
• Acute kiney injury
• Sepsis
• Fluid resuscitation
• Propensity score matching
• Critical care

Destekleyen Kurum

None — this research received no specific grant or financial support from any funding agency in the public, commercial, or not-for-profit sectors.

Etik Beyan

This study was a secondary analysis of the MIMIC-IV database, a publicly available repository of fully de-identified data. Establishment of the database was approved by the institutional review boards of the Massachusetts Institute of Technology and Beth Israel Deaconess Medical Center, with a waiver of informed consent. No additional ethics committee approval was required for this secondary analysis, which was conducted in accordance with the Declaration of Helsinki.

Teşekkür

None. No individuals other than the author contributed to the preparation of this manuscript.

Kaynakça

1. 1. Caironi P, Tognoni G, Masson S, et al. Albumin replacement in patients with severe sepsis or septic shock. N Engl J Med. 2014;370:1412-1421. doi:10.1056/NEJMoa1305727
2. 2. Finfer S, Bellomo R, Boyce N, et al. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med. 2004;350:2247-2256. doi:10.1056/NEJMoa040232
3. 3. Geng L, Tian X, Gao Z, et al. Different concentrations of albumin versus crystalloid in patients with sepsis and septic shock: a meta-analysis of randomized clinical trials. J Intensive Care Med. 2023;38:679-689. doi:10.1177/08850666231170778
4. 4. Bannard-Smith J, Elrakhawy M, Norman G, et al. The efficacy, safety and effectiveness of hyperoncotic albumin solutions in patients with sepsis: a systematic review and meta-analysis. J Intensive Care Soc. Published online 2024. doi:10.1177/17511437241259437
5. 5. Vincent JL, De Backer D, Wiedermann CJ. Fluid management in sepsis: the potential beneficial effects of albumin. J Crit Care. 2016;35:161-167. doi:10.1016/j.jcrc.2016.04.019
6. 6. Vincent JL. Fluid management in the critically ill. Kidney Int. 2019;96:52-75. doi:10.1016/j.kint.2018.11.047
7. 7. Xu JY, Chen QH, Xie JF, et al. Comparison of the effects of albumin and crystalloid on mortality in adult patients with severe sepsis and septic shock: a meta-analysis of randomized clinical trials. Crit Care. 2014;18:702. doi:10.1186/s13054-014-0702-y
8. 8. Vasques F, Duscio E, Romitti F, et al. Septic shock-3 vs 2: an analysis of the ALBIOS study. Crit Care. 2018;22:237. doi:10.1186/s13054-018-2169-8

