The safety of modern hydroxyethyl starch in living donor liver transplantation: a comparison with human albumin

Perioperative administration of albumin in adult patients undergoing liver transplantation: A systematic review

Hypoalbuminemia is a risk factor for mortality in patients with end-stage liver disease (ESLD) and in those undergoing orthotopic liver transplantation (OLT), since it represents a biomarker of post-operative delayed functional recovery of the graft. Despite albumin infusion during and after OLT is frequently adopted in recipients with hypoalbuminemia, it remains unclear whether this procedure could improve post OLT clinical outcomes. Observational studies indicated that treatment with albumin after OLT might be beneficial in reducing ascites and acute kidney injury (AKI) development. However, considering potential complications and the cost of albumin therapy, the decision to use albumin after OLT should be based on careful consideration of patient's individual needs and risks. In addition, the threshold plasma value of albumin below which it could be clinically useful to infuse albumin has not been clearly defined. This systematic review, prepared in accordance with the PRISMA 2020 guidelines, aimed to assess the efficacy of albumin infusion in patients undergoing OLT, in the prevention or treatment of ascites, AKI, and ischemia reperfusion syndrome, as well as its potential impact on patient survival. Furthermore, this review aimed to illustrate the pathophysiological bases justifying the use of albumin infusion in a subset of patients receiving OLT.

Anesthesia for Combined Heart-Liver Transplantation: A Narrative Review

In 1984, 21 years after the first liver transplantation, Thomas Starzl achieved a milestone by performing the world's first combined heart-liver transplantation. While still uncommon, the practice of combined heart-liver transplants is on the rise globally. In this review, the authors delve into the current literature on this procedure, highlighting the evolving landscape and key considerations for anesthesiologists. Over the years, there has been a remarkable increase in the number of combined heart-liver transplantations conducted worldwide. This surge is largely attributed to the growing population of adult survivors with single-ventricle physiology, palliated with a Fontan procedure, who later present with late Fontan failure and Fontan-associated liver disease. Research indicates that combined heart-liver transplantation is an effective treatment option, with reported outcomes comparable with isolated heart or liver transplants. Managing anesthesia during a combined heart-liver transplant procedure is challenging, especially in the context of underlying Fontan physiology. International experience in this field remains somewhat limited, with most techniques derived from expert opinions or experiences with single-organ heart and liver transplants. These procedures are highly complex and performed infrequently. As the number of combined heart-liver transplants continues to rise globally, there is a growing need for clear guidance on periprocedural surgical and anesthetic management. Anesthesiologists overseeing these patients must consider multiple factors, balancing various comorbidities with significant hemodynamic and metabolic shifts. An increase in (multicenter) studies focusing on specific interventions to enhance patient and organ outcomes is anticipated in the coming years.

A Critical Reassessment of the Kidney Risk Caused by Tetrastarch Products in the Perioperative and Intensive Care Environments

Purpose: To reassess the results of former meta-analyses focusing on the relationship between novel HES preparations (130/0.4 and 130/0.42) and acute kidney injury. Previous meta-analyses are based on studies referring to partially or fully unpublished data or data from abstracts only. Methods: The studies included in the former meta-analyses were scrutinized by the authors independently. We completed a critical analysis of the literature, including the strengths, weaknesses and modifiers of the studies when assessing products, formulations and outcomes. Results: Both the published large studies and meta-analyses show significant bias in the context of the deleterious effect of 6% 130/0.4-0.42 HES. Without (1) detailed hemodynamic data, (2) the exclusion of other nephrotoxic events and (3) a properly performed evaluation of the dose-effect relationship, the AKI-inducing property of 6% HES 130/0.4 or 0.42 should not be considered as evidence. The administration of HES is safe and effective if the recommended dose is respected. Conclusions: Our review suggests that there is questionable evidence for the deteriorating renal effect of these products. Further well-designed, randomized and controlled trials are needed. Additionally, conclusions formulated for resource-rich environments should not be extended to more resource-scarce environments without proper qualifiers provided.

Comparing the effect of administering gelatin-low dose albumin versus albumin on renal function in liver transplantation: A randomized clinical trial

BACKGROUND

Acute kidney injury (AKI) is a common complication after liver transplantation (LT) that is independently associated with an increased risk of morbidity and mortality. This study aimed to evaluate the effects of administering gelatin-low dose albumin versus albumin on renal function and other early outcomes in LT.

METHODS

This randomized controlled clinical trial was conducted on 140 patients undergoing LT from brain death donors. Patients were randomly assigned to two groups: albumin or modified gelatin with albumin. Blood samples were collected before (T0) and on the first (T1), second (T2), third (T3), fifth (T4), and last day of hospitalization (T5) after LT for the detection of laboratory parameters, including renal and liver function tests.

RESULTS

The incidence of AKT on the basis of RIFLE criteria was 31.42% in the gelatin group (R: 59.10%, I: 36.40%, and F: 4.50%) and 25.71% in the albumin group (R: 66.70%, I: 27.80%, and F: 5.50%) (p = .845). Two patients in the gelatin and one in the albumin groups required renal replacement therapy (RRT). There was no significant difference between groups when the trends of changes in renal and liver function parameters were assessed during the study period (T0-T5). Furthermore, the incidence of complications was similar across groups.

CONCLUSION

This study showed that modified gelatin could be used without inappropriate outcomes on renal function in patients with normal preoperative kidney function tests undergoing LT.

Perioperative fluid management and outcomes in adult deceased donor liver transplantation - A systematic review of the literature and expert panel recommendations

BACKGROUND

Fluid management practices during and after liver transplantation vary widely among centers despite better understanding of the pathophysiology of end-stage liver disease and of the effects of commonly used fluids. This reflects a lack of high quality trials in this setting, but also provides a rationale for both systematic review of all relevant studies in liver recipients and evaluation of new evidence from closely related domains, including hepatology, non-transplant abdominal surgery, and critical care.

OBJECTIVES

To develop evidence-based recommendations for perioperative fluid management to optimize immediate and short-term outcomes following liver transplantation.

DATA SOURCES

Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central.

METHODS

Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Studies included those evaluating the following postoperative outcomes: acute kidney injury, respiratory complications, operative blood loss/red cell units required, and intensive care length of stay. PROSPERO protocol ID: CRD42021241392 RESULTS: Following expert panel review, 18 of 1624 screened studies met eligibility criteria for inclusion in the final quantitative synthesis. These included six single center RCTs, 11 single center observational studies, and one observational study comparing centers with different fluid management techniques. Definitions of interventions and outcomes varied between studies. Recommendations are therefore based substantially on expert opinion and evidence from other clinical settings.

