Comparison of 6% hydroxyethyl starch 130/0.4 vs 5% albumin in cardiopulmonary bypass for cardiac surgery

Abstract

BACKGROUND

The choice of priming and volume replacement fluids during cardiopulmonary bypass (CPB) in cardiac surgery impacts hemodynamic stability, coagulation, renal function, and patient outcomes. Hydroxyethyl starch (HES) 130/0.4 and human albumin are commonly used colloids, but their relative safety and efficacy remain debated.

AIM

To compare the outcomes of 6% HES 130/0.4 vs 5% albumin in patients undergoing cardiac surgery with CPB.

METHODS

A comprehensive literature search was performed in PubMed, EMBASE, ScienceDirect, and grey literature sources up to August 2025. Randomized controlled trials and controlled observational studies comparing 6% HES 130/0.4 with 5% albumin in patients who underwent cardiac surgery were included. Data extraction and risk of bias assessment followed PRISMA and Cochrane guidelines. Meta-analyses were conducted using RevMan 5.4, applying random-effects models. Heterogeneity was assessed with I² statistics, and meta-regression explored baseline covariables. Publication bias was evaluated with funnel plots and the Egger’s test.

RESULTS

Twelve studies involving 908 patients (455 in the HES group, 453 in the albumin group) were included. No significant differences were observed between the HES and albumin groups for postoperative blood loss [mean difference = 42.4 mL, 95% confidence interval (CI): -90.0 to 174.9; P = 0.53], packed red blood cell transfusion [odds ratio (OR) = 0.78, 95%CI: 0.65-1.10; P = 0.16)], mortality (OR = 1.11, 95%CI: 0.63-1.96; P = 0.80), intensive care unit stay, hospital stay, or postoperative platelet count and creatinine levels. However, HES was associated with a significantly higher risk of acute kidney injury (AKI) (OR = 1.79, 95%CI: 1.08-2.97; P = 0.02), indicating that while many clinical outcomes showed no significant difference, there is a specific safety concern related to renal function with HES use. Meta-regression did not identify baseline factors explaining heterogeneity in bleeding or AKI outcomes (all P > 0.10). No significant publication bias was detected.

CONCLUSION

The 6% HES 130/0.4 and 5% albumin exhibit similar efficacy for volume management in cardiac surgery with CPB; however, HES is associated with a higher risk of AKI.

Keywords: Cardiopulmonary bypass; Cardiac surgery; Hydroxyethyl starch; Albumin; Acute kidney injury; Platelet count; Blood loss

Core Tip: This meta-analysis systematically compared 6% hydroxyethyl starch 130/0.4 and 5% human albumin as priming and volume replacement fluids in cardiac surgery with cardiopulmonary bypass. It highlighted comparable safety and efficacy profiles between the two colloids in terms of bleeding, transfusion needs, intensive care unit stay, and mortality while identifying a higher risk of acute kidney injury associated with hydroxyethyl starch. These findings challenge traditional preferences and emphasize the need for individualized fluid choice guided by patient factors and evolving regulatory considerations in perioperative cardiac care.