The dose of hydroxyethyl starch 6% 130/0.4 for fluid therapy and the incidence of acute kidney injury after cardiac surgery: A retrospective matched study

Abstract

The safety of hydroxyethyl starches (HES) is still under debate. No studies have compared different dosing regimens of HES in cardiac surgery. We analyzed whether the incidence of Acute Kidney Injury (AKI) differed taking into account a weight-adjusted cumulative dose of HES 6% 130/0.4 for perioperative fluid therapy. This retrospective cohort study included all adult patients undergoing elective or emergency cardiac surgery with or without cardiopulmonary bypass. Exclusion criteria were patients on renal replacement therapy (RRT), cardiac trauma surgery, heart transplantation, patients with ventricular assist devices, subjects who required a surgical revision for bleeding and those whose medical records were incomplete. Primary endpoint was AKI following the creatinine based RIFLE classification. Secondary endpoints were 30-day mortality and RRT. Patients were divided into 2 groups whether they had received a cumulative HES dose of < 30 mL/kg (Low HES) or ≥ 30 mL/kg (High HES) during the intra- and postoperative period. A total of 1501 patients were analyzed with 983 patients in the Low HES and 518 subjects in the High HES group. 185 (18.8%) patients in the Low HES and 119 (23.0%) patients in the High HES group developed AKI (P = 0.06). In multivariable regression analysis the dose of HES administered per weight was not associated with AKI. After case-control matching 217 patients were analyzed in each group. AKI occurred in 39 (18.0%) patients in the Low HES and 50 (23.0%) patients in the High HES group (P = 0.19). In conditional regression analysis performed on the matched groups a lower weight-adjusted dose of HES was significantly associated with a reduced incidence of AKI [(Odds Ratio (95% CI) = 0.825 (0.727–0.936); P = 0.003]. In the absence of any safety study the cumulative dose of modern HES in cardiac surgery should be kept less than 30 mL/kg.

Comparison of acute kidney injury between open and laparoscopic pylorus-preserving pancreaticoduodenectomy: Propensity score analysis

“…In a prospective randomized controlled trial performed by Myburgh et al [ 33 ] which enrolled 7000 patients in the ICU of 32 hospitals, the use of HES was associated with increased risk of kidney injury and renal replace therapy. However, the relationship between HES administration and the incidence of postoperative AKI has not been clarified [ 34 – 36 ]. There was no difference in the occurrence of AKI and need for renal replace therapy between the patients who were administered HES and crystalloids in a meta-analysis which included 13 trials (n = 741), thus the authors concluded that there are not enough data to identify the outcomes related to HES [ 37 ].…”

STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management

“…175,176 A retrospective cohort study found a lower dose of HES was significantly associated with a reduced incidence of acute renal injury and recommended that the cumulative dose of modern HES in cardiac surgery should be kept less than 30 mL/kg. 177 MASSIVE TRANSFUSION. A recent study provided some helpful prediction algorithms and management options for patients at higher risk of massive transfusion.…”

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

“…However, there are studies that use other AKI criteria to evaluate postoperative AKI. In a recent study of 1,500 patients, the authors found that the use of HES 6% 130/0.4 for volume replacement had no association with the 30-day mortality and renal replacement therapy, even based on RIFLE classification, as Dr. Reinhart recommended, if the hydroxyethyl starch 6% 130/0.4 fluid were kept below 30 mL/kg, 14 which none of our patients exceeded. In another meta-analysis of 17 randomized studies with a total of 1,230 patients evaluating renal safety of hydroxyethyl starches 130/0.40 in surgical patients (9 of the 17 studies were in cardiac surgery), no evidence for renal dysfunction was observed using RIFLE and Acute Kidney Injury Network classifications.…”