CONCLUSIONS

A moderately restrictive or "replacement only" fluid regime is recommended, especially during the dissection phase of the transplant procedure. Sustained hypervolemia, based on absence of fluid responsiveness, elevated filling pressures and/or echocardiographic findings, should be avoided (Quality of Evidence: Moderate | Grade of Recommendation: Weak for restrictive fluid regime. Strong for avoidance of hypervolemia). Mean Arterial Pressure (MAP) should be maintained at >60-65 mmHg in all cases (Quality of Evidence: Low | Grade of Recommendation: Strong). There is insufficient evidence in this population to support preferential use of any specific colloid or crystalloid for routine volume replacement. However, we recommend against the use of 130/.4 HES given the high incidence of AKI in this population.

Perioperative management of adult living donor liver transplantation: Part 1 - recipients

Living donor liver transplantation was first developed to mitigate the limited access to deceased donor organs in Asia in the 1990s. This alternative liver transplantation option has become an established and widely practiced transplantation method for adult patients suffering from end-stage liver disease. It has successfully addressed the shortage of deceased donors. The Society for the Advancement of Transplant Anesthesia and the Korean Society of Transplant Anesthesia jointly reviewed published studies on the perioperative management of live donor liver transplant recipients. The review aims to offer transplant anesthesiologists and critical care physicians a comprehensive overview of the perioperative management of adult live liver transplantation recipients. We feature the status, outcomes, surgical procedure, portal venous decompression, anesthetic management, prevention of acute kidney injury, avoidance of blood transfusion, monitoring and therapeutic strategies of hemodynamic derangements, and Enhanced Recovery After Surgery protocols for liver transplant recipients. This article is protected by copyright. All rights reserved.

Safety and efficacy of tetrastarches in surgery and trauma: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Hydroxyethyl starch (HES) 130 is a frequently used fluid to replace intravascular losses during surgery or trauma. In the past years, several trials performed in critically ill patients have raised questions regarding the safety of this product. Our aim in this meta-analysis was to evaluate the safety and efficacy of 6% HES during surgery and in trauma.

METHODS

This systematic review and meta-analysis was registered at PROSPERO (CRD42018100379). We included 85 fully published articles from 1980 to June 2018 according to the protocol and three additional recent articles up to June 2020 in English, French, German, and Spanish reporting on prospective, randomised, and controlled clinical trials applying volume therapy with HES 130/0.4 or HES 130/0.42, including combinations with crystalloids, to patients undergoing surgery. Comparators were albumin, gelatin, and crystalloids only. A meta-analysis could not be performed for the two trauma studies as there was only one study that reported data on endpoints of interest.

RESULTS

Surgical patients treated with HES had lower postoperative serum creatinine (P<0.001) and showed no differences in renal dysfunction, renal failure, or renal replacement therapy. Although there was practically no further difference in the colloids albumin or gelatin, the use of HES improved haemodynamic stability, reduced need for vasopressors (P<0.001), and decreased length of hospital stay (P<0.001) compared with the use of crystalloids alone.

CONCLUSIONS

HES was shown to be safe and efficacious in the perioperative setting. Results of the present meta-analysis suggest that when used with adequate indication, a combination of intravenous fluid therapy with crystalloids and volume replacement with HES as colloid has clinically beneficial effects over using crystalloids only.

Effects of hydroxyethyl starch and gelatin on the risk of acute kidney injury following orthotopic liver transplantation: A multicenter retrospective comparative clinical study

Objectives

This multicenter retrospective study aimed to compare the effects of HES and gelatin (GEL) on the risk of post-OLT AKI.

Method

A total of 1,672 patients undergoing OLT were enrolled from major transplant centers in China between 2005 and 2013. These patients were divided into three groups: GEL, hydroxyethyl starch (HES), and GEL + HES group.

Results

There was no significant difference in the incidence of post-OLT AKI among the GEL, HES, and GEL + HES groups. The GEL + HES group had a lower incidence of stage II post-OLT AKI than the other two groups. Compared with patients receiving GEL, patients receiving HES did not harbor an increased risk of AKI. Our results showed that MELD score (adjusted odds ratio [OR], 1.579; 95% confidence interval [CI], 1.123–2.219; P = 0.009) and preoperative anemia (adjusted OR, 1.533; 95% CI, 1.212–1.939; P < 0.001) were independent risk factors for post-OLT AKI, and normal preoperative Scr level (vs abnormal; adjusted OR, 0.402; 95% CI, 0.222–0.729; P = 0.003) was independent protective factors for post-OLT AKI.

Conclusion

This large-scale multicenter retrospective study found that the intraoperative use of HES did not increase the overall incidence of post-OLT AKI in patients when compared with GEL, and whether to increase the risk of post-OLT AKI needs to be further explored.

Intravenous Fluid of Choice in Major Abdominal Surgery: A Systematic Review

Background

Intravenous fluid therapy plays a role in maintaining the hemodynamic status for tissue perfusion and electrolyte hemostasis during surgery. Recent trials in critically ill patients reported serious side effects of some types of fluids. Since the most suitable type of fluid is debatable, a consensus in perioperative patients has not been reached.

Method

We performed a systematic review of randomized control trials (RCTs) that compared two or more types of fluids in major abdominal surgery. The outcomes were related to bleeding, hemodynamic status, length of hospital stay, and complications, such as kidney injury, electrolyte abnormality, major cardiac adverse event, nausea, vomiting, and mortality. A literature search was performed using Medline and EMBASE up to December 2019. The data were pooled to investigate the effect of fluid on macrocirculation and intravascular volume effect.

Results

Forty-three RCTs were included. Eighteen fluids were compared: nine were crystalloids and nine were colloids. The results were categorized into macrocirculation and intravascular volume effect, microcirculation, anti-inflammatory parameters, vascular permeability, renal function (colloids), renal function and electrolytes (crystalloids), coagulation and bleeding, return of bowel function, and postoperative nausea vomiting (PONV). We found that no specific type of fluid led to mortality and every type of colloid was equivalent in volume expansion and did not cause kidney injury. However, hydroxyethyl starch and dextran may lead to increased bleeding. Normal saline can cause kidney injury which can lead to renal replacement therapy, and dextrose fluid can decrease PONV.

Conclusion

In our opinion, it is safe to give a balanced crystalloid as the maintenance fluid and give a colloid, such as HES130/0.4, 4% gelatin, or human albumin, as a volume expander.

Validation of electrical velocimetry in resuscitation of patients undergoing liver transplantation. Observational study

Major hemodynamic changes are frequently noted during liver transplantation (LT). We evaluated the performance of electrical velocimetry (EV) as compared to that of TEE in SV optimization during liver transplantation. This was an observational study in 32 patients undergoing LT. We compared SV values measured simultaneously by EV (SV_EV) and TEE (SV_TEE) at baseline 30 min after induction, at the end of dissection phase, 30 min after anhepatic phase, 30 min after reperfusion. We also evaluated the reliability of EV to track changes In SV before and after 49 fluid challenges. Finally, the SV variation (SVV) and pulse pressure variation (PPV) were tested as predictors for volume responsiveness, defined as an increase in SV ≥ 10% after 250 ml of colloid. For 112 paired SV data, the overall correlation was 0.76 and bias (limits of agreement) 0.3 (- 29 to 29) ml percentage error 62%. The EV was able to track changes in SV with a concordance rate of 97%, and a sensitivity and specificity of 93% to detect a positive fluid challenge. The AUC values (with 95% confidence intervals) for SVV and PPV were 0.68 (0.52-0.83) and 0.72 (0.57-0.86), respectively, indicating low predictive capacity in these setting. The absolute values of SV derived from EV did not agree with SV derived from TEE. However, EV was able to track the direction of changes in SV during hemodynamic management of patients undergoing liver transplantation.Clinical trial registration: Clinicaltrials.gov Identifier: NCT03228329 prospectively Registered on 13-July-2017.

