Introduction Hyperoncotic albumin is being discussed as an adjunct to diuretics to facilitate fluid off-loading in critically ill patients with fluid accumulation. However, its effectiveness and clinical benefits remain controversial. This critical appraisal examines the current body of evidence to evaluate both the potential benefits and limitations of albumin co-administration with diuretics and/or renal replacement therapy (RRT) in achieving effective net fluid removal in the intensive care unit (ICU). Evidence Acquisition We performed a systematic literature review of randomized controlled trials (RCTs) and observational studies up to January 2025, adhering to Cochrane Collaboration guidelines. Studies were included if they assessed fluid balance in patients receiving albumin in conjunction with diuretics or RRT for fluid removal. The primary outcome was average daily net fluid balance and secondary outcomes included mortality, ventilator-free days, length of stay, acute kidney injury and change in Sequential Organ Failure Assessment score. Evidence Synthesis Only four studies involving 196 patients have evaluated net fluid balance in patients receiving albumin as an adjunct to diuretics. Our analysis revealed no significant difference in the average daily net fluid balance between the albumin and control groups (mean difference: -0.22 L/d; 95% CI: -0.88 to 0.43; with high heterogeneity in the reported results. Insufficient data on secondary outcomes was found. No data on the safety-profile in fluid de-resuscitation and on cost-effectiveness are currently available. The methodology of the existing literature is biased, contradictory and of poor overall quality. Conclusions This review of albumin co-administration with diuretics and/or RRT in fluid de-resuscitation in the critical ill underscores the limited and often contradictory evidence currently available, despite the frequent use of this practice in clinical settings. Further high-quality research is warranted to determine its efficacy in achieving negative fluid balance and to clarify its impact on clinically relevant patient outcomes.
Faltys et al. (Sun,) studied this question.