Effect of waxy maize-derived hydroxyethyl starch 130/0.4 on renal function in surgical patients. Anesthesiology. 2013;118:387-394. [PMID: 23340352 DOI: 10.1097/aln.0b013e31827e5569]

Postoperative Acute Kidney Injury and Blood Product Transfusion After Synthetic Colloid Use During Cardiac Surgery

OBJECTIVES

This study assessed the effect of 2 types of hydroxyethyl starches (HES) on renal integrity and blood transfusion in cardiac surgery patients.

DESIGN

Retrospective investigation.

SETTING

Patients from a single tertiary medical center.

PARTICIPANTS

Inclusion criteria included coronary artery bypass graft (CABG) and/or valve surgery that included cardiopulmonary bypass with aortic cross-clamping.

INTERVENTIONS

Intraoperative HES and blood product administration.

MEASUREMENTS AND MAIN RESULTS

The study comprised 1,265 patients who met inclusion criteria. Of these patients, 70% received HES, and of these, 47% received<1,000 mL and 53% received≥1,000 mL. There was no difference in the development of acute kidney injury between the 2 groups. A parsimonious propensity model for colloids showed that combined CABG and valve surgery were less likely to be associated with HES administration than was CABG alone (OR 0.68, confidence interval [CI] 0.46-0.97; p = 0.04). Intra-aortic balloon pump use was less likely to be associated with HES administration (OR 0.57, CI 0.38-0.86; p = 0.007). Patients with chronic kidney disease, stages 3 to 5, were less likely to receive HES, with an OR of 0.56 (CI 0.38-0.84; p = 0.004); 0.51 (CI 0.20-1.33; p = 0.170); and 0.23 (CI 0.12-0.44; p<0.0001), respectively, for each stage. No difference was noted in red blood cell transfusion. However, fresh frozen plasma, cryoprecipitate, and platelet transfusions were significantly higher with larger volumes of HES, with an OR of 2.03 (CI 1.64-2.52; p<0.001); 1.60 (CI 1.30-1.97; p<0.000); and 1.62 (CI 1.21-2.15; p = 0.006), respectively. No differences in surgical mortality were found between the colloid and noncolloid groups.

CONCLUSIONS

This study showed no association of postoperative acute kidney injury and red blood cell transfusion between the colloid and noncolloid groups. Although the complication rate was higher with HES administration, there was no difference in surgery mortality between the 2 groups.

Effects of 6% hydroxyethyl starch 130/0.4 on postoperative blood loss and kidney injury in off-pump coronary arterial bypass grafting: A retrospective study

We retrospectively evaluated the effects of 6% hydroxyethyl starch (HES) 130/0.4 on postoperative blood loss and acute kidney injury (AKI) in patients undergoing off-pump coronary artery bypass grafting (OPCAB).Electronic medical records of 771 patients who underwent OPCAB in our hospital between July 2012 and July 2014 were reviewed, and 249 patients without intraoperative HES-exposure (group NoHES) were matched 1:N with intraoperative HES-exposed 413 patients (group HES) based on propensity score. The effects of intraoperative HES on postoperative cumulative blood loss within the first 24 hours, need for bleeding-related reoperation, and occurrence of postoperative AKI (determined by KDIGO and RIFLE criteria) were analyzed.In our propensity score matched cohort, there were no significant differences between groups for median postoperative 24 hours blood loss (525 mL in group HES vs. 540 mL in group NoHES, P = .203) or need for bleeding-related reoperation (OR, 2.44; 95% confidence interval [CI], 0.64-9.34, P = .19). However, postoperative AKI (assessed by 2 criteria) occurred more frequently in group HES than in group NoHES (by KDIGO criteria: 10.7% vs. 3.6%; OR 3.43 [95% CI, 1.67-7.04]; P < .001 and by RIFLE criteria: 9.6% vs. 2%; OR 3.32 [95% CI, 1.34-8.24]; P = .01). The median volume of infused HES per patient weight was 16 mL/kg in group HES.In the patients undergoing OPCAB, intraoperative 6% HES 130/0.4 did not increase postoperative bleeding. However, renal safety remains a concern. Intraoperative use of HES should be determined cautiously during OPCAB.

Administration of HES in elderly patients undergoing hip arthroplasty under spinal anesthesia is not associated with an increase in renal injury

Background

Hydroxyethyl starch (HES) is applied to achieve volume expansion during surgery; however, nephrotoxicity may be induced in patients with sepsis. Simultaneously, neutrophil gelatinase-associated lipocalin (NGAL) and IL-18 have been illustrated as pivotal indicators to diagnose the acute kidney injury (AKI) early. This multi-center, randomized, double-blinded, placebo-controlled study aimed to investigate whether 6% HES 130/0.4 administration caused postoperative AKI, which can be revealed by urinary and plasma NGAL and IL-18 estimations in elderly patients with normal renal function undergoing hip arthroplasty under spinal anesthesia.