Validity of mini-fluid challenge for predicting fluid responsiveness following liver transplantation

BACKGROUND

Mini-fluid challenge is a well tested and effective tool to predict fluid responsiveness under various clinical conditions. However, mini-fluid challenge has never been tested in patients with end-stage liver disease. This study investigated whether infusion of 150 ml albumin 5% can predict fluid responsiveness in cirrhotic patients following liver transplant.

METHODS

Fifty patients receiving living donor liver transplant were included in the analysis. Mini-fluid challenge composed of 150 ml of albumin 5% administered over 1 min in three consecutive 50-ml fluid boluses. An additional 350 ml was then infused at a constant rate over 15 min (for a total of 500 ml). Stroke volume (SV) was measured as the product of the subaortic velocity time integral (VTI) and left ventricular outflow tract (LVOT) area. Fluid responsiveness was defined as an increase in SV by ≥15% after the infusion.

RESULTS

Fifty patients were enrolled in the study. Fourteen patients were classified with Child A, 15 patients with Child B, and 21 patients with Child C cirrhosis. Thirty four patients were fluid responders and 16 patients were fluid non-responders. After 150 ml of albumin 5%, the SV increased significantly in our cohort. The area under receiver operating curve (AUROC) was 0.7 (95% confidence interval [CI] 0.5-0.8, P = 0.005). In subgroup analysis, the SV increased significantly after mini fluid challenge in the Child A group (P = 0.017) but not Child B or C groups (P = 0.3 and 0.29, respectively). The AUROC for mini-fluid challenge in the Child A group was 0.86 (95% confidence interval [CI] 0.6-0.9, P = 0.0004), while mini-fluid challenge failed to discriminate between responders and non-responders in Child B and C groups.

CONCLUSION

A mini-fluid challenge of 150 ml albumin 5% can predict fluid responsiveness in liver transplant patients with fair sensitivity and specifiicty. Subgroup analyis revealed that minifluid challenge can predict fluid responsiveness in patients with Child A cirrhosis but not patients with Child B or C cirrhosis.

TRIAL REGISTRATION

NCT03396159 . (Prospective registered). Initial registration date was 10/01/2018.

Perioperative fluid management in major hepatic resection: an integrative review

BACKGROUND

Fluid intervention and vasoactive pharmacological support during hepatic resection depend on the preference of the attending clinician, institutional resources, and practice culture. Evidence-based recommendations to guide perioperative fluid management are currently limited. Therefore, we provide a contemporary clinical integrative overview of the fundamental principles underpinning fluid intervention and hemodynamic optimization for adult patients undergoing major hepatic resection.

DATA SOURCES

A literature review was performed of MEDLINE, EMBASE and the Cochrane Central Registry of Controlled Trials using the terms "surgery", "anesthesia", "starch", "hydroxyethyl starch derivatives", "albumin", "gelatin", "liver resection", "hepatic resection", "fluids", "fluid therapy", "crystalloid", "colloid", "saline", "plasma-Lyte", "plasmalyte", "hartmann's", "acetate", and "lactate". Search results for MEDLINE and EMBASE were additionally limited to studies on human populations that included adult age groups and publications in English.

RESULTS

A total of 113 articles were included after appropriate inclusion criteria screening. Perioperative fluid management as it relates to various anesthetic and surgical techniques is discussed.

CONCLUSIONS

Clinicians should have a fundamental understanding of the surgical phases of the resection, hemodynamic goals, and anesthesia challenges in attempts to individualize therapy to the patient's underlying pathophysiological condition. Therefore, an ideal approach for perioperative fluid therapy is always individualized. Planning and designing large-scale clinical trials are imperative to define the optimal type and amount of fluid for patients undergoing major hepatic resection. Further clinical trials evaluating different intraoperative goal-directed strategies are also eagerly awaited.

Protecting the Kidney in Liver Transplant Recipients: Practice-Based Recommendations From the American Society of Transplantation Liver and Intestine Community of Practice

Both acute and chronic kidney disease are common after liver transplantation and result in significant morbidity and mortality. The introduction of the Model for End-stage Liver Disease score has directly correlated with an increased prevalence of perioperative renal dysfunction and the number of simultaneous liver-kidney transplantations performed. Kidney dysfunction in this population is typically multifactorial and related to preexisting conditions, pretransplantation renal injury, perioperative events, and posttransplantation nephrotoxic immunosuppressive therapies. The management of kidney disease after liver transplantation is challenging, as by the time the serum creatinine level is significantly elevated, few interventions affect the course of progression. Also, immunological factors such as antibody-mediated kidney rejection have become of greater interest given the rising liver-kidney transplant population. Therefore, this review, assembled by experts in the field and endorsed by the American Society of Transplantation Liver and Intestine Community of Practice, provides a critical assessment of measures of renal function and interventions aimed at preserving renal function early and late after liver and simultaneous liver-kidney transplantation. Key points and practice-based recommendations for the prevention and management of kidney injury in this population are provided to offer guidance for clinicians and identify gaps in knowledge for future investigations.

Impact of perioperative administration of 6 % hydroxyethyl starch 130/0.4 on serum cystatin C-derived renal function after radical prostatectomy: a single-centre retrospective study

Background

Hydroxyethyl starch (HES) is used for repletion of acute intravasal volume loss in surgical patients. However, in critically ill patients, HES is associated with acute kidney injury. We aimed to evaluate the effect of HES on perioperative cystatin C (cystC)-derived estimated glomerular filtration rates (eGFR_cystC) in patients undergoing open and robot-assisted radical prostatectomy.

Methods

In this retrospective study we included 179 patients who underwent general anaesthesia for radical prostatectomy received HES perioperatively, and had complete cystC and fluid therapy data available. CystC and corresponding eGFR_cystC at postoperative days 1, 3, and 5 were compared with preoperative baseline using Wilcox rank-sum test.

Results

In 179 eligible patients, 6 % HES 130/0.4 was administered in a median (25th to 75th percentile) dose of 1000 mL (1000 to 1000 mL). Baseline eGFR_cystC was 109.4 mL/min (100.3 to 118.7 mL/min). eGFR_cystC on postoperative days 1, 3, and 5 was 120.4 mL/min (109.4 to 134.0 mL/min), 120.4 mL/min (109.4 to 132.9 mL/min), and 117.9 mL/min (106.6 to 129.8 mL/min), respectively (p < 0.001 compared with baseline, each). No patient had an eGFR_cystC-decrease of ≥25 % from baseline.

