Hydroxyethyl Starch and Acute Kidney Injury in Orthotopic Liver Transplantation

Abstract

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 lab 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 homogenous 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 as compared to albumin (adjusted odds ratio 2.94, 95% CI: 1.13-7.7, p=0.027). The linear trend between colloidal use (5% albumin only vs. albumin/HES vs. HES only, ranked ordering) and “Injury” was statistically significant (p=0.048). A propensity-matched analysis also showed a significant difference in 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 as compared to 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.

Perioperative acute kidney injury

“…[114][115][116][117] ii8 | Goren and Matot AKI. 91 108 112 117 118 In a recent paper, Hartog and colleagues 119 raised concerns regarding the intraoperative use of HES and concluded that in the absence of proven benefit and considering the methodological problems with studies supporting the use of HES, they do not recommend use of HES solutions in any clinical situation.…”

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

“…To further complicate the results, several surgical studies including cardiac surgery have been retracted after scientific misconduct 20 . Recently, there were a few new observational studies on hydroxyethyl starch and AKI in non-cardiac surgeries 7,8 . Our goal was to look specifically at cardiac surgical population due to the unique physiological changes that CPB predisposes and compare two different types of 6% HES and their effects on the development of postoperative AKI and the need for blood product transfusion in comparison to patients who did not receive HES.…”

Transesophageal ultrasonography during orthotopic liver transplantation: Show me more

“…62 Given the uncertainty regarding the safety of artificial colloids (gelatin and hydroxyethyl starch) in liver transplantation patients, we routinely use albumin 4% bolus of 3 mL/Kg as a fluid challenge, as well as blood products. 63 Last but not least, liver transplantation is associated with increased bleeding, mostly as a result of bad fluid therapy. 64 However, it should be recalled that although LT is associated with increased bleeding, altered coagulation with a prothrombotic state may also occur.…”