Impact of balanced tetrastarch raw material on perioperative blood loss: a randomized double blind controlled trial

A Critical Reassessment of the Kidney Risk Caused by Tetrastarch Products in the Perioperative and Intensive Care Environments

Purpose: To reassess the results of former meta-analyses focusing on the relationship between novel HES preparations (130/0.4 and 130/0.42) and acute kidney injury. Previous meta-analyses are based on studies referring to partially or fully unpublished data or data from abstracts only. Methods: The studies included in the former meta-analyses were scrutinized by the authors independently. We completed a critical analysis of the literature, including the strengths, weaknesses and modifiers of the studies when assessing products, formulations and outcomes. Results: Both the published large studies and meta-analyses show significant bias in the context of the deleterious effect of 6% 130/0.4-0.42 HES. Without (1) detailed hemodynamic data, (2) the exclusion of other nephrotoxic events and (3) a properly performed evaluation of the dose-effect relationship, the AKI-inducing property of 6% HES 130/0.4 or 0.42 should not be considered as evidence. The administration of HES is safe and effective if the recommended dose is respected. Conclusions: Our review suggests that there is questionable evidence for the deteriorating renal effect of these products. Further well-designed, randomized and controlled trials are needed. Additionally, conclusions formulated for resource-rich environments should not be extended to more resource-scarce environments without proper qualifiers provided.

Strategies for post-cardiac surgery acute kidney injury prevention: A network meta-analysis of randomized controlled trials

Objects

Cardiac surgery is associated with acute kidney injury (AKI). However, the effects of various pharmacological and non-pharmacological strategies for AKI prevention have not been thoroughly investigated, and their effectiveness in preventing AKI-related adverse outcomes has not been systematically evaluated.

Methods

Studies from PubMed, Embase, and Medline and registered trials from published through December 2021 that evaluated strategies for preventing post-cardiac surgery AKI were identified. The effectiveness of these strategies was assessed through a network meta-analysis (NMA). The secondary outcomes were prevention of dialysis-requiring AKI, mortality, intensive care unit (ICU) length of stay (LOS), and hospital LOS. The interventions were ranked using the P-score method. Confidence in the results of the NMA was assessed using the Confidence in NMA (CINeMA) framework.

Results

A total of 161 trials (involving 46,619 participants) and 53 strategies were identified. Eight pharmacological strategies {natriuretic peptides [odds ratio (OR): 0.30, 95% confidence interval (CI): 0.19-0.47], nitroprusside [OR: 0.29, 95% CI: 0.12-0.68], fenoldopam [OR: 0.36, 95% CI: 0.17-0.76], tolvaptan [OR: 0.35, 95% CI: 0.14-0.90], N-acetyl cysteine with carvedilol [OR: 0.37, 95% CI: 0.16-0.85], dexmedetomidine [OR: 0.49, 95% CI: 0.32-0.76;], levosimendan [OR: 0.56, 95% CI: 0.37-0.84], and erythropoietin [OR: 0.62, 95% CI: 0.41-0.94]} and one non-pharmacological intervention (remote ischemic preconditioning, OR: 0.76, 95% CI: 0.63-0.92) were associated with a lower incidence of post-cardiac surgery AKI with moderate to low confidence. Among these nine strategies, five (fenoldopam, erythropoietin, natriuretic peptides, levosimendan, and remote ischemic preconditioning) were associated with a shorter ICU LOS, and two (natriuretic peptides [OR: 0.30, 95% CI: 0.15-0.60] and levosimendan [OR: 0.68, 95% CI: 0.49-0.95]) were associated with a lower incidence of dialysis-requiring AKI. Natriuretic peptides were also associated with a lower risk of mortality (OR: 0.50, 95% CI: 0.29-0.86). The results of a sensitivity analysis support the robustness and effectiveness of natriuretic peptides and dexmedetomidine.

Conclusion

Nine potentially effective strategies were identified. Natriuretic peptide therapy was the most effective pharmacological strategy, and remote ischemic preconditioning was the only effective non-pharmacological strategy. Preventive strategies might also help prevent AKI-related adverse outcomes. Additional studies are required to explore the optimal dosages and protocols for potentially effective AKI prevention strategies.

