Renal Dysfunction After Hydroxyethyl Starch: In Response

Abstract

We thank Dr Celik for his simulating remarks and would like to answer to his criticisms in detail: 1. In a study of our group using different HES preparations in elderly patients (>60 yr) undergoing major abdominal surgery (2) we found indeed a small increase in some markers of altered kidney function (e.g., α-1-microglobulin). However, also patients in whom gelatin was given showed similar changes. As gelatin is unlikely to alter kidney function, these changes are most likely due to an extended surgical trauma rather than due to IV administration of HES. 2. The same results were seen in elderly cardiac surgery patients (3) also indicating considerable negative effects of the cardiopulmonary bypass rather than negative effects of modern HES preparations. 3. In the study from Dehne et al. (4), 1000 mL of HES was continuously given over 24 h in critically ill intensive care patients (n = 10)—a rather unusual technique to correct hypovolemia in these patients. A group of patients without volume served as a control (n = 15)—also rather unusual that critically ill patient do not need volume. Significantly more of the HES-treated patients needed hemofiltration due to development of acute renal failure (ARF). Whether these patients were removed from the further study or not remains unclear. Moreover, this was a very small study without power analysis! 4. In the study from Schortgen (5), a HES preparation with high molar substitution (MS) (HES 200/0.62) was used in intensive care patients and compared with a group in whom gelatin was given. Unfortunately, the HES-patients showed higher creatinine levels than gelatin patients already prior to the study. HES patients showed higher creatinine levels during the study period, however, there were no differences between the two groups with regard to the need of hemofiltration/dialysis and outcome. The authors concluded that by using more rapidly degradable HES preparations (with a lower MS) these negative results on kidney function may not have been noticed. 5. This statement remains unclear: “Renal impairment is also seen with high-molecular weight HES preparations used in the United States.” The study (6) Dr. Celik cited has the title: “Hydroxyethyl starches does no impair immediate renal function in kidney transplant recipients...”. 6. In the retrospective study in cardiac surgery by Winkelmeyer et al. (7), an HES preparation with a very large MW (670 kd) and a very high MS (0.75) was shown to alter kidney function; this is an argument pro the fact that the different HES preparations have to be distinguished—especially slowly degradable HES preparations that show considerable risk to produce kidney dysfunction. 7. It remains unclear what the reported differences in histamine release have to do with possible alterations in kidney function (8). 8. In the study using albumin in patients with spontaneous bacterial peritonitis, one group received albumin, and a control group received no additional volume (9). As expected, the untreated (hypovolemic) control patients developed kidney dysfunction more often; this has nothing to do with beneficial effects of albumin on kidney function! This comparison is not fair. 9. Finally, Dr. Celik has (unfortunately) forgotten to mention a recently published study using a new, third-generation HES preparation (HES 130/0.4) in patients with mild-to-severe renal dysfunction before IV HES administration (1). No negative effects on cre-atinine clearance were seen with the HES preparation. Summarizing all studies, it seems to be well established that some older HES preparations (especially with a higher MW and a higher MS) may be associated with alterations in kidney function. Joachim Boldt, MD Hans-Joachim Priebe, FRCA