Methods

120 ASA I–III, patients aged >65 y undergoing hip arthroplasty under spinal anesthesia randomly received 6% HES 130/0.4 or sodium lactate Ringer’s solution 7.5 mL/kg during the first hour of surgery. 118 patients completed the study. Blood pressure, NGAL concentrations, IL18, β₂ micro-albumin and albumin in urine and creatinine, NGAL and IL-18 in plasma were repeatedly measured before, during, and after surgery.

Results

The groups were balanced in mean arterial pressure, urine and plasma NGAL, plasma IL-18 and creatinine, urine β₂ microalbumin and albumin (P > 0.05). Urine IL-18 was dramatically elevated in both groups after surgery (P < 0.05), but did not vary significantly between the groups (P > 0.05).

Conclusion

Elderly patients undergoing surgery under spinal anesthesia are a high-risk population in AKI. These patients with normal renal function receiving a spinal anesthesia for a short duration surgery would not develop AKI when 500 mL (small volume) HES is infused.

Trial registration

Identifier: NCT02361736. Registration date was 2 February 2015.

Perioperative intravenous fluid therapy in children: guidelines from the Association of the Scientific Medical Societies in Germany

This consensus- based S1 Guideline for perioperative infusion therapy in children is focused on safety and efficacy. The objective is to maintain or re-establish the child's normal physiological state (normovolemia, normal tissue perfusion, normal metabolic function, normal acid- base- electrolyte status). Therefore, the perioperative fasting times should be as short as possible to prevent patient discomfort, dehydration, and ketoacidosis. A physiologically composed balanced isotonic electrolyte solution (BS) with 1-2.5% glucose is recommended for the intraoperative background infusion to maintain normal glucose concentrations and to avoid hyponatremia, hyperchloremia, and lipolysis. Additional BS without glucose can be used in patients with circulatory instability until the desired effect is achieved. The additional use of colloids (albumin, gelatin, hydroxyethyl starch) is recommended to recover normovolemia and to avoid fluid overload when crystalloids alone are not sufficient and blood products are not indicated. Monitoring should be extended in cases with major surgery, and autotransfusion maneuvers should be performed to assess fluid responsiveness.

Acute kidney injury in the perioperative period and in intensive care units (excluding renal replacement therapies)

Acute kidney injury (AKI) is a syndrome that has progressed a great deal over the last 20 years. The decrease in urine output and the increase in classical renal biomarkers, such as blood urea nitrogen and serum creatinine, have largely been used as surrogate markers for decreased glomerular filtration rate (GFR), which defines AKI. However, using such markers of GFR as criteria for diagnosing AKI has several limits including the difficult diagnosis of non-organic AKI, also called "functional renal insufficiency" or "pre-renal insufficiency". This situation is characterized by an oliguria and an increase in creatininemia as a consequence of a reduction in renal blood flow related to systemic haemodynamic abnormalities. In this situation, "renal insufficiency" seems rather inappropriate as kidney function is not impaired. On the contrary, the kidney delivers an appropriate response aiming to recover optimal systemic physiological haemodynamic conditions. Considering the kidney as insufficient is erroneous because this suggests that it does not work correctly, whereas the opposite is occurring, because the kidney is healthy even in a threatening situation. With current definitions of AKI, normalization of volaemia is needed before defining AKI in order to avoid this pitfall.

Effect of Hydroxyethyl Starch on Acute Kidney Injury After Living Donor Hepatectomy

BACKGROUND

Concerns about the adverse effects of hydroxyethyl starch (HES) on renal function have been raised in recent studies involving critically ill patients. We aimed to evaluate the effect of HES on acute kidney injury (AKI) after living donor right hepatectomy.

METHODS

We performed a 1:3 propensity score matching analysis of the medical records of 1641 living donors who underwent a donor right hepatectomy. They were divided into the control group (n = 60), who received only crystalloids, and the colloid group (n = 1,581), who received HES 130/0.4 and crystalloids. Postoperative AKI was determined by AKI Network (AKIN) and Risk, Injury, Failure, Loss, End-stage (RIFLE) criteria.

RESULTS

A 1:3 propensity score matching was performed in 206 donors, 54 donors in the control group and 152 donors in the colloid group. For the matched colloid group, the median amount of 7.65 mL/kg (interquartile range, 6.64-9.20) of colloid and 58.19 mL/kg (interquartile range, 45.63-71.51) of crystalloid were given. The median amount of administered crystalloid in the control group was 56.48 mL/kg (interquartile range, 47.94-76.12) after propensity score matching. The incidences of AKI were not different between the control and colloid groups (P = .460 by AKIN criteria; P = .999 by RIFLE criteria).

