Is the literature inconclusive about the harm from HES? No
- PDF / 941,498 Bytes
- 3 Pages / 595.276 x 790.866 pts Page_size
- 110 Downloads / 205 Views
EDITORIAL
Is the literature inconclusive about the harm from HES? No Christian J. Wiedermann1*, Rinaldo Bellomo2 and Anders Perner3 © 2016 Springer-Verlag Berlin Heidelberg and ESICM
Introduction Colloid solutions may be more effective than crystalloid solutions in expanding the intravascular space, which may result in improved hemodynamics and reduced tissue edema. Whether this is clinically important is unknown. Despite lack of evidence of overall benefit in terms of clinical or patient-important outcome measures, hydroxyethyl starch (HES), an artificial colloid solution, has been used in a variety of clinical settings to treat hypovolemia including during surgery, after trauma and burns, in sepsis, and in critically ill patients. As we will outline below, HES has clear side effects based on well-described pathophysiologic pathways resulting in worse outcome in critically ill patients. Acute kidney injury Hydroxyethyl starch has been shown to increase the risk of acute kidney injury (AKI) and need for renal replacement therapy (RRT) as compared to other fluid solutions in different clinical settings [1]. The effects are independent of molecular weight, molar substitution, C2/C6 ratio, and dose of HES. Increased use of RRT with HES vs other fluids has been shown in surgical and non-surgical intensive care patients, and in patients with sepsis [2–5]. Because most of these data are from trials done in ICU, the effects of HES on kidney function in the intraoperative period have yet to be settled. The nephrotoxic pathway of HES is likely secondary to renal tissue uptake and storage because HES cannot be degraded once it leaves the circulation [6, 7]. Moreover, HES is by no means confined to the intravascular *Correspondence: [email protected] 1 Department of Internal Medicine, Central Hospital of Bolzano, Lorenz‑Böhler‑Street 5, 39100 Bolzano, BZ, Italy Full author information is available at the end of the article Contrasting viewpoints can be found at doi:10.1007/s00134-016-4278-7 and doi:10.1007/s00134-016-4329-0.
compartment. Up to 50 % of administered volumes cannot be accounted for in blood or urine at 24 h after infusion meaning that this amount resides in other compartments where it cannot be degraded [6]. In the kidney, HES may induce osmotic nephrotic lesions [7] and tubular obstruction by hyperviscous urine and inflammation [8]. HES-related inflammation has also been observed in other organs months after intravenous infusion, including liver and bone marrow [7].
Bleeding In general, the data on HES and clinical bleeding are less robust than those on AKI. However, recent trials have shown increased risk of bleeding with the use of HES as compared to crystalloid solutions in patients with sepsis [9] and those undergoing major surgery [10, 11]. In a meta-analysis of patients undergoing cardiac surgery, HES solutions were associated with increased postoperative blood loss and rates of reoperation for bleeding compared to albumin [12]. Other meta-analyses including data on HES and bleeding have
Data Loading...