Conclusions

The results indicate that the administration of a median dose of 1000 mL of 6 % HES 130/0.4 is not associated with a postoperative deterioration of renal function in patients with normal to near-normal baseline renal function undergoing radical prostatectomy.

Clinical practice guide for the choice of perioperative volume-restoring fluid in adult patients undergoing non-cardiac surgery

The present Clinical practice guide responds to the clinical questions about security in the choice of fluid (crystalloid, colloid or hydroxyethyl starch 130) in patients who require volume replacement during perioperative period of non-cardiac surgeries. From the evidence summary, recommendations were made following the GRADE methodology. In this population fluid therapy based on crystalloids is suggested (weak recommendation, low quality evidence). In the events where volume replacement is not reached with crystalloids, the use of synthetic colloids (hydroxyethyl starch 130 or modified fluid gelatin) is suggested instead of 5% albumin (weak recommendation, low quality evidence). The choice and dosage of the colloid should be based in the product characteristics, patient comorbidity and anesthesiologist's experience.

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.

Hydroxyethyl starch and acute kidney injury in orthotopic liver transplantation: a single-center retrospective review

BACKGROUND

Acute kidney injury (AKI) is a frequent complication of orthotopic liver transplantation (OLT). Hepatic failure pathophysiology and intraoperative events contribute to AKI after OLT. Colloids are routinely used to maintain intravascular volume during OLT. Recent evidence has implicated 6% hydroxyethyl starch (HES) (130/0.4) with AKI in critically ill patients.

METHODS

We performed a retrospective cross-sectional analysis of electronic anesthesia records, surgical dictations, and perioperative laboratory results. Postoperative AKI incidence was determined by RIFLE (Risk Injury Failure Loss End-Stage) criteria. AKI was staged into Risk, Injury, and Failure based on change in serum creatinine from preoperative baseline to peak level by postoperative day 7. Uni- and multivariate analysis was used to evaluate the association between type of intraoperative colloid administered and AKI.

RESULTS

One hundred seventy-four adult patients underwent OLT and had complete records for review. Of these, 50 received only 5% albumin, 25 received both 5% albumin and HES, and 99 received only HES. Albumin-only, albumin and HES, and HES-only groups were otherwise homogeneous based on patient characteristics and intraoperative variables. There was a statistically significant linear-by-linear association between type of colloid(s) administered and AKI (Rifle Criteria-Injury Stage). Patients administered HES were 3 times more likely to develop AKI within 7 days after OLT compared with albumin (adjusted odds ratio 2.94, 95% confidence interval, 1.13-7.7, P = 0.027). The linear trend between colloidal use (5% albumin only versus albumin/HES versus HES only, ranked ordering) and "injury" was statistically significant (P = 0.048). A propensity-matched analysis also showed a significant difference in the incidence of AKI between the patients receiving albumin compared with HES (P = 0.044).

CONCLUSIONS

Patients receiving 6% HES (130/0.4) likely had an increased odds of AKI compared with patients receiving 5% albumin during OLT. These retrospective findings are consistent with recent clinical trials that found an association between 6% HES (130/0.4) and renal injury in critically ill patients.

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.

Intraoperative terlipressin therapy reduces the incidence of postoperative acute kidney injury after living donor liver transplantation

OBJECTIVE

To evaluate the effect of intraoperative infusion with terlipressin on the incidence of acute kidney injury (AKI) after living donor liver transplantation (LDLT).

DESIGN

Retrospective case-controlled study.

SETTING

Government hospital.

PARTICIPANTS

The medical records of 303 patients who underwent LDLT were reviewed retrospectively.

INTERVENTIONS

Patients were divided into 2 groups on the basis of intraoperative administration of terlipressin. The primary outcome was AKI, as defined by the Acute Kidney Injury Network criteria. Secondary outcomes included the requirement for postoperative dialysis and in-hospital mortality.

MEASUREMENTS AND MAIN RESULTS

The incidence of AKI was 38% (n = 115); AKI occurred in 24 (24.2%) patients who received terlipressin versus 91 (44.6%) in the control group (p = 0.001). The incidence of postoperative dialysis was 9.2% (n = 28). Postoperative dialysis was needed by 8 patients (8.1%) in the terlipressin group versus 20 patients (9.8%) in the control group (p = 0.62). Multivariate logistic regression analysis indicated that terlipressin protected against AKI (odds ratio [OR], 0.4; 95% confidence interval [CI], 0.2-0.8; p = 0.013) but not the need for dialysis (OR, 0.7; 95% CI, 0.2-2.2; p = 0.53) or the in-hospital mortality (OR, 1.1; 95% CI, 0.5-2.3; p = 0.7). Adjustment, using the propensity score, did not alter the association between the use of terlipressin and AKI reduction (OR, 0.46; 95% CI, 0.22-0.89; p = 0.03).

CONCLUSION

These results suggested that intraoperative terlipressin therapy is associated with significant reductions in the risk of AKI in LDLT patients.

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.

Hydroxyethyl starch for resuscitation

PURPOSE OF REVIEW

Resuscitation with hydroxyethyl starch (HES) is controversial. In this review, we will present the current evidence for the use of HES solutions including data from recent high-quality randomized clinical trials.

RECENT FINDINGS

Meta-analyses of HES vs. control fluids show clear signals of harm including adverse effects on kidney and haemostatic function, and trends towards increased mortality. These results are mainly based on recent large randomized clinical trials comparing tetrastarch (HES 130/0.4 and HES 130/0.42) vs. crystalloid in patients in the ICU. Trials in trauma and surgical patients cannot adequately assess safety issues and do not show clear benefit with the use of HES. There is currently no firm evidence that tetrastarch has better safety profile than the former HES solutions.

SUMMARY

There is no evidence for an overall beneficial effect of HES in any subgroup of critically ill patients, but there are clear signs of harm. As safer alternatives exist, we recommend that HES is no longer used in critically ill patients.

Incidence of postoperative death and acute kidney injury associated with i.v. 6% hydroxyethyl starch use: systematic review and meta-analysis

BACKGROUND

Trials suggest that the use of i.v. hydroxyethyl starch (HES) solutions is associ-ated with increased risk of death and acute kidney injury (AKI) in critically ill patients. It is uncertain whether similar adverse effects occur in surgical patients.

METHODS

Systematic review and meta-analysis of trials in which patients were randomly allocated to 6% HES solutions or alternative i.v. fluids in patients undergoing surgery. Ovid Medline, Embase, Cinhal, and Cochrane Database of Systematic Reviews were searched for trials comparing 6% HES with clinically relevant non-starch comparator. The primary end-point was hospital mortality. Secondary endpoints were requirement for renal replacement therapy (RRT) and author-defined AKI. Pre-defined subgroups were cardiac and non-cardiac surgery.