CONCLUSION

Intraoperative administration of HES may not be associated with AKI after living donor hepatectomy. This result can provide useful information on perioperative fluid management in living liver donors.

Impact of balanced tetrastarch raw material on perioperative blood loss: a randomized double blind controlled trial

BACKGROUND

As 6% hydroxyethyl starch (HES) 130/0.40 or 130/0.42 can originate from different vegetable sources, they might have different clinical effects. The purpose of this prospective, randomized, double-blind controlled trial was to compare two balanced tetrastarch solutions, one maize-derived and one potato-derived, on perioperative blood loss in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB).

METHODS

We randomly assigned 118 patients undergoing elective cardiac surgery into two groups, to receive either a maize- or a potato-derived HES solution. Study fluids were administered perioperatively (including priming of CPB) until the second postoperative day (POD#2) using a goal directed algorithm. The primary outcome was calculated postoperative blood loss up to POD#2. Secondary outcomes included short-term incidence of acute kidney injury (AKI), and long-term effect (up to one yr) on renal function.

RESULTS

Preoperative and intraoperative characteristics of the subjects were similar between groups. Similar volumes of HES were administered (1950 ml [1250-2325] for maize-HES and 2000 ml [1500-2700] for potato-HES; P=0.204). Calculated blood loss (504 ml [413-672] for maize-HES vs 530 ml [468-705] for potato-HES; P=0.107) and the need for blood components were not different between groups. The incidence of AKI was similar in both groups (P=0.111). Plasma creatinine concentration and glomerular filtration rates did vary over time, although changes were minimal.

CONCLUSIONS

Under our study conditions, HES 130/0.4 or 130/0.42 raw material did not have a significant influence on perioperative blood loss. Moreover, we did not find any effect of tetrastarch raw material composition on short and long-term renal function.

CLINICAL TRIAL REGISTRATION

EudraCT number: 2011-005920-16.

Controversies in the use of hydroxyethyl starch solutions in small animal emergency and critical care

OBJECTIVES

To (1) review the development and medical applications of hydroxyethyl starch (HES) solutions with particular emphasis on its physiochemical properties; (2) critically appraise the available evidence in human and veterinary medicine, and (3) evaluate the potential risks and benefits associated with their use in critically ill small animals.

DATA SOURCES

Human and veterinary original research articles, scientific reviews, and textbook sources from 1950 to the present.

HUMAN DATA SYNTHESIS

HES solutions have been used extensively in people for over 30 years and ever since its introduction there has been a great deal of debate over its safety and efficacy. Recently, results of seminal trials and meta-analyses showing increased risks related to kidney dysfunction and mortality in septic and critically ill patients, have led to the restriction of HES use in these patient populations by European regulatory authorities. Although the initial ban on the use of HES in Europe has been eased, proof regarding the benefits and safety profile of HES in trauma and surgical patient populations has been requested by these same European regulatory authorities.

VETERINARY DATA SYNTHESIS

The veterinary literature is limited mostly to experimental studies and clinical investigations with small populations of patients with short-term end points and there is insufficient evidence to generate recommendations.

CONCLUSIONS

Currently, there are no consensus recommendations regarding the use of HES in veterinary medicine. Veterinarians and institutions affected by the HES restrictions have had to critically reassess the risks and benefits related to HES usage based on the available information and sometimes adapt their procedures and policies based on their reassessment. Meanwhile, large, prospective, randomized veterinary studies evaluating HES use are needed to achieve relevant levels of evidence to enable formulation of specific veterinary guidelines.

Algorithm-guided goal-directed haemodynamic therapy does not improve renal function after major abdominal surgery compared to good standard clinical care: a prospective randomised trial

BACKGROUND

Acute kidney injury is a common complication after major surgery. In this study, we investigated whether an algorithm-guided goal-directed haemodynamic therapy (GDT) can improve renal outcome compared to good standard clinical care.

METHODS

A total of 180 patients undergoing major abdominal surgery were prospectively and randomly assigned to one of two groups: in the GDT group, patients were treated with a GDT algorithm using transpulmonary thermodilution while standard care was applied to the control patients. Change in creatinine was studied as the primary end point, postoperative complications as well as 1-year mortality as secondary outcomes. Haemodynamics in GDT and control patients were compared calculating goal-achievement rates.

