Large volume infusions of hydroxyethyl starch during cardiothoracic surgery may be associated with postoperative kidney injury: propensity-matched analysis

Abstract

BackgroundThe safety of intraoperative administration of hydroxyethyl starch (HES) has been debated. We hypothesized that intraoperative use of HES is associated with postoperative acute kidney injury (AKI) following cardiopulmonary bypass (CPB).Materials and methodsPatients who underwent cardiothoracic surgery using CPB between 2007 and 2014 were retrospectively reviewed. The incidence of AKI within 7 days after surgery, defined by the Kidney Disease Improving Global Outcome criteria, was compared for patients who did or did not receive 6% (70/0.5) or 6% (130/0.4) HES for anesthesia management before or after CPB. Multivariable logistic regression and propensity matching analysis were performed to examine whether use of HES is associated with postoperative AKI. Outcomes comparing patients receiving HES ≥ 1000 mL and < 1000 mL were also compared.ResultsData from 1976 patients were reviewed. All patients received 70/0.5 HES as a part of the priming solution for CPB. The incidence of postoperative AKI was 28.2% in patients who received HES and 26.0% in patients who did not (p = 0.33). In multivariable analysis, there was no correlation between the use of HES and the incidence of AKI (odds ratio 0.87, 95% CI 0.30–2.58, p = 0.81). Propensity matching showed that the incidence of AKI was not significantly different between 481 patients administered with HES and 962 patients (26.6% vs. 26.9%, p = 0.95) who did not receive HES for anesthesia management. However, peak creatinine levels, needed for renal replacement therapy, and in-hospital mortality were higher, and 28-day hospital-free days were lower in patients receiving HES ≥ 1000 mL than those receiving HES < 1000 mL (p < 0.05).ConclusionsIntraoperative use of HES was not associated with postoperative AKI following CPB. However, administration of large volumes of HES may be associated with kidney-related adverse clinical outcomes.

Analysis of intraoperative modifiable factors to prevent acute kidney injury after elective noncardiac surgery: intraoperative hypotension and crystalloid administration related to acute kidney injury

“…Preoperative blood pressure was measured with the patient at rest in the ward the day before surgery with a Terumo electronic sphygmomanometer ES-H55 [ 15 ]. Intraoperative blood pressure data and patient demographic information were extracted from ORSYS using the Vipros data-mining software (DOWELL Co., Ltd., Japan) [ 16 ]. Intraoperative blood pressure values were measured with a Philips IntelliVue MP70.…”

Resuscitation fluids as drugs: targeting the endothelial glycocalyx

“…Resuscitation with HES can lead to AKI, [ 36 ] which may be related to the decreased glomerular filtration and interstitial inflammatory changes caused by the high oncotic pressure of HES. [ 37 ] HES is also associated with deterioration of coagulation function, which can be partially explained by hemodilution. Other mechanisms can also explain this deterioration of coagulation, such as detrimental influences of factor VIII, factor XIII, fibrinolysis, and von Willebrand factor.…”

“…Importantly, the guidelines do not recommend using synthetic colloids first for fluid resuscitation, especially HES, [6] possibly because synthetic colloids have several disadvantages. Resuscitation with HES can lead to AKI, [36] which may be related to the decreased glomerular filtration and interstitial inflammatory changes caused by the high oncotic pressure of HES [37] . HES is also associated with deterioration of coagulation function, which can be partially explained by hemodilution.…”

Acute kidney injury after cardiac surgery

“…When necessary, intravenous fluid administration should be performed using balanced crystalloid solutions [25,26]. Hydroxyethyl starch should not be used in cardiac surgery patients, because large randomized controlled trials (RCTs) demonstrated an increased risk for postoperative AKI and requirement for renal replacement therapy associated with the use of hydroxyethyl starch (HES) [27–29].…”