RESULTS

Four hundred and fifty-six papers were identified; of which 19 met the inclusion criteria. In total, 1567 patients were included in the analysis. Dichotomous outcomes were expressed as a difference of proportions [risk difference (RD)]. There was no difference in hospital mortality [RD 0.00, 95% confidence interval (CI) -0.02, 0.02], requirement for RRT (RD -0.01, 95% CI -0.04, 0.02), or AKI (RD 0.02, 95% CI -0.02 to 0.06) between compared arms overall or in predefined subgroups.

CONCLUSIONS

We did not identify any differences in the incidence of death or AKI in surgical patients receiving 6% HES. Included studies were small with low event rates and low risk of heterogeneity. Narrow CIs suggest that these findings are valid. Given the absence of demonstrable benefit, we are unable to recommend the use of 6% HES solution in surgical patients.

Hydroxyethyl starch (HES) versus other fluid therapies: effects on kidney function

BACKGROUND

Hydroxyethyl starches (HES) are synthetic colloids commonly used for fluid resuscitation to replace intravascular volume, yet they have been increasingly associated with adverse effects on kidney function. This is an update of a Cochrane review first published in 2010.

OBJECTIVES

To examine the effects of HES on kidney function compared to other fluid resuscitation therapies in different patient populations.

SEARCH METHODS

We searched the Cochrane Renal Group's specialised register, the Cochrane Central Register of Controlled Trials (CENTRAL, in The Cochrane Library), MEDLINE, EMBASE, MetaRegister and reference lists of articles. The most recent search was completed on November 19, 2012.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs in which HES was compared to an alternate fluid therapy for the prevention or treatment of effective intravascular volume depletion. Primary outcomes were renal replacement therapy (RRT), author-defined kidney failure and acute kidney injury (AKI) as defined by the RIFLE criteria.

DATA COLLECTION AND ANALYSIS

Screening, selection, data extraction and quality assessments for each retrieved article were carried out by two authors using standardised forms. All outcomes were analysed using relative risk (RR) and 95% confidence intervals (95% CI). Authors were contacted when published data were incomplete. Preplanned sensitivity and subgroup analyses were performed after data were analysed with a random-effects model.

MAIN RESULTS

This review included 42 studies (11,399 patients) including 19 studies from the original review (2010), as well as 23 new studies. Fifteen studies were excluded from the original review (nine retracted from publication due to concerns about integrity of data and six lacking individual patient creatinine data for the calculation of RIFLE criteria). Overall, there was a significant increase in the need for RRT in the HES treated individuals compared to individuals treated with other fluid therapies (RR 1.31, 95% CI 1.16 to 1.49; 19 studies, 9857 patients) and the number with author-defined kidney failure (RR 1.59, 95% CI 1.26 to 2.00; 15 studies, 1361 patients). The RR of AKI based on RIFLE-F (failure) criteria also showed an increased risk of AKI in individuals treated with HES products (RR 1.14, 95% CI 1.01 to 1.30; 15 studies, 8402 participants). The risk of meeting urine output and creatinine based RIFLE-R (risk) criteria for AKI was in contrast in favour of HES therapies (RR 0.95, 95% CI 0.91 to 0.99; 20 studies, 8769 patients). However, when RIFLE-R urine output based outcomes were excluded as per study protocol, the direction of AKI risk again favoured the other fluid type, with a non-significant RR of AKI in HES treated patients (RR 1.05, 95% CI 0.97 to 1.14; 8445 patients). A more robust effect was seen for the RIFLE-I (injury) outcome, with a RR of AKI of 1.22 (95% CI 1.08 to 1.37; 8338 patients). No differences between subgroups for the RRT and RIFLE-F based outcomes were seen between sepsis versus non-sepsis patients, high molecular weight (MW) and degree of substitution (DS) versus low MW and DS (≥ 200 kDa and > 0.4 DS versus 130 kDa and 0.4 DS) HES solutions, or high versus low dose treatments (i.e. ≥ 2 L versus < 2 L). There were differences identified between sepsis versus non-sepsis subgroups for the RIFLE-R and RIFLE-I based outcomes only, which may reflect the differing renal response to fluid resuscitation in pre-renal versus sepsis-associated AKI. Overall, methodological quality of the studies was good.

AUTHORS' CONCLUSIONS

The current evidence suggests that all HES products increase the risk in AKI and RRT in all patient populations and a safe volume of any HES solution has yet to be determined. In most clinical situations it is likely that these risks outweigh any benefits, and alternate volume replacement therapies should be used in place of HES products.

Effect of waxy maize-derived hydroxyethyl starch 130/0.4 on renal function in surgical patients

BACKGROUND

The aim of this meta-analysis was to evaluate renal safety with the active substance of the latest generation of waxy maize-derived hydroxyethyl starch in surgical patients. The authors focused on prospective, randomized, controlled studies that documented clinically relevant variables with regard to renal effects of waxy maize-derived hydroxyethyl starch 130/0.40.

MATERIALS AND METHODS

The authors carefully searched for all available prospective, randomized studies and evaluated the greatest delta from baseline values in renal safety variables (serum creatinine values, calculated creatinine clearance, incidence of renal replacement therapy, and acute renal failure). The authors included 17 studies that analyzed patients (n = 1,230) undergoing a variety of surgical procedures.

RESULTS

For maximum serum creatinine values, the effect size estimate was 0.068 (95% CI = -0.227 to 0.362), P = 0.65. For calculated creatinine clearance values, pooled risk difference was 0.302 (95% CI = -0.098 to 0.703), P = 0.14. For incidence of acute renal failure, pooled risk difference was 0.0003 (95% CI = -0.018 to 0.019), P = 0.98. For incidence of renal replacement therapy, pooled risk difference was -0.003 (95% CI = -0.028 to 0.022), P = 0.85.

CONCLUSIONS

The authors found no evidence for renal dysfunction caused by modern waxy maize-derived hydroxyethyl starch 130/0.40 in surgical patients.

Hydroxyethyl starch 130/0.38-0.45 versus crystalloid or albumin in patients with sepsis: systematic review with meta-analysis and trial sequential analysis

OBJECTIVE

To assess the effects of fluid therapy with hydroxyethyl starch 130/0.38-0.45 versus crystalloid or albumin on mortality, kidney injury, bleeding, and serious adverse events in patients with sepsis.

DESIGN

Systematic review with meta-analyses and trial sequential analyses of randomised clinical trials.

DATA SOURCES

Cochrane Library, Medline, Embase, Biosis Previews, Science Citation Index Expanded, CINAHL, Current Controlled Trials, Clinicaltrials.gov, and Centerwatch to September 2012; hand search of reference lists and other systematic reviews; contact with authors and relevant pharmaceutical companies.

STUDY SELECTION

Eligible trials were randomised clinical trials comparing hydroxyethyl starch 130/0.38-0.45 with either crystalloid or human albumin in patients with sepsis. Published and unpublished trials were included irrespective of language and predefined outcomes.

