Early Albumin Use and Mortality in Critically III Children with Severe Hypoalbuminemia: a Target Trial Emulation Study

Hypoalbuminemia is highly prevalent in critically ill children and is an established independent risk factor for mortality. Whether albumin supplementation is associated with improved survival remains unclear, particularly in pediatric populations where causal evidence is sparse. This retrospective cohort study used data from the Pediatric Intensive Care (PIC) database, a single-center pediatric-specific critical care database in China, and adopted a target trial emulation (TTE) framework. Children whose first albumin measurement within 24 h of ICU admission was below 30 g/L were included (N = 1,649). Time zero was defined as the first detection of albumin below 30 g/L. The exposure was receipt of at least one dose of human albumin within 24 h after time zero. Primary outcomes were 7-day and 28-day all-cause mortality, estimated using IPTW-weighted Cox proportional hazards models with doubly robust adjustment. Sensitivity to unmeasured confounding was assessed by E-value. Among 1,649 children, 374 (22.7