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Hydroxyethyl Starch 130/0.4: Does “Modern” Mean Safe?

Wiedermann, Christian J., MD, FACP

Section Editor(s): Saidman, Lawrence

doi: 10.1213/ane.0b013e3181b366c4
Letters to the Editor: Letters & Announcements
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Department of Internal Medicine; Central Hospital; Bolzano (BZ), Italy; christian.wiedermann@asbz.it

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To the Editor:

In a recent review, Boldt1 reserves the term “modern” for hydroxyethyl starch (HES) 130/0.4, resoundingly endorsing its safety profile. However, the cited supporting evidence consists solely of selected small studies. Furthermore, accumulating data suggest that HES 130/0.4 is probably no safer than other HES solutions and may even be less safe. The incidence of acute renal failure did not differ between recipients of HES 130/0.4 and older HES solutions in an international prospective cohort of 1013 critically ill patients2 and increased significantly at HES 130/0.4 doses >33 mL/kg in a retrospective study of 2911 surgical intensive care unit patients (adjusted odds ratio, 1.85; 95% confidence interval, 1.01–3.41).3 No significant difference in renal replacement therapy requirement could be detected after HES 130/0.4 versus HES 200/0.62 administration in a retrospective study of 64 renal transplant recipients.4 Switching from albumin to HES 130/0.4 was associated with a dose-related renal replacement therapy increase of over 12-fold in a retrospective study of 44 patients with severe pulmonary failure.5

In a randomized trial of 45 cardiac surgery patients, postoperative infusion of 15 mL/kg HES 130/0.4 significantly retarded coagulation and reduced clot strength compared with the same dose of albumin, based on thromboelastography.6 HES 130/0.4 is promoted for its rapid plasma clearance, which does not, however, imply low tissue storage. One-third of administered HES 130/0.4 cannot be recovered in plasma or urine within 24 h,7 an even greater proportion than that for HES 450/0.7 (19%–23%).8 Greater tissue storage might be related to the high C2/C6 ratio of HES 130/0.4 (9 vs 5 for HES 450/0.7). In a new case report, a patient receiving HES 130/0.4 for septic shock developed acute renal failure with biopsy-proven osmotic nephrosis.9

In conclusion, before alleging its safety, HES 130/0.4 needs to be evaluated in rigorous large-scale randomized trials.

Christian J. Wiedermann, MD, FACP

Department of Internal Medicine

Central Hospital

Bolzano (BZ), Italy

christian.wiedermann@asbz.it

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REFERENCES

1.Boldt J. Modern rapidly degradable hydroxyethyl starches: current concepts. Anesth Analg 2009;108:1574–82
2.Schortgen F, Girou E, Deye N, Brochard L. The risk associated with hyperoncotic colloids in patients with shock. Intensive Care Med 2008;34:2157–68
3.Schabinski F, Oishi J, Tuche F, Luy A, Sakr Y, Bredle D, Hartog C, Reinhart K. Effects of a predominantly hydroxyethyl starch (HES)-based and a predominantly non HES-based fluid therapy on renal function in surgical ICU patients. Intensive Care Med 2009 Jun 17 [Epub ahead of print]
4.Blasco V, Leone M, Antonini F, Geissler A, Albanese J, Martin C. Comparison of the novel hydroxyethylstarch 130/0.4 and hydroxyethylstarch 200/0.6 in brain-dead donor resuscitation on renal function after transplantation. Br J Anaesth 2008;100: 504–8
5.Briegel I, Dolch M, Rehm M, Thiel M, Schelling G. Hydroxyethylstarch increases the risk for acute renal failure in patients with severe ARDS. Anesthesiology 2007;107:A1514
6.Schramko AA, Suojaranta-Ylinen RT, Kuitunen AH, Kukkonen SI, Niemi TT. Rapidly degradable hydroxyethyl starch solutions impair blood coagulation after cardiac surgery: a prospective randomized trial. Anesth Analg 2009; 108:30–6
7.Waitzinger J, Bepperling F, Pabst G, Opitz J, Müller M, Baron JF. Pharmacokinetics and tolerability of a new hydroxyethyl starch (HES) specification [HES (130/0.4)] after single-dose infusion of 6% or 10% solutions in healthy volunteers. Clin Drug Invest 1998;16: 151–60
8.Metcalf W, Papadopoulos A, Tufaro R, Barth A. A clinical physiologic study of hydroxyethyl starch. Surg Gynecol Obstet 1970;131:255–67
9.Hagne C, Schwarz A, Gaspert A, Giambarba C, Keusch G. HAES in der Sepsis: ein Damoklesschwert? Schweiz Med Forum 2009;9:304–6
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