DATA EXTRACTION

Two reviewers independently assessed studies for inclusion and extracted data on methods, interventions, outcomes, and risk of bias. Risk ratios and mean differences with 95% confidence intervals were estimated with fixed and random effects models.

RESULTS

Nine trials that randomised 3456 patients with sepsis were included. Overall, hydroxyethyl starch 130/0.38-0.45 versus crystalloid or albumin did not affect the relative risk of death (1.04, 95% confidence interval 0.89 to 1.22, 3414 patients, eight trials), but in the predefined analysis of trials with low risk of bias the relative risk of death was 1.11 (1.00 to 1.23, trial sequential analysis (TSA) adjusted 95% confidence interval 0.95 to 1.29, 3016 patients, four trials). In the hydroxyethyl starch group, renal replacement therapy was used more (1.36, 1.08 to 1.72, TSA adjusted 1.03 to 1.80, 1311 patients, five trials), and the relative risk of acute kidney injury was 1.18 (0.99 to 1.40, TSA adjusted 0.90 to 1.54, 994 patients, four trials). More patients in the hydroxyethyl starch group were transfused with red blood cells (1.29, 1.13 to 1.48, TSA adjusted 1.10 to 1.51, 973 patients, three trials), and more patients had serious adverse events (1.30, 1.02 to 1.67, TSA adjusted 0.93 to 1.83, 1069 patients, four trials). The transfused volume of red blood cells did not differ between the groups (mean difference 65 mL, 95% confidence interval -20 to 149 mL, three trials).

CONCLUSION

In conventional meta-analyses including recent trial data, hydroxyethyl starch 130/0.38-0.45 versus crystalloid or albumin increased the use of renal replacement therapy and transfusion with red blood cells, and resulted in more serious adverse events in patients with sepsis. It seems unlikely that hydroxyethyl starch 130/0.38-0.45 provides overall clinical benefit for patients with sepsis.

Fluid resuscitation with 6 % hydroxyethyl starch (130/0.4 and 130/0.42) in acutely ill patients: systematic review of effects on mortality and treatment with renal replacement therapy

PURPOSE

To determine whether fluid resuscitation of acutely ill adults with 6 % hydroxyethyl starch (6 % HES 130) with a molecular weight of 130 kD and a molar substitution ratio of approximately 0.4 (6 % HES 130) compared with other resuscitation fluids results in a difference in the relative risk of death or treatment with renal replacement therapy (RRT).

METHODS

Systematic review and meta-analysis of randomized controlled trials comparing intravascular fluids for resuscitation of hospitalised adults that reported mortality or treatment with RRT. The risk of bias was assessed independently by two reviewers and meta-analysis was performed using random effects.

RESULTS

Thirty-five trials enrolling 10,391 participants were included. The three largest trials had the lowest risk of bias, were published (or completed) in 2012, and together enrolled 77 % of all participants. Death occurred in 928 of 4,691 patients (19.8 %) in the 6 % HES 130 group versus 871 of 4,720 (18.5 %) in the control fluid groups relative risk (RR) in the 6 % HES 130 group 1.08, 95 % confidence interval (CI) 1.00 to 1.17, I (2) = 0 %). Treatment with RRT occurred in 378 of 4,236 patients (8.9 %) in the 6 % HES 130 group versus 306 of 4,260 (7.2 %) in the control fluid group (RR in the 6 % HES 130 group 1.25, 95 % CI 1.08 to 1.44, I (2) = 0 %).

CONCLUSIONS

The quality and quantity of data evaluating 6 % hydroxyethyl starch (130/0.4 and 130/0.42) as a resuscitation fluid has increased in the last 12 months. Patients randomly assigned to resuscitation with 6 %HES 130 are at significantly increased risk of being treated with RRT.

Fluid resuscitation with 6% hydroxyethyl starch (130/0.4) in acutely ill patients: an updated systematic review and meta-analysis

BACKGROUND

Recent research suggests that 6% hydroxyethyl starch (HES) 130/0.4 is one of the most frequently used resuscitation fluids worldwide. The retraction of studies evaluating its use necessitates a reevaluation of available evidence regarding its safety and efficacy.

METHODS

We performed a systematic review and meta-analysis of unretracted randomized controlled trials comparing the effects of 6% HES 130/0.4 with other colloid or crystalloid solutions on mortality, acute kidney injury/failure, and bleeding in acutely ill or perioperative patients. A sensitivity analysis including the data from retracted studies was also conducted.

RESULTS

Overall, 36 studies reporting 2149 participants met the inclusion criteria, of which 11 (n = 541) have been retracted. Of the remaining 25 studies, there was a high risk of bias in 17 studies; 19 studies (n = 1246) were conducted in perioperative patients and 6 (n = 362) in critically ill patients. Sixteen studies reported mortality: 104 deaths in 1184 participants. The relative risk of death was 0.95 (95% confidence interval 0.64-1.42, I(2) = 0%, P = 0.73); including the retracted studies added a further 14 deaths and the relative risk was 0.92 (95% confidence interval 0.63-1.34, I(2) = 0%, P = 0.95). The data reporting acute kidney injury, red blood cell transfusion, and bleeding were of insufficient quantity and quality and not amenable to meta-analysis.

CONCLUSIONS

Published studies are of poor quality and report too few events to reliably estimate the benefits or risks of administering 6% HES 130/0.4. This same conclusion is reached with or without the retracted studies. Given the widespread use of 6% HES 130/0.4, high-quality trials reporting a large number of events are urgently required.

Colloid solutions for fluid resuscitation

BACKGROUND

Colloids are widely used in the replacement of fluid volume. However, doubts remain as to which colloid is best. Different colloids vary in their molecular weight and therefore in the length of time they remain in the circulatory system. Because of this, and their other characteristics, they may differ in their safety and efficacy.

OBJECTIVES

To compare the effects of different colloid solutions in patients thought to need volume replacement.

SEARCH METHODS

We searched the Cochrane Injuries Specialised Register (searched 1 December 2011), the Cochrane Central Register of Controlled Trials 2011, issue 4 (The Cochrane Library); MEDLINE (Ovid) (1948 to November Week 3 2011); EMBASE (Ovid) (1974 to 2011 Week 47); ISI Web of Science: Science Citation Index Expanded (1970 to 1 December 2011); ISI Web of Science: Conference Proceedings Citation Index-Science (1990 to 1 December 2011); CINAHL (EBSCO) (1982 to 1 December 2011); National Research Register (2007, Issue 1) and PubMed (searched 1 December 2011). Bibliographies of trials retrieved were searched, and for the initial version of the review drug companies manufacturing colloids were contacted for information (1999).

SELECTION CRITERIA

Randomised controlled trials comparing colloid solutions in critically ill and surgical patients thought to need volume replacement.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data and assessed the quality of the trials. The outcomes sought were death, amount of whole blood transfused, and incidence of adverse reactions.

