A Comment on a Meta-analysis That Suggests Efficacy of Albumin in Burn Shock Resuscitation

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In Navickis et al,1 the “significant baseline risk imbalances” within the two case–control studies result in the authors’ choice to include adjusted data, introducing a risk of bias. The mortality rate in Cochran et al2 was adjusted from a 1.9-fold increase in mortality with albumin vs controls (95% confidence interval [CI]: 0.8–4.2) to an odds ratio (OR) of 0.25 (95% CI: 0.07–0.88) because of a massive effect of inhalation injuries in that sample (OR = 37.61). It is misleading to report that albumin patients were more likely to survive when they were more likely to die as described in the original article. Allocation bias plays a role in imbalanced baseline characteristics in retrospective analyses, which biases the unadjusted results. However, the selective reporting of only adjusted data is equally biased and needs to be more transparent. The underlying study also has a 3-fold increase in acute respiratory distress syndrome in the albumin-treated patients (unadjusted OR = 3.13, 95% CI: 1.76–5.55), which should be present in Figure 4.
The “before” and “after” studies3,4 labeled as “non-albumin” vs “albumin” misrepresent the underlying data. Neither background publication has information for the subset of patients who received albumin compared with those who did not. In the article by Park et al3, 59% of patients represented herein as “albumin” patients did not actually receive colloid therapy. The article by Ennis et al4 does not state the fraction of patients who received albumin. These nonrandomized studies provide the majority of the weight in Figures 1 and 2, and inferences from these analyses are therefore limited.
In a prior meta-analyses, burn patients demonstrated increase in mortality when treated with albumin (OR = 1.765; 95% CI: 0.97–3.17 and OR = 2.46; 95% CI: 1.11–5.19) vs non-albumin-treated patients. The added studies are not high enough quality to reverse this trend.
The author would like to thank Dr. Christine N Yost, PharmD, and Dr. Alison Paplaskas, PharmD, for their review and comments.
This letter to the editor discusses the use of albumin off-label for the resuscitation of burn shock patients. This discussion is in reference to original articles and their analysis of this off-label use.
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