The effect of tetrastarch solution for capillary leak syndrome following allogeneic hematopoietic stem cell transplantation: A report of 2 cases

Capillary leak syndrome (CLS) is a severe complication of allogeneic hematopoietic stem cell transplantation (HSCT) characterized by weight gain, generalized edema, hypotension, and hypoalbuminemia. The primary pathogenesis is injury of the capillary endothelium resulting in a loss of intravascular fluid into the interstitial space. Treatment is limited to vascular endothelial growth factor withdrawal and systemic corticosteroids. We report two cases with CLS where weight gain, ascites, and hypotension developed after neutrophil engraftment following allogeneic HSCT. We obtained serial electrolytes, blood urea nitrogen, creatinine, and albumin from these patients. Ultrasound with Doppler tracing performed on both patients showed no reversal of portal venous flow. Issues addressed were the restoration of regular hydration by hydroxyethyl starch (HES) solutions, together with systemic corticosteroids and forced diuresis. Tetrastarch was administered 10 and 20 days, respectively. Both patients recovered without sequelae. CLS is a frequent complication after allogeneic HSCT. The effects of HES on CLS merit further consideration and prospective study.

Effect of 6% hydroxyethyl starch 130/0.4 on kidney and haemostatic function in cardiac surgical patients: a randomised controlled trial

Whether third‐generation hydroxyethyl starch solutions provoke kidney injury or haemostatic abnormalities in patients having cardiac surgery remains unclear. We tested the hypotheses that intra‐operative administration of a third‐generation starch does not worsen postoperative kidney function or haemostasis in cardiac surgical patients compared with human albumin 5%. This triple‐blind, non‐inferiority, clinical trial randomly allocated patients aged 40–85 who underwent elective aortic valve replacement, with or without coronary artery bypass grafting, to plasma volume replacement with 6% starch 130/0.4 vs. 5% human albumin. Our primary outcome was postoperative urinary neutrophil gelatinase‐associated lipocalin concentrations, a sensitive and early marker of postoperative kidney injury. Secondarily, we evaluated urinary interleukin‐18; acute kidney injury using creatinine RIFLE criteria, coagulation measures, platelet count and function. Non‐inferiority (delta 15%) was assessed with correction for multiple comparisons. We enrolled 141 patients (69 starch, 72 albumin) as planned. Results of the primary analysis demonstrated that postoperative urine neutrophil gelatinase‐associated lipocalin (median (IQR [range])) was slightly lower with hydroxyethyl starch (5 (1–68 [0–996]) ng.ml⁻¹) vs. albumin (5 (2–74 [0–1604]) ng.ml⁻¹), although not non‐inferior [ratio of geometric means (95%CI) 0.91 (0.57, 1.44); p = 0.15] due to higher than expected variability. Urine interleukin‐18 concentrations were reduced, but interleukin‐18 and kidney injury were again not non‐inferior. Of 11 individual coagulation measures, platelet count and function, nine were non‐inferior to albumin. Two remaining measures, thromboelastographic R value and arachidonic acid‐induced platelet aggregation, were clinically similar but with wide confidence intervals. Starch administration during cardiac surgery produced similar observed effects on postoperative kidney function, coagulation, platelet count and platelet function compared with albumin, though greater than expected variability and wide confidence intervals precluded the conclusion of non‐inferiority. Long‐term mortality and kidney function appeared similar between starch and albumin.

Long-term Impact of Crystalloid versus Colloid Solutions on Renal Function and Disability-free Survival after Major Abdominal Surgery

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

The authors recently demonstrated that administration of balanced hydroxyethyl starch solution as part of intraoperative goal-directed fluid therapy was associated with better short-term outcomes than administration of a balanced crystalloid solution in patients having major open abdominal surgery. In the present study, a 1-yr follow-up of renal and disability outcomes in these patients was performed.

Methods

All patients enrolled in the earlier study were followed up 1 yr after surgery for renal function and disability using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS). The main outcome measure was the estimated glomerular filtration rate. Other outcomes were serum creatinine, urea, pruritus, and WHODAS score. Groups were compared on a complete-case analysis basis, and modern imputation methods were then used in mixed-model regressions to assess the stability of the findings taking into account the missing data.

Results

Of the 160 patients enrolled in the original study, follow-up data were obtained for renal function in 129 and for WHODAS score in 114. There were no statistically significant differences in estimated glomerular filtration rate at 1 yr (ml min−1 1.73 m−2): 80 [65 to 92] for crystalloids versus 74 [64 to 94] for colloids; 95% CI [−10 to 7], P = 0.624. However, the WHODAS score (%) was statistically significantly lower in the colloid than in the crystalloid group (2.7 [0 to 12] vs. 7.6 [1.3 to 18]; P = 0.015), and disability-free survival was higher (79% vs. 60%; 95% CI [2 to 39]; P = 0.024).

Conclusions

In patients undergoing major open abdominal surgery, there was no evidence of a statistically significant difference in long-term renal function between a balanced hydroxyethyl starch and a balanced crystalloid solution used as part of intraoperative goal-directed fluid therapy, although there was only limited power to rule out a clinically significant difference. However, disability-free survival was significantly higher in the colloid than in the crystalloid group.

