Abstract
Hypovolaemia is extremely common among surgical and intensive care patients. The best strategy for volume replacement therapy has been the focus of debate for several years. The lack of acceptance of hydroxyethylstarch (HES) for volume replacement therapy is most likely due to reports of abnormal coagulation and to recently published studies indicating negative effects of HES on renal function. All HES solutions are not created equal — they widely differ with regard to their physicochemical characteristics (concentration, mean molecular weight (Mw), degree of substitution [DS], C2/C6-substitution ratio). These differences have important consequences for adverse effects such as alterations in the coagulation process and on kidney function. Conflicting results about the effects of different HES solutions on renal function may also be due to varying clinical protocols, selection of patients, and different criteria for volume replacement. Theoretical and documented hazards are associated with each kind of volume replacement therapy. There appears to be no reason to banish modern HES preparations with a low or medium Mw (e.g. 70, 130 or 200kD) and a low DS (0.4 or 0.5) in patients without pre-existing kidney dysfunction. In patients with known renal dysfunction (e.g. plasma creatinine level >3 mg/dl), all HES preparations should be used cautiously and other volume replacement regimens (e.g. gelatins) should be considered since no convincing data are yet available for the latest generation of HES (Mw 130; DS 0.4).
Similar content being viewed by others
References
Deane SA, Gaudry PL, Woods P, et al. The management of injuries - a review of death in hospital. Aust N Z J Surg 1988; 58: 463–9
Edwards JD. A new debate: colloid versus colloid?. In: Vincent JL, editor. Yearbook of Intensive Care and Emergency Medicine. Berlin, Heidelberg, New York: Springer, 1994: 152–64
Cittanova ML, Leblanc I, Legendre Ch, et al. Effect of hydroxyethylstarch in brain-dead kidney donors on renal function in kidney-transplant recipients. Lancet 1996; 348: 1620–2
De Labarthe A, Jacobs F, Blot F, et al. Acute renal failure secondary to hydroxyethylstarch administration in a surgical patient. Am J Med 2001; 111: 417–8
Schortgen F, Lacherade JC, Bruneel F, et al. Effects of hydroxyethylstarch and gelatin on renal function in severe sepsis: a multicenter randomised study. Lancet 2001; 357: 911–6
Peron S, Mouthon L, Guettier C, et al. Hydroxyethyl starch-induced renal insufficiency after plasma exchange in a patient with polymyositis and liver cirrhosis. Clin Nephrol 2001; 55: 408–11
Byrick RJ, Rose DK. Review article: pathophysiology and prevention of acute renal failure: the role of the anaesthetist. Can J Anaesth 1990; 37: 457–67
Rahn KH. Acute disturbances of renal function. Chest 1991; 100: 197S–9S
Moran M, Kapsner C. Acute renal failure associated with elevated plasma oncotic pressure. N Engl J Med 1987; 317: 150–3
Kulka PJ, Tryba M, Zenz M. Preoperative alpha-2-adrenergic receptor agonists prevent the deterioration of renal function after cardiac surgery: results of a randomized, controlled trial. Crit Care Med 1996; 24: 947–52
Lote CJ, Harper L, Savage COS. Mechanisms of acute renal failure. Br J Anaesth 1996; 77: 82–9
Aronson S, Blumenthal R. Perioperative renal dysfunction and cardiovascular anesthesia: concerns and controversies. J Cardiothorac Vasc Anesth 1998; 12: 567–86
Lindeman RD. Changes in renal function with aging: Implications for treatment. Drugs Aging 1992; 2: 423–31
Ritschel WA. Gerontokinetics: the pharmacokinetics of drugs in the elderly patient. Caldwell (NJ): Telford Press, 1988: 114–24
Beyer R, Harmening U, Rittmeyer O, et al. Use of modified fluid gelatin and hydroxyethyl starch for colloidal volume replacement in major orthopaedic surgery. Br J Anaesth 1997; 78: 44–50
Hussain SF, Drew PJT. Acute renal failure after infusion of gelatins. BMJ 1989; 299: 1137–8
Kurnik BRC, Singer F, Groh WC. Case report: dextran-induced acute renal failure. Am J Med Sci 1991; 302: 28–30
Figueroa JE, Burgos-Calderon R. Renal toxicity of low molecular weight dextran: a review of the literature. J La State Med Soc 1974; 126: 425–7
