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

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 I 2 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.