MAIN RESULTS

Eighty-six trials, with a total of 5,484 participants, met the inclusion criteria. Quality of allocation concealment was judged to be adequate in 33 trials and poor or uncertain in the rest.Deaths were reported in 57 trials. For albumin or plasma protein fraction (PPF) versus hydroxyethyl starch (HES) 31 trials (n = 1719) reported mortality. The pooled relative risk (RR) was 1.06 (95% confidence interval (CI) 0.86 to 1.31). When the trials by Boldt were removed from the analysis the pooled RR was 0.90 (95% CI 0.68 to 1.20). For albumin or PPF versus gelatin, nine trials (n = 824) reported mortality. The RR was 0.89 (95% CI 0.65 to 1.21). Removing the study by Boldt from the analysis did not change the RR or CIs. For albumin or PPF versus dextran four trials (n = 360) reported mortality. The RR was 3.75 (95% CI 0.42 to 33.09). For gelatin versus HES 22 trials (n = 1612) reported mortality and the RR was 1.02 (95% CI 0.84 to 1.26). When the trials by Boldt were removed from the analysis the pooled RR was 1.03 (95% CI 0.84 to 1.27). RR was not estimable in the gelatin versus dextran and HES versus dextran groups.Forty-one trials recorded the amount of blood transfused; however, quantitative analysis was not possible due to skewness and variable reporting. Twenty-four trials recorded adverse reactions, with two studies reporting possible adverse reactions to gel and one to HES.

AUTHORS' CONCLUSIONS

From this review, there is no evidence that one colloid solution is more effective or safe than any other, although the CIs were wide and do not exclude clinically significant differences between colloids. Larger trials of fluid therapy are needed if clinically significant differences in mortality are to be detected or excluded.

Colloid solutions for fluid resuscitation

BACKGROUND

Colloids are widely used in the replacement of fluid volume. However doubts remain as to which colloid is best. Different colloids vary in their molecular weight and therefore in the length of time they remain in the circulatory system. Because of this and their other characteristics, they may differ in their safety and efficacy.

OBJECTIVES

To compare the effects of different colloid solutions in patients thought to need volume replacement.

SEARCH METHODS

We searched the Cochrane Injuries Specialised Register (searched 1 Dec 2011), Cochrane Central Register of Controlled Trials 2011, issue 4 (The Cochrane Library); MEDLINE (Ovid) (1948 to November Week 3 2011); EMBASE (Ovid) (1974 to 2011 Week 47); ISI Web of Science: Science Citation Index Expanded (1970 to 1 Dec 2011); ISI Web of Science: Conference Proceedings Citation Index-Science (1990 to 1 Dec 2011); CINAHL (EBSCO) (1982 to 1 Dec 2011); National Research Register (2007, Issue 1) and PubMed (searched 1 Dec 2011). Bibliographies of trials retrieved were searched, and for the initial version of the review drug companies manufacturing colloids were contacted for information (1999).

SELECTION CRITERIA

Randomised controlled trials comparing colloid solutions in critically ill and surgical patients thought to need volume replacement.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data and assessed the quality of the trials. The outcomes sought were death, amount of whole blood transfused, and incidence of adverse reactions.

MAIN RESULTS

Ninety trials, with a total of 5678 participants, met the inclusion criteria. Quality of allocation concealment was judged to be adequate in 35 trials and poor or uncertain in the rest.Deaths were obtained in 61 trials. For albumin or PPF versus hydroxyethyl starch (HES) 32 trials (n = 1769) reported mortality. The pooled relative risk (RR) was 1.07 (95% CI 0.87 to 1.32). When the trials by Boldt were removed from the analysis the pooled RR was 0.90 (95% CI 0.68 to 1.20). For albumin or PPF versus gelatin, nine trials (n = 824) reported mortality. The RR was 0.89 (95% CI 0.65 to 1.21). Removing the study by Boldt from the analysis did not change the RR or confidence intervals. For albumin or PPF versus Dextran four trials (n = 360) reported mortality. The RR was 3.75 (95% CI 0.42 to 33.09). For gelatin versus HES 25 trials (n = 1756) reported mortality and the RR was 1.03 (95% CI 0.84 to 1.26). When the trials by Boldt were removed from the analysis the pooled RR was 1.04 (95% CI 0.85 to 1.27). RR was not estimable in the gelatin versus dextran and HES versus dextran groups.Forty five trials recorded the amount of blood transfused, however quantitative analysis was not possible due to skewness and variable reporting. Twenty-four trials recorded adverse reactions, with two studies reporting possible adverse reactions to Gel and one to HES.

AUTHORS' CONCLUSIONS

From this review, there is no evidence that one colloid solution is more effective or safe than any other, although the confidence intervals are wide and do not exclude clinically significant differences between colloids. Larger trials of fluid therapy are needed if clinically significant differences in mortality are to be detected or excluded.

The use of terlipressin during living donor liver transplantation: Effects on systemic and splanchnic hemodynamics and renal function

OBJECTIVES

To assess the effect of the intraoperative use of terlipressin on splanchnic hemodynamics and postoperative renal function in patients undergoing liver transplantation.

DESIGN

Open-label, prospective, randomized study.

SETTING

Single-center study.

PATIENTS

Thirty patients who underwent elective, living-donor liver transplantation with portal pressure >20 mm Hg.

INTERVENTIONS

Patients were assigned randomly to one of two equal groups. The control group received saline, whereas the treatment group (TP group) received an initial bolus dose of terlipressin (1 mg over 30 mins) followed immediately by a continuous infusion of 2 μg·kg(-1)·h(-1) for 48 hrs.

MEASUREMENTS AND MAIN RESULTS

Portal pressure and gas exchange (radial artery, portal vein, and hepatic vein, blood gas analyses, and lactate concentration) were assessed at baseline (after ligation of the hepatic artery) and 2 hrs after drug administration. Systemic hemodynamic data and calculated tissue oxygenation parameters were compared throughout the procedure. Renal function was assessed by measurement of serum cystatin C after induction of anesthesia and on the first 2 days postoperatively. After the infusion of terlipressin, portal venous pressure decreased significantly from 26.3 ± 3.3 to 21.3 ± 3.6 mm Hg (p < .001). The mean arterial pressure and systemic vascular resistance were significantly higher in the TP group than in the control group, whereas heart rate and cardiac index were comparable between the groups. Portal and hepatic base excess, and the level of serum lactate, did not differ between the two groups. The serum levels of both cystatin C and creatinine were significantly higher in the control group than in the TP group on postoperative day 2.

CONCLUSION

Perioperative use of terlipressin abrogates the early postoperative decline in renal function of patients who have chronic liver disease and undergo liver transplantation without any detrimental effect on hepatosplanchnic gas exchange and lactate metabolism.