RESULTS

Postoperative change in creatinine (18 ± 39 μmol/l (control) vs. 16 ± 42 μmol/l (GDT); mean difference (95 % confidence interval) 1.6 μmol/l (-10 to 13 μmol/l)) was comparable between the GDT and the control group. Postoperative complications and mortality during hospital stay and after 1 year were not influenced by the use of a GDT algorithm. Achievement rates of haemodynamic goals were not higher in the GDT group compared to the already high (>80 %) rates in the control group. Multivariate regression analysis revealed intraoperative hypotension (MAP < 70 mmHg) and postoperative hypovolaemia (GEDI < 640 ml/m(2)) as risk factors for postoperative renal impairment.

CONCLUSIONS

In this study, GDT was not superior to standard clinical care in order to avoid renal failure after major abdominal surgery. The reason for this finding is most likely the high achievement rate of haemodynamic goals in the control group, which cannot be improved by the GDT algorithm.

TRIAL REGISTRATION

Clinicaltrials.gov; NCT01035541; registered 17 December 2009.

Effect of Hydroxyethyl Starch on Outcomes in High-Risk Vascular Surgery Patients: A Retrospective Analysis

OBJECTIVE

To assess the effect of using hydroxyethyl starch (HES) for intraoperative fluid therapy on outcomes in high-risk vascular surgery patients.

DESIGN

Retrospective case series.

SETTING

Single-center academic hospital.

PARTICIPANTS

The study included 1,395 adult vascular surgery patients with peripheral vascular disease.

INTERVENTIONS

Retrospective review of hospital databases.

MEASUREMENTS AND MAIN RESULTS

Outcomes were compared between patients who were intraoperatively administered HES (Voluven [Fresenius Kabi, Bad Homburg, Germany] or Pentaspan [Bristol-Myers Squibb Canada, Montreal, Quebec, Canada]) versus patients who received only crystalloids during their procedure. Logistic regression was used to assess for association between these groups and mortality (in-hospital, 30-day), intensive care unit admission, hemodialysis requirement, vasopressor requirement, and ventilator requirement. Overall, 796 patients had complete fluid records and were included in the analysis. After adjustment for potential confounders, receiving an HES solution was associated with increased likelihood of 30-day mortality (odds ratio [OR] 2.11, 95% confidence interval [CI] 1.05-3.80), postoperative requirement for hemodialysis (OR 6.17, 95% CI 1.09-35.10), intensive care unit admission (OR 3.52, 95% CI 2.15-5.74), and mechanical ventilation (OR 3.16, 95% CI 1.84-5.41).

CONCLUSIONS

Intraoperative administration of HES was associated with an increased likelihood of adverse outcomes compared with use of crystalloids alone.

To use or not to use hydroxyethyl starch in intraoperative care: are we ready to answer the 'Gretchen question'?

PURPOSE OF REVIEW

The decision of the European Medicines Agency (EMA) against the use of hydroxyethyl starch (HES)-based volume replacement solutions in critically ill patients has led to a general uncertainty when dealing with HES-based solutions, even though HES-containing solutions can still be used for the treatment of hypovolaemia caused by acute (sudden) blood loss. This review discusses current evidence of the intraoperative use of HES-based solutions.

RECENT FINDINGS

HES solutions are often criticized for possible side-effects on the kidney, the coagulation system or tissue storage. Relevant differences exist between modern 6% HES 130/0.4 and older generation of starches. Because of pathophysiological differences between elective surgery and critical illness, the evidence on renal injury and coagulation impairment with HES administration cannot be generalized. Current data suggest that there is no clinically relevant impact of 6% HES 130/0.4 administration on perioperative renal function and coagulation. Over-resuscitation is a frequent problem associated with adverse outcomes. Due to the higher volume effect, fluid overload with HES is probably more harmful than with crystalloids, whereas goal-directed use of HES may be able to reduce intraoperative fluid accumulation and overload.

SUMMARY

The use of 6% HES 130/0.4 in elective surgery patients is associated with reduced fluid accumulation and no clinically relevant difference in bleeding or the rate of acute kidney injury as compared with crystalloid use alone. Current data do not allow a conclusion on mortality. As they provide no benefit, older starch preparations should not be used.

Fluid loading in abdominal surgery - saline versus hydroxyethyl starch (FLASH Trial): study protocol for a randomized controlled trial

Background

Inappropriate fluid therapy during surgery is associated with significant morbidity and mortality. Few studies have examined the effects of particular types of fluids (crystalloid or colloid solutions) in surgical patients, especially with the goal of hemodynamic optimization. Isotonic saline is the most commonly used fluid worldwide but may be associated with potential nephrotoxicity. Hydroxyethyl starch (HES) solutions are widely used in surgical patients as a component of goal-directed fluid optimization strategies, but several large multicenter studies have suggested increased rates of acute kidney injury and adverse events with the use of HES in ICU patients. Despite what may be inferred from physiological studies, the benefit and harm of 0.9 % saline and HES during hemodynamic therapy have not been clearly established in surgical patients.

