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

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.