A systematic review of third-generation hydroxyethyl starch (HES 130/0.4) in resuscitation: safety not adequately addressed

BACKGROUND

Hydroxyethyl starches (HES) are widely used for intravascular volume therapy in surgical, emergency, and intensive care patients. There are safety concerns with regard to coagulopathy, renal failure, pruritus, tissue storage, and mortality. Third-generation HES 130/0.4 is considered to have an improved risk profile. A common rationale for the use of HES is the belief that 3 to 4 times more crystalloid than colloid volume is needed to achieve similar hemodynamic end points. Our goal was to assess whether published studies on HES 130/0.4 resuscitation are sufficiently well designed to draw conclusions about the safety of this compound. In addition, we wanted to assess crystalloid-to-colloid fluid ratios in studies with goal-directed fluid regimen.

METHODS

Systematic review of randomized controlled trials in which HES 130/0.4 is used for resuscitation.

RESULTS

We identified 56 randomized controlled trials (RCTs) with HES 130/0.4 in. acute hypovolemia, mainly from the elective surgical setting (n = 45). Surgical studies were small-sized (median 25 patients in the HES groups, range 10 to 90) and of short duration (median 12 hours, range 0.5 to 144 hours). The median cumulative HES dose was 2465 mL (range 328 to 6229 mL), corresponding to 35 mL/kg in a 70-kg patient, the daily dose limit being 50 mL/kg. End points mostly addressed variable surrogate outcomes. Sixty percent of control fluids were other HES solutions, gelatins, or dextran, which have a similar risk profile. Without exception, these studies were not designed for clinically important safety outcomes, primarily because they were too small, used mostly inadequate control fluids, and had inappropriately short observation periods. Therefore, and also because of heterogeneity of patient groups and outcome definitions, results from these studies cannot be pooled. These studies do not allow any conclusion about the safety of HES 130/0.4. There is a common belief that 3 to 4 times more crystalloid than colloid volume is necessary to achieve similar hemodynamic effects. We found a considerably lower ratio in surgical studies (mean 1.8, SD 0.1).

CONCLUSIONS

In summary, the extent of fluid load reduction that can be achieved by HES 130/0.4 is overestimated. Use of older HES solutions may be associated with serious side effects, and clinicians should be aware that there is no convincing evidence that third-generation HES 130/0.4 is safe in surgical, emergency, or intensive care patients despite publication of numerous clinical studies.

[Perioperative anaesthetic practices in liver transplantation in France: Evolution between 2004 and 2008]

OBJECTIVES

To determine the evolution of French perioperative anaesthetic practices in liver transplantation between 2004 and 2008.

STUDY DESIGN

Phone survey.

METHODS

In 2004 and 2008, a similar questionnaire has been administered by phone to a senior anaesthesiologist from each French centre performing adult liver transplantation (n = 21). Results were compared using Fisher test and p < 0.05 was considered significant.

RESULTS

Between 2004 and 2008, there was a trend towards an increase of centres performing transplantation for more than 40% of Child C patients (p = 0.1). Simultaneously, work force dedicated to liver transplantation cases has been reduced since in 2008, one anaesthesiologist was in charge in 90% of the centres (p = 0.06 vs 2004). Perioperative practices remained largely heterogeneous between centres with regard to hemodynamic monitoring, fluid and blood products management, antifibrinolytics use or postoperative analgesia.

CONCLUSIONS

This French survey has shown a reduction of work force dedicated to a liver transplantation from 2004 to 2008 simultaneously with a trend towards a greater severity of liver recipients. Practices heterogeneity reflect at least in part, unresolved questions about the best perioperative management for liver transplantation and the need for guidelines. Working for standardization of our practices and multicentric trials could allow gaining a better understanding of what should be the good practices in perioperative management of liver transplantation.

[Guidelines on therapy with blood components and plasma derivatives: human albumin. Recommendations of the scientific advisory board of the Medical Council]

Human albumin (HA) is by far the most expensive option for volume replacement and correction of hypoalbuminemia but is still widely used. The value of HA in the clinical setting continues to be controversial and it remains unclear whether there is still a place for using such a high-priced substance in the present cost-consciousness climate. Thus the Medical Council has presented some recommendations with regard to blood and plasma products including HA. There appear to be no indications for HA to correct hypovolemia either perioperatively or in the intensive care setting including children and patients undergoing cardiac or liver surgery. For maintaining colloid oncotic pressure (COP) cheaper modern synthetic colloids can be alternatively given and the value of HA for correcting hypoalbuminemia is also not clearly justified. Some small uncontrolled studies have shown that only patients with liver cirrhosis, spontaneous bacterial peritonitis and massive ascites drainage may profit from HA. Theoretical benefits such as oxygen radical scavenging or binding of toxic substances are no indications for using HA as beneficial clinical consequences have not yet been demonstrated. Experimental data from cell lines or animals must be viewed with skepticism because they do not mimic the clinical setting. According to the recommendations of the scientific advisory board of the Medical Council the use of HA should be considered very cautiously.

Hydroxyethyl starch 130/0.4 attenuates early hepatic damage in ischemia/reperfusion injury

PURPOSE

Ischemia/reperfusion injury (IRI) remains a clinical challenge. We tested the hypothesis that fluid therapy using hydroxyethyl starch (HES) 130/0.4 during the early phase of IRI in rat liver decreases markers of hepatic injury.

METHODS

We induced liver IRI in three groups of rats anesthetized with ketamine and chlorpromazine by means of 60 min of segmental hepatic ischemia followed by 120 min of reperfusion. At the onset of reperfusion, Group 1 (IRI + HES; n = 12) was given 13 mL.kg(-1) of HES; Group 2 (IRI + HS; n = 12) received the same volume of 7.5% saline (HS), and Group 3 (IRI-only; n = 12) received no fluid. Three other groups of 12 animals each were sham-operated and received the same fluid as the test groups. We euthanized the animals after three hours, drew blood for alanine aminotransferase (ALT) quantification, and took ischemic liver samples for histomorphological study.

RESULTS

Serum ALT activity was greater in all of the IRI groups than in the sham-operated animals. The ALT activity was 1,081 +/- 575 IU.L(-1) in IRI + HES Group 1; 2,363 +/- 1,839 IU.L(-1) in IRI + HS Group 2; and 2,866 +/- 2,491 IU.L(-1) in IRI-only Group 3. There was a statistically significant difference between the IRI + HES and the IRI-only groups (P = 0.001), but not between the IRI + HS and the IRI-only groups (P > 0.05). Likewise, histological scores were greater in all IRI groups compared with the sham-operated animals. Scores were higher in the IRI-only group (median 3.5) than in the groups receiving fluid (IRI + HES median 2; IRI + HS median 3). The difference between IRI + HES and IRI-only was statistically significant (P = 0.008) but not so between IRI + HS and IRI-only (P > 0.05).

CONCLUSIONS

Giving HES 130/0.4 attenuates rat liver IRI compared with no fluid, while giving HS does not. This suggests a role for HES in hepatoprotection associated with liver IRI.