Methods/Design

The FLASH trial is an investigator-initiated, prospective, multicenter, randomized, double-blinded, two-arm trial, randomizing 826 patients with moderate-to-high risk of postoperative complications to receive 6 % HES 130/0.4 or 0.9 % saline during individualized goal-directed fluid optimization. The primary outcome measure is a composite of death or major postoperative complications within 14 days following surgery.

The sample size will allow the detection of a 10 % absolute between-group difference in the primary outcome measure with a type 1 error rate of 5 % and power of 95 %, assuming a 5 % mortality rate and 20 % morbidity (thus 25 % for the composite endpoint).

Discussion

The FLASH trial may provide important data on the efficacy and safety of commonly used fluid solutions and could have a significant impact on future treatment of surgical patients.

Trial registration

ClinicalTrials.gov Identifier: NCT02502773. Registered 16 June 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-1085-3) contains supplementary material, which is available to authorized users.

Fluid management in living donor hepatectomy: Recent issues and perspectives

The importance of the safety of healthy living liver donors is widely recognized during donor hepatectomy which is associated with blood loss, transfusion, and subsequent post-operative morbidity. Although the low central venous pressure (CVP) technique can still be effective, it may not be advantageous concerning the safety of healthy donors undergoing hepatectomy. Emerging evidence suggests that stroke volume variation (SVV), a simple and useful index for fluid responsiveness and preload status in various clinical situations, can be applied as a guide for fluid management to reduce blood loss during living donor hepatectomy. Synthetic colloid solutions are also associated with serious adverse events such as the use of renal replacement therapy and transfusion in critically ill or septic patients. However, it is uncertain whether the intra-operative use of colloid solution is associated with similarly adverse effects in patients undergoing living donor hepatectomy. In this review article we discuss the recent issues regarding the low CVP technique and the high SVV method, i.e., maintaining 10%-20% of SVV, for fluid management in order to reduce blood loss during living donor hepatectomy. In addition, we briefly discuss the effects of intra-operative colloid or crystalloid administration for surgical rather than septic or critically ill patients.

Beautiful small: Misleading large randomized controlled trials? The example of colloids for volume resuscitation

In anesthesia and intensive care, treatment benefits that were claimed on the basis of small or modest-sized trials have repeatedly failed to be confirmed in large randomized controlled trials. A well-designed small trial in a homogeneous patient population with high event rates could yield conclusive results; however, patient populations in anesthesia and intensive care are typically heterogeneous because of comorbidities. The size of the anticipated effects of therapeutic interventions is generally low in relation to relevant endpoints. For regulatory purposes, trials are required to demonstrate efficacy in clinically important endpoints, and therefore must be large because clinically important study endpoints such as death, sepsis, or pneumonia are dichotomous and infrequently occur. The rarer endpoint events occur in the study population; that is, the lower the signal-to-noise ratio, the larger the trials must be to prevent random events from being overemphasized. In addition to trial design, sample size determination on the basis of event rates, clinically meaningful risk ratio reductions and actual patient numbers studied are among the most important characteristics when interpreting study results. Trial size is a critical determinant of generalizability of study results to larger or general patient populations. Typical characteristics of small single-center studies responsible for their known fragility include low variability of outcome measures for surrogate parameters and selective publication and reporting. For anesthesiology and intensive care medicine, findings in volume resuscitation research on intravenous infusion of colloids exemplify this, since both the safety of albumin infusion and the adverse effects of the artificial colloid hydroxyethyl starch have been confirmed only in large-sized trials.

Ringer's lactate, but not hydroxyethyl starch, prolongs the food intolerance time after major abdominal surgery; an open-labelled clinical trial

Background

The infusion of large amounts of Ringer’s lactate prolongs the functional gastrointestinal recovery time and increases the number of complications after open abdominal surgery. We performed an open-labelled clinical trial to determine whether hydroxyethyl starch or Ringer’s lactate exerts these adverse effects when the surgery is performed by laparoscopy.

Methods

Eighty-eight patients scheduled for major abdominal cancer surgery (83% by laparoscopy) received a first-line fluid treatment with 9 ml/kg of either 6% hydroxyethyl starch 130/0.4 (Voluven) or Ringer’s lactate, just after induction of anaesthesia; this was followed by a second-line infusion with 12 ml/kg of either starch or Ringer’s lactate over 1 hour. Further therapy was managed at the discretion of the attending anaesthetist. Outcome data consisted of postoperative gastrointestinal recovery time, complications and length of hospital stay.

