STUDY QUESTION What are the effects of fluid therapy with hydroxyethyl starch (HES) 130/0.38-0.45 versus crystalloid or albumin on mortality, kidney injury, bleeding, and serious adverse events in patients with sepsis? SUMMARY ANSWER In meta-analyses of trials with low risk of bias, HES 130/0.38-0.45 versus crystalloid or albumin may have increased mortality in patients with sepsis. The use of renal replacement therapy and red blood cells and the occurrence of serious adverse events were clearly increased with HES, and it seems unlikely that HES provides overall clinical benefit for patients with sepsis. WHAT IS KNOWN AND WHAT THIS PAPER ADDS HES 130/0.38-045 is the most commonly used colloid worldwide, but its safety and efficacy have not been established in patients with sepsis. This study pooled the results of existing randomised clinical trials and showed that treatment with HES increased the risk of having renal replacement therapy, transfusion with red blood cells, and serious adverse events.