Monitoring of pulse pressure variation using a new smartphone application (Capstesia) versus stroke volume variation using an uncalibrated pulse wave analysis monitor: a clinical decision making study during major abdominal surgery

Pulse pressure variation (PPV) and stroke volume variation (SVV) can be used to assess fluid status in the operating room but usually require dedicated advanced hemodynamic monitors. Recently, a smartphone application (Capstesia™), which automatically calculates PPV from a picture of the invasive arterial pressure waveform from any monitor screen (PPV_CAP), has been developed. The purpose of this study was to compare PPV_CAP with SVV from an uncalibrated pulse wave analysis monitor (SVV_PC). In 40 patients undergoing major abdominal surgery, we compared PPV_CAP with SVV_PC at post-induction, pre-incision, post-incision, end of surgery, and during every hypotensive episode (mean arterial pressure < 65 mmHg). We classified PPV_CAP and SVV_PC into three categories reflecting the thresholds used for the decision to administer fluids: no fluid administration (PPV and SVV < 9%), gray zone (PPV and SVV 9-13%), and fluid administration (PPV and SVV > 13%). The agreement between SVV_PC and PPV_CAP for these three categories was measured by the number of concordant paired measurements divided by the total number of paired measurements and Cohen's kappa coefficient. In the 549 pairs of PPV-SVV data obtained, the overall agreement of PPV_CAP with SVV_PC was 79%, and the kappa coefficient was moderate (0.55). The highest agreement and kappa coefficient value were observed after the induction of anesthesia before surgical incision. PPV_CAP and SVV_PC would have resulted in completely opposite clinical decisions regarding fluid administration in 1% of the cases. In this clinical decision making study in patients undergoing major abdominal surgery, we observed a moderate agreement between PPV_CAP and SVV_PC with regard to categories used to guide fluid administration. Trial Registration: Clinical Trials.gov (NCT03137901).

Practical impact of a decision support for goal-directed fluid therapy on protocol adherence: a clinical implementation study in patients undergoing major abdominal surgery

The purpose of this study was to assess the effects of using a real time clinical decision-support system, "Assisted Fluid Management" (AFM), to guide goal-directed fluid therapy (GDFT) during major abdominal surgery. We compared a group of patients managed using the AFM system with a historical cohort of patients (control group) who had been managed using a manual GDFT strategy. Adherence to the protocol was defined as the relative intraoperative time spent with a stroke volume variation (SVV) < 13%. We hypothesised that patients in the AFM group would have more time during surgery with a SVV < 13% compared to the control group. All patients had a radial arterial line connected to a pulse contour analysis monitor and received a 2 ml/kg/h maintenance crystalloid infusion. Additional 250 ml crystalloid boluses were administered whenever measured SVV ≥ 13% in the control group, and when the software suggested a fluid bolus in the AFM group. We compared 46 AFM-guided patients to 38 controls. Patients in the AFM group spent significantly more time during surgery with a SVV < 13% compared to the control group (median 92% [82, 96] vs. 76% [54, 86]; P < 0.0005), and received less fluid overall (1775 ml [1225, 2425] vs. 2350 ml [1825, 3250]; P = 0.010). The incidence of postoperative complications was comparable in the two groups. Implementation of a decision support system for GDFT guidance resulted in a significantly longer period during surgery with a SVV < 13% with a reduced total amount of fluid administered. Trial registration: Clinical Trials.gov (NCT03141411).

The effects of crystalloid versus synthetic colloid in vitro on immune cells, co-cultured with mouse splenocytes

This study assessed the effects of crystalloid versus synthetic colloid in vitro on immune cells co-cultured with mouse splenocytes. Mouse splenocytes were co-cultured with three different types of fluid: Plasma solution-A^® (CJ HealthCare, Seoul, Korea; the crystalloid group); Tetraspan 6%^® (B. Braun Medical, Melsungen, Germany; the Colloid-T group); and Volulyte 6%^® (Fresenius Kabi, Bad Homburg vor dér-Höhe, Germany; Colloid-V group). To evaluate the acquired immune response, cluster of differentiation (CD) 4⁺ T cells and CD8⁺ T cells were measured. To evaluate the innate immune response, neutrophils were measured. The frequencies of CD4⁺ and CD8⁺ T cells did not differ significantly among the three groups on day 1 or 3. However, the frequencies of CD4⁺ and CD8⁺ T cells in the two synthetic colloid groups were significantly higher than those in the crystalloid group on day 7. On day 1, the frequency of neutrophils was significantly lower in the two synthetic colloid groups, compared with the crystalloid group. However, the values on the other days were similar among all three groups. In conclusion, crystalloid had a limited effect on the immune response; on the other hand, synthetic colloid increased the acquired immune response, although it temporarily inhibited the innate immune response.