Results

The order of the infusions had no impact on the outcome. Both the administration of ≥ 2 L of Ringer’s lactate and the development of a surgical complication were associated with a longer time period of paralytic ileus and food intolerance (two-way ANOVA, P < 0.02), but only surgical complications prolonged the length of hospital stay (P < 0.001). The independent effect of Ringer’s lactate and complications of food intolerance time amounted to 2 days each. The infusion of ≥ 1 L of hydroxyethyl starch did not adversely affect gastrointestinal recovery.

Conclusions

Ringer’s lactate, but not hydroxyethyl starch, prolonged the gastrointestinal recovery time in patients undergoing laparoscopic cancer surgery. Surgical complications prolonged the hospital stay.

Colloids versus crystalloids in objective-guided fluid therapy, systematic review and meta-analysis. Too early or too late to draw conclusions

INTRODUCTION

Several clinical trials on Goal directed fluid therapy (GDFT) were carried out, many of those using colloids in order to optimize the preload. After the decision of European Medicines Agency, there is such controversy regarding its use, benefits, and possible contribution to renal failure. The objective of this systematic review and meta-analysis is to compare the use of last-generation colloids, derived from corn, with crystalloids in GDFT to determine associated complications and mortality.

METHODS

A bibliographic research was carried out in MEDLINE PubMed, EMBASE and Cochrane Library, corroborating randomized clinical trials where crystalloids are compared to colloids in GDFT for major non-cardiac surgery in adults.

RESULTS

One hundred thirty references were found and among those 38 were selected and 29 analyzed; of these, six were included for systematic review and meta-analysis, including 390 patients. It was observed that the use of colloids is not associated with the increase of complications, but rather with a tendency to a higher mortality (RR [95% CI] 3.87 [1.121-13.38]; I(2)=0.0%; p=0.635).

CONCLUSIONS

Because of the limitations of this meta-analysis due to the small number of randomized clinical trials and patients included, the results should be taken cautiously, and the performance of new randomized clinical trials is proposed, with enough statistical power, comparing balanced and unbalanced colloids to balanced and unbalanced crystalloids, following the protocols of GDFT, considering current guidelines and suggestions made by groups of experts.

Prevention of renal dysfunction in postoperative elderly patients

PURPOSE OF REVIEW

To describe the effect of ageing on kidney function and to summarize the benefits of advocated measures to prevent perioperative acute kidney injury (AKI) in elderly patients.

RECENT FINDINGS

Given a reduced renal reserve and the burden of comorbidities, the senescent kidney is susceptible to develop perioperative AKI and is less able to recover when injury occurs. Current evidence suggests that preoperative statin therapy, tight glycemic control or urine alkalinization with bicarbonate do not protect the kidneys from harm. The theoretical kidney protective effect of preoperative aspirin therapy or renal vasodilatation with atrial natriuretic peptide or fenoldopam is only supported by low-quality evidence that needs further evaluation. Although questions regarding the amount and timing of fluid resuscitation during surgery are seeking answers in ongoing multicenter studies, the harmful effect of hydroxyethyl starches (HES) and hyperchloremic solutions is now surrounded by strong evidence.

SUMMARY

The future increase in elderly patients being exposed to surgery calls for improved perioperative management to prevent collaterally increased AKI. Although pharmacological therapies aiming to protect the kidneys from harm are under evaluation, hemodynamic optimization and avoidance of nephrotoxic drugs, including HES and hyperchloremic solutions, are critical for the elderly perioperative patient.

Use of perioperative hydroxyethyl starch 6% and albumin 5% in elective joint arthroplasty and association with adverse outcomes: a retrospective population based analysis

OBJECTIVE

To determine whether the perioperative use of hydroxyethyl starch 6% and albumin 5% in elective joint arthroplasties are associated with an increased risk for perioperative complications.

DESIGN

Retrospective cohort study of population based data between 2006 and 2013.

SETTING

Data from 510 different hospitals across the United States participating in the Premier Perspective database.

PARTICIPANTS

1,051,441 patients undergoing elective total hip and knee arthroplasties.

EXPOSURES

Perioperative fluid resuscitation with hydroxyethyl starch 6% or albumin 5%, or neither.

MAIN OUTCOME MEASURES

Acute renal failure and thromboembolic, cardiac, and pulmonary complications.

RESULTS

Compared with patients who received neither colloid, perioperative fluid resuscitation with hydroxyethyl starch 6% or albumin 5% was associated with an increased risk of acute renal failure (odds ratios 1.23 (95% confidence interval 1.13 to 1.34) and 1.56 (1.36 to 1.78), respectively) and most other complications. A recent decrease in hydroxyethyl starch 6% use was noted, whereas that of albumin 5% increased.

