Thursday, June 28, 2012

IN THE NEWS: Hydroxyethyl Starch and Ringer's battle it out in NEJM

Hydroxyethyl starch(HES) has been used for volume resuscitation.  It is amylopectin+ hydroxyethyl groups in 0.9% saline or LR.  40-64% of it is excreted by the kidneys.  It is reabsorbed via pinocytosis and no enzymes exist to metabolize the intracellular substances and this leads to accumulation of cellular water and osmotic damage. This can also be seen in IV sucrose or dextran induced injury. This is similar to some forms of IVIG induced injury. Risk factors associated with renal injury have been described as prior CKD, DM, old age, large HES volumes>1 liter.  We as nephrologists have always been skeptical of this agent as its association with osmotic nephrosis.  The first case evert described of osmotic nephrosis with HES was in a kidney transplant patient. A recent NEJM publication looked at a multi centered, blinded trial that randomly assigned patients with severe sepsis to either 6% HES or LR at a dose of 33ml/kg of IBW per day.  The outcome was death and dependence of dialysis. The results showed a significant increased risk of death or dependence of dialysis at 90 days in HES group compared to LR.   The VISEP study had observed similar results but had lower power than this study. This study was randomized and also was international and included university and non university settings. A cochrane review done on this topic prior to this study was not conclusive.  In that meta analysis of 34 studies, it showed that HES had adverse kidney effects mainly in septic patients versus non septic patients. Long terms toxic effects of HES can be seen not only in kidney but in other organs such as bone marrow and liver as well.

After these trials:- probably should be avoided especially in high risk group.
Take a look at a prior post on this topic. 
Check out the article in NEJM.
Some articles that might shed some light on the damage done on cells by HES are presented here

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