Albumin Replacement in Severe Sepsis or Septic Shock

To the Editor: The Albumin Italian Outcome Sepsis study conducted by Caironi et al. (April 10 issue)1 is the third large-scale, randomized trial to compare albumin with crystalloids in adult patients with severe sepsis. The first such trial was the Saline versus Albumin Fluid Evaluation study.2 In addition, the Early Albumin Resuscitation during Septic Shock study has been completed and its mortality results published.3 In all three trials, mortality was lower among patients receiving albumin, and the respective relative risks coincided closely, ranging from 0.87 to 0.94 (Fig. 1). Although the effect did not attain statistical significance in any of the individual trials, the pooled relative risk in all three trials is 0.92 (95% confidence interval [CI], 0.84 to 1.00; P = 0.046), indicating a significant reduction in mortality associated with albumin use among adults with severe sepsis. This result supports the conclusion of a previous metaanalysis involving predominantly small trials with different control fluids and patient populations.4 The result is also consistent with the observed reduction in mortality associated with albumin use among patients with spontaneous bacterial peritonitis, a disease that shares important pathophysiological features with severe sepsis.5