CONCLUSIONS

Similar to studies in critically ill patients, we showed that use of hydroxyethyl starch 6% was associated with an increased risk of acute renal failure and other complications in the elective perioperative orthopedic setting. This increased risk also applied to albumin 5%. These findings raise questions regarding the widespread use of these colloids in elective joint arthroplasty procedures.

Hydroxyethyl starch versus other fluids for non-septic patients in the intensive care unit: a meta-analysis of randomized controlled trials

INTRODUCTION

Use of hydroxyethyl starch (HES) in septic patients is reported to increase the mortality and incidence of renal replacement therapy (RRT). However, whether or not use of HES would induce the same result in non-septic patients in the intensive care unit (ICU) remains unclear. The objective of this meta-analysis was to evaluate 6% HES versus other fluids for non-septic ICU patients.

METHODS

Randomized controlled trials (RCTs) were searched from Pubmed, OvidSP, Embase database and Cochrane Library, published before November, 2013. A meta-analysis was made on the effect of 6% HES versus other fluids for non-septic ICU patients, including mortality, RRT incidence, bleeding volume, red blood cell (RBC) transfusion and fluid application for non-septic patients in ICU.

RESULTS

Twenty-two RCTs were included, involving 6,064 non-septic ICU patients. Compared with the other fluids, 6% HES was not associated with decreased overall mortality (RR = 1.03, 95%CI: 0.09 to 1.17; P = 0.67; I(2) = 0). There was no significant difference in RRT incidence, bleeding volume and red blood cell transfusion between 6% HES group and the other fluid groups. However, patients in HES group received less total intravenous fluids than those receiving crystalloids during the first day in ICU (SMD = -0.84; 95%CI: -1.39 to -0.30; P = 0.003, I(2) = 74%).

CONCLUSIONS

This meta-analysis found no increased mortality, RRT incidence, bleeding volumes or RBC transfusion in non-septic ICU patients, but the sample sizes were small and the studies generally were of poor quality.

Efficacy and safety of 6% hydroxyethyl starch 130/0.4 (Voluven) for perioperative volume replacement in children undergoing cardiac surgery: a propensity-matched analysis

INTRODUCTION

Six percent hydroxyethyl starch (HES) 130/0.4 is considered an alternative to human albumin (HA) and crystalloids for volume replacement in children undergoing cardiac surgery. In this large propensity-matched analysis, we aimed to assess the efficacy and safety of replacing HA with HES for intraoperative volume therapy in children undergoing cardiac surgery with cardiopulmonary bypass (CPB).

METHODS

We retrospectively reviewed our database, including children who underwent cardiac surgery between January 2002 and December 2010. Four percent HA was used until 2005; it was replaced by HES thereafter. Demographic data, intra- and postoperative blood loss and blood component transfusions were recorded, together with the incidence of postoperative complications and mortality. We performed a propensity-matched analysis using 13 possible confounding factors to compare children who received either HES or HA intraoperatively. The primary objectives included the effects of both fluids on intraoperative fluid balance (difference between fluids in and fluids out (efficacy)) and blood loss and exposure to allogeneic blood products (safety). Secondary safety outcomes were mortality and the incidence of postoperative renal dysfunction.

RESULTS

Of 1,832 children reviewed, 1,495 were included in the analysis. Intraoperative use of HES was associated with a less positive fluid balance. Perioperative blood loss, volume of red blood cells and fresh frozen plasma administered, as well as the number of children who received transfusions, were also significantly lower in the HES group. No difference was observed regarding the incidence of postoperative renal failure requiring renal replacement therapy or of morbidity and mortality.

CONCLUSIONS

These results confirm that the use of HES for volume replacement in children during cardiac surgery with CPB is as safe as HA. In addition, its use might be associated with less fluid accumulation. Further large studies are needed to assess whether the reduction in fluid accumulation could have a significant impact on postoperative morbidity and mortality.

The impact of hydroxyethyl starches in cardiac surgery: a meta-analysis

Introduction

Recent studies in septic patients showed that adverse effects of hydroxyethyl starches (HESs) possibly outweigh their benefits in severely impaired physiological haemostasis. It remains unclear whether this also applies to patient populations that are less vulnerable. In this meta-analysis, we evaluated the impact of various HES generations on safety and efficacy endpoints in patients undergoing cardiac surgery.

Methods

We searched the PubMed, Embase and Cochrane Central Register of Controlled Trials databases for randomised controlled trials (RCTs) in the English or German language comparing the use of HES to any other colloid or crystalloid during open heart surgery.