Feest TG. Low molecular weight dextran: a continuing cause of acute renal failure. BMJ 1976; 2: 1300–1
Treib J, Haass A, Pindur G, et al. HES 200/0.5 is not HES 200/0.5 - influence of the C2/C6 hydroxyethylation ratio of hydroxyethyl starch (HES) on hemorheology, coagulation and elimination kinetics. Thromb Haemost 1995; 74: 1452–6
Traylor RJ, Pearl R. Crystalloid versus colloid: all colloids are not created equal. Anesth Analg 1996; 83: 209–12
Kief H, Engelhart K. Reabsorptive Vacuolisation der gewundenen Nierenhauptstücke (sog. osmotische Nephrose). Frank Zeitschr für Path 1966; 75: 53–9
Iana A, Schwartz D. Renal tubular cellular and molecular events in acute renal failure. Nephron 1994; 68: 413–8
Chinitz JL, Kim KE, Onesti G, et al. Pathophysiology and prevention of dextran-40-induced anuria. J Lab Clin Med 1971; 77: 76–87
Hester J, McEntegrat C, Hulse JD, et al. Clinical study no. 607-85-09. Rockville (MD); Dupont
Kortilla K, Grohn P, Gordin A, et al. Effects of hydroxyethyl starch and dextran on plasma volume and blood hemostasis and blood coagulation. J Clin Pharmacol 1984; 24: 273–82
Mizuta S, Ikeda K, Iguchi K. Clinical study with hydroxyethly starch 200/0.6: hemodynamic data, metabolism and elimination. Med Consult New Remedies 1971: 8: 2493–2500
Kloetz U, Kroemer U. Clinical pharmacokinetic considerations in the use of plaxma volume expanders. Clin Pharmacokinet 1987; 12: 123–35
Baron JF. Clinical use of hydroxyethyl starches. In: Vincent JL, editor. Update in intensive care and emergency medicine. Vol. 14. New York (NY); Springer, 1991: 403–14
Druml W, Pölzleitner D, Laggner AN, et al. Dextran-40, acute renal failure, and elevated plasma oncotic pressure. N Engl J Med 1988; 318: 252–3
Rozich JD, Paul RV. Acute renal failure precipitated by elevated colloid osmotic pressure. Am J Med 1989; 87: 358–60
Legendre C, Thervet E, Page B, et al. Hydroxyethylstarch and osmotic-nephrosis-like lesions in kidney transplantation. Lancet 1993; 342: 248–9
Coronel B, Mercatello A, Martin X, et al. Hydroxyethylstarch and renal function in kidney transplant recipients. Lancet 1997; 349: 884
London MJ, Ho SJ, Triedman JK, et al. A randomized clinical trial of 10% pentastarch (low molecular weight hydroxyethyl starch) versus 5% albumin for plasma volume expansion after cardiac operations. J Thorac Cardiovasc Surg 1989; 97: 785–97
Vogt NH, Bothner U, Lerch G, et al. Large-dose administration of 6% hydroxyethyl starch 200/0.5 for total hip arthroplasty: plasma homeostasis, hemostasis, and renal function compared to use of 5% human albumin. Anesth Analg 1996; 83: 262–8
Boldt J, Müller M, Mentges D, et al. Volume therapy in the critically ill: is there a difference? Intensive Care Med 1998; 24: 28–36
Kumle B, Boldt J, Piper SN, et al. The influence of different intravascular volume replacement regimens on renal function in the elderly. Anesth Analg 1999; 89: 1124–30
Allison KP, Gosling P, Jones S, et al. Randomized trial of hydroxyethyl starch versus gelatine for trauma resuscitation. J Trauma 1999; 47: 1114–21
Deman A, Peeters P, Sennesael J. Hydroxyethyl starch does not impair immediate renal function in kidney transplant recipients: a retrospective, multicenter analysis. Nephrol Dial Transplant 1999; 14: 1517–20
Boldt J, Lehmann A, Römpert R, et al. Volume therapy with a new hydroxyethyl starch solution in cardiac surgical patients before cardiopulmonary. J Cardiothorac Vasc Anesth 2000; 14: 264–8
Dehne MG, Mühling J, Sablotzki A, et al. Hydroxyethylstarch (HES) does not directly affect renal function in patients with no prior renal impairment. J Clin Anesth 2001; 13: 103–11
Astiz ME, Rackow EC. Crystalloid-colloid controversy revisited. Crit Care Med 1999; 27: 34–5
Acknowledgements
No sources of funding were used to assist in the preparation of this manuscript. The author has no conflicts of interest that are directly relevant to the content of this manuscript.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Boldt, J. Hydroxyethylstarch as a Risk Factor for Acute Renal Failure. Drug-Safety 25, 837–846 (2002). https://doi.org/10.2165/00002018-200225120-00002
Published:
Issue Date:
DOI: https://doi.org/10.2165/00002018-200225120-00002