9. 9. Zhou S, Zeng Z, Wei H, et al. Early combination of albumin with crystalloids administration might be beneficial for the survival of septic patients: a retrospective analysis from MIMIC-IV database. Ann Intensive Care. 2021;11:42. doi:10.1186/s13613-021-00830-8
10. 10. Yalan Q, Yinzhou L, Binfei T, et al. Early high-volume resuscitation with crystalloid solution combined with albumin improves survival of critically ill patients: a retrospective analysis from MIMIC-IV database. Burns. 2024;50:893-902. doi:10.1016/j.burns.2024.01.016
11. 11. Patanwala AE, Flannery AH, Mehta HB, et al. Comparative effectiveness of albumin versus no albumin on renal replacement therapy and mortality in patients with septic shock and renal impairment. Chest. 2025;167:1090-1098. doi:10.1016/j.chest.2024.10.012
12. 12. Jiang L, Jiang S, Zhang M, et al. Albumin versus other fluids for fluid resuscitation in patients with sepsis: a meta-analysis. PLoS One. 2014;9:e114666. doi:10.1371/journal.pone.0114666
13. 13. Rochwerg B, Alhazzani W, Sindi A, et al. Fluid resuscitation in sepsis: a systematic review and network meta-analysis. Ann Intern Med. 2014;161:347-355. doi:10.7326/M14-0178
14. 14. Wiedermann CJ. Moderator effect of hypoalbuminemia in volume resuscitation and plasma expansion with intravenous albumin solution. Int J Mol Sci. 2022;23:14175. doi:10.3390/ijms232214175
15. 15. Cortegiani A, Grasselli G, Meessen J, et al. Albumin replacement therapy in immunocompromised patients with sepsis: secondary analysis of the ALBIOS trial. J Crit Care. 2021;63:83-91. doi:10.1016/j.jcrc.2021.01.016
16. 16. Brinkman HM, Kashani KB, Gallo de Moraes A, et al. Impact of early albumin use for resuscitation in patients with septic shock and cirrhosis. Can J Gastroenterol Hepatol. 2025;2025:8637440. doi:10.1155/cjgh/8637440
17. 17. Angeli P. A step forward in the choice of fluid for early resuscitation of critically ill patients with cirrhosis. Hepatol Int. 2021;15:858-859. doi:10.1007/s12072-021-10211-9
18. 18. Durand F, Kellum JA, Nadim MK. Fluid resuscitation in patients with cirrhosis and sepsis: a multidisciplinary perspective. J Hepatol. 2023;79:240-246. doi:10.1016/j.jhep.2023.02.024
19. 19. McKee A, Moriber N, Tornwall J. Intravenous fluid therapy choice in trauma patients in the intensive care unit: a scoping review. Crit Care Nurse. 2025;45:41-49. doi:10.4037/ccn2025318
20. 20. Amer MAM, Eskander MS, Ryad FM. Comparison between crystalloid versus colloid in septic shock. QJM. 2021;114(suppl 1):hcab097.021. doi:10.1093/qjmed/hcab097.021
21. 21. Abedi F, Zarei B, Elyasi S. Albumin: a comprehensive review and practical guideline for clinical use. Eur J Clin Pharmacol. 2024;80:1151-1169. doi:10.1007/s00228-024-03664-y
22. 22. Altawalbeh SM, Almestarihi EM, Khasawneh RA. Clinical and economic outcomes associated with intravenous albumin fluid use in the intensive care unit: a retrospective cohort study. Expert Rev Pharmacoecon Outcomes Res. 2023;23:789-796. doi:10.1080/14737167.2023.2215431
23. 23. Kakaei F, Hashemzadeh S, Asheghvatan A, et al. Albumin as a resuscitative fluid in patients with severe sepsis: a randomized clinical trial. Adv Biosci Clin Med. 2017;5:8-16. doi:10.7575/aiac.abcmed.17.05.04.02
24. 24. Dong L, Wu X, Zhao C, et al. Impact and clinical significance of different types of fluid resuscitation on the glycocalyx in patients with early sepsis and septic shock: a single center, prospective, randomized controlled trial. Zhonghua Wei Zhong Bing Ji Jiu Yi Xue. 2025;37:237-244. doi:10.3760/cma.j.cn121430-20240711-00583
25. 25. Wiedermann CJ, Zaboli A, Turcato G. Synthesis of expert opinions on fluid management in severe sepsis: a contextual review of human albumin and crystalloids. Heart Lung. 2025;70:339-359. doi:10.1016/j.hrtlng.2025.01.010
26. 26. Arabi YM, Belley-Cote E, Carsetti A, et al. European Society of Intensive Care Medicine clinical practice guideline on fluid therapy in adult critically ill patients. Part 1: the choice of resuscitation fluids. Intensive Care Med. 2024;50:813-831. doi:10.1007/s00134-024-07369-9
27. 27. Johnson AEW, Bulgarelli L, Shen L, et al. MIMIC-IV, a freely accessible electronic health record dataset. Sci Data. 2023;10:1. doi:10.1038/s41597-022-01899-x
28. 28. Van Rossum G, Drake FL. Python 3 Reference Manual. CreateSpace Independent Publishing Platform; 2009. 29. McKinney W. Data structures for statistical computing in Python. In: Proceedings of the 9th Python in Science Conference. 2010:56-61. doi:10.25080/Majora-92bf1922-00a
29. 30. Harris CR, Millman KJ, van der Walt SJ, et al. Array programming with NumPy. Nature. 2020;585:357-362. doi:10.1038/s41586-020-2649-2
30. 31. Virtanen P, Gommers R, Oliphant TE, et al. SciPy 1.0: fundamental algorithms for scientific computing in Python. Nat Methods. 2020;17:261-272. doi:10.1038/s41592-019-0686-2
31. 32. Seabold S, Perktold J. Statsmodels: econometric and statistical modeling with Python. In: Proceedings of the 9th Python in Science Conference. 2010:92-96.
32. 33. Pedregosa F, Varoquaux G, Gramfort A, et al. Scikit-learn: machine learning in Python. J Mach Learn Res. 2011;12:2825-2830.
33. 34. Inker LA, Eneanya ND, Coresh J, et al. New creatinine- and cystatin C-based equations to estimate GFR without race. N Engl J Med. 2021;385:1737-1749. doi:10.1056/NEJMoa2102953
34. 35. Rochwerg B, Alhazzani W, Gibson A, et al. Fluid type and the use of renal replacement therapy in sepsis: a systematic review and network meta-analysis. Intensive Care Med. 2015;41:1561-1571. doi:10.1007/s00134-015-3794-1
35. 36. Qayyum S, Shahid K. Fluid resuscitation in septic patients. Cureus. 2023;15:e44317. doi:10.7759/cureus.44317
36. 37. Sort P, Navasa M, Arroyo V, et al. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med. 1999;341:403-409. doi:10.1056/NEJM199908053410603
37. 38. Caraceni P, Riggio O, Angeli P, et al. Long-term albumin administration in decompensated cirrhosis (ANSWER): an open-label randomised trial. Lancet. 2018;391:2417-2429. doi:10.1016/S0140-6736(18)30840-7
38. 39. Taylor C, Yang L, Finfer S, et al. An international comparison of the cost of fluid resuscitation therapies. Aust Crit Care. 2021;34(1):23-32. doi:10.1016/j.aucc.2020.06.001 (PMID 32828672).
39. 40. Vural N, Duyan M, Saridas A, et al. The predictive value of inflammatory biomarkers in distinguishing testicular torsion and epididymo-orchitis. Mev Med Sci. 2024;4:113-118.
40. 41. Maiwall R, Kumar A, Pasupuleti SSR, et al. A randomized controlled trial comparing 20% albumin to plasmalyte in patients with cirrhosis and sepsis-induced hypotension (ALPS trial). J Hepatol. 2022;77:670-682. doi:10.1016/j.jhep.2022.03.043
41. 42. Philips CA, Maiwall R, Sharma MK, et al. Comparison of 5% human albumin and normal saline for fluid resuscitation in sepsis induced hypotension among patients with cirrhosis (FRISC study): a randomized controlled trial. Hepatol Int. 2021;15:983-994. doi:10.1007/s12072-021-10164-z