Results

Blood loss and transfusion requirements were higher for older starches with mean molecular weights more than 200 kDa compared to other volume substitutes. In contrast, this effect was not observed with latest-generation tetrastarches (130/0.4), which performed even better when compared to albumin (blood loss of tetrastarch versus albumin: standardised mean difference (SMD), −0.34; 95% CI, −0.63, −0.05; P = 0.02; versus gelatin: SMD, −0.06; 95% CI, −0.20, 0.08; P = 0.39; versus crystalloids: SMD, −0.05; 95% CI, −0.20, 0.10; P = 0.54). Similar results were found for transfusion needs. Lengths of stay in the intensive care unit or hospital were significantly shorter with tetrastarches compared to gelatin (intensive care unit: SMD, −0.10; 95% CI, −0.15, −0.05; P = 0.0002) and crystalloids (hospital: SMD, −0.52; 95% CI, −0.90, −0.14; P = 0.007).

Conclusions

In this meta-analysis of RCTs, we could not identify safety issues with tetrastarches compared with other colloid or crystalloid solutions in terms of blood loss, transfusion requirements or hospital length of stay in patients undergoing cardiac surgery. The safety data on coagulation with older starches raise some issues that need to be addressed in future trials.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-014-0656-0) contains supplementary material, which is available to authorized users.

Lack of nephrotoxicity by 6% hydroxyethyl starch 130/0.4 during hip arthroplasty: a randomized controlled trial

BACKGROUND

Hydroxyethyl starch (HES) is commonly used as plasma expander during surgery but may be nephrotoxic as seen in studies in patients with sepsis. The authors hypothesized that the possible nephrotoxicity of 6% HES 130/0.4 could be revealed by measurements of urinary excretion of neutrophil gelatinase-associated lipocalin (u-NGAL) in patients with normal renal function during hip arthroplasty.

METHODS

In this randomized, double-blinded, placebo-controlled study, 40 patients referred for hip arthroplasty received either 6% HES 130/0.4 or isotonic saline 0.9%; 7.5 ml/kg during the first hour of surgery and 5 ml/kg during the following hours; 38 patients completed the study. U-NGAL, urine albumin, blood pressure, and plasma concentrations of creatinine, renin, NGAL, albumin, angiotensin-II, and aldosterone were measured before, during, and after surgery. U-NGAL was defined as primary outcome.

RESULTS

There were no significant differences in U-NGAL (mean difference and 95% CI), plasma creatinine, and urine albumin during the study. U-NGAL and urine albumin increased significantly in both groups the morning after surgery but was normalized at follow-up after 10 to 12 days. Mean arterial pressure was significantly higher during the recovery period in the HES group compared with that in the control group (91 [13] and 83 [6] mmHg, mean [SD], P < 0.03). Plasma renin and angiotensin-II were nonsignificantly different in both groups, whereas plasma aldosterone was significantly lower in the HES group. Plasma albumin was reduced in both groups, but to a significantly lower level in the HES group.

CONCLUSION

The study showed no evidence of a harmful effect of intraoperative infusion of 6% HES 130/0.4 on renal function in patients during hip arthroplasty.

Fluids in acute respiratory distress syndrome: pros and cons

PURPOSE OF REVIEW

Fluid resuscitation in acute respiratory distress syndrome (ARDS) is not well documented. Clinical evidence comes from studies in critically ill patients, but these patients respond differently to fluids depending on the presence or absence of sepsis.

RECENT FINDINGS

Clinical trials have shown adverse effects on kidney and hemostatic functions and trends toward increased mortality after hydroxyethyl starch infusion. Although well conducted, the methodology deserves attention concerning the infused volume, hemodynamic goals and the presence of septic and nonseptic patients. Small single-center studies have shown beneficial results associated with colloidal molecules through innovative methodological apparatus. Ongoing clinical trials allied to retrospective and prospective trials may favor the introduction of albumin in the critically ill population.

SUMMARY

In order to evaluate the pros and cons of using fluids in ARDS patients, it is important to carefully analyze the latest trials. Recent studies have emphasized the importance of better understanding endothelial pathophysiology during fluid management in ARDS patients. Certainly, further studies analyzing fluid strategies in septic and nonseptic ARDS patients are needed.

Hydroxyeyhyl starch: Controversies revisited

Hydroxyethyl starch (HES) family has been one of the cornerstones in fluid management for over four decades. Recent evidence from clinical studies and meta-analyses has raised few concerns about the safety of these fluids, especially in certain subpopulations of patients. High-quality clinical trials and meta-analyses have emphasized nephrotoxic effects, increased risk of bleeding, and a trend toward higher mortality in these patients after the use of HES solutions. Scientific evidence was derived from international guidelines, aggregated research literature, and opinion-based evidence was obtained from surveys and other activities (e.g., internet postings). On critical analysis of the current data available, it can be summarized that further large scale trials are still indicated before HES can be discarded.