European hydroxyethyl starch: a safe and inexpensive alternative to albumin.

Abstract

To the Editor: In their review article, Warren and Durieux [1] indicate that the exclusive use of hydroxyethyl starch (HES) might save approximately $50 million/year in the United States. They assume a price of $43 for 500 mL HES, while albumin is supposed to cost $66. However, the price of HES in Europe is significantly lower. The hospital cost of 500 mL 6% HES 70/0.5 (Rheohes[registered sign]; B. Braun Melsungen AG, Melsungen, Germany) at the University of the Saarland (Germany) is only 15 DM (approximately $9), while the price of 500 mL 5% albumin amounts to 112.00 DM (approximately $66), which is the same as in the United States. The difference in prices for HES preparations is even more surprising since we found that the American high molecular weight (MW) HES 480/0.7 (Hespan) shows remarkable disadvantages compared with the HES preparations preferred in Europe [2,3]. These HES are less expensive, and they could replace albumin almost completely because they do not affect the coagulation system. Thus, the use of these HES preparations would lower costs considerably. The literature review by Warren and Durieux [1] on the effects of HES on coagulation over the last 30 yr includes controversial and conflicting data, as they admit. Our present studies explain these partly controversial observations [4,5]. We were able to prove that there are remarkable differences between HES products depending on the initial MW, substitution degree, and C2/C6 hydroxyethylation ratio. This applies especially to the disturbances of the coagulation system. According to our results, the disturbance of the factor VIII/von Willebrand complex depends decisively on the in vivo MW of the HES, which might differ considerably from the initial MW because HES is degraded in vivo. The decrease in the factor VIII/von Willebrand complex is affected by the larger the dose, the initial MW, the substitution degree, and the C2/C6 ratio of a HES because the large molecules, which are difficult to eliminate, are predominantly responsible for the clotting disorder [4-7]. Bleeding complications might be avoided if the appropriate HES with a low in vivo MW is chosen (e.g., HES 200/0.5 or HES 70/0.5). These starches do not affect the factor VIII/von Willebrand complex significantly up to doses of 750 g over 10 days [5,8]. This also explains why 9 of 11 bleeding complications described in the literature over the last 10 yr were observed after high MW HES 480/0.7. We do not know of any such complications after low MW HES. When using HES preparations of a low to medium initial MW (70-200 kD), a substitution degree of approximately 0.5, and a low C2/C6 ratio [3-8], an increase in hemorrhagic diatheses, even after larger doses or repeated administration, should not be feared. The administration of albumin can be restricted to patients with a marked protein deficiency. This could result in considerable cost savings. J. Treib, MD A. Haass, MD K. Schimrigk, MD Department of Neurology; University of the Saarland; D-66421 Homburg, Germany