Effects of dextran 40 on urine flow and composition during renal hypoperfusion in dogs with osmotic nephrosis

Use or Misuse of Albumin in Critical Ill Patients

Since 1940 albumin has been used worldwide and is widely available commercially since this time. However, a meta-analysis in 1998 challenged the use of albumin and identified a trend toward higher mortality in critically ill patients who had received albumin. Since then, many studies including multicenter randomized controlled trials have been carried out investigating the safety and efficacy of albumin treatment in different patient cohorts. In this context, patient cohorts that benefit from albumin were identified. However, particularly in non-liver patients, the use of albumin remains controversial. In our comprehensive review, we would like to highlight the most important studies in the recent 20 years and therefore offer an evidence-based outlook for the use of albumin for patients treated in the ICU.

Postmortem evaluation of renal tubular vacuolization in critically ill dogs

OBJECTIVE

To describe the frequency of renal tubular vacuolization (RTV) as a surrogate of osmotic nephrosis and assess hyperosmolar agents as predictors of RTV severity.

DESIGN

Retrospective study (February 2004-October 2014).

SETTING

Veterinary teaching hospital.

ANIMALS

Fifty-three client-owned, critically ill dogs that had a postmortem examination.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The frequency, severity, and location of RTV were determined in small group of critically ill dogs postmortem. Logistic regression was performed to assess cumulative 6% HES (670/0.75) and mannitol dose as predictors for RTV severity with presenting serum creatinine concentration, cumulative furosemide dose, and duration of hospitalization as covariates. RTV was noted in 45 (85%) of 53 critically ill dogs and was most commonly located to the medullary rays (68%). Cumulative 6% HES (670/0.75) dose (P = 0.009) and presenting serum creatinine concentration (P = 0.027) were significant predictors of RTV severity. For every 1 mL/kg increase in 6% HES (670/0.75) dose that a dog received, there was 1.6% increased chance of having more severe RTV (OR 1.016; 95% CI 1.004-1.029). In addition, for every 88.4 μmol/L (1 mg/dL) increase in presenting serum creatinine, there was a 22.7% increased chance of having more severe RTV (OR 1.227; 95% CI 1.023-1.472). Cumulative mannitol (P = 0.548) and furosemide (P = 0.136) doses were not significant predictors of RTV severity.

CONCLUSION

In a small group of critically ill dogs, there was a high frequency of RTV identified on postmortem examination. Administration of 6% HES (670/0.75) and presenting serum creatinine concentration were significant predictors of RTV severity. Larger prospective studies are needed to determine the etiology and significance of RTV in dogs.

Prevention of Acute Renal Failure - Fluid Repletion and Colloids

Hypovolemia alone or in conjunction with other factors is a main reason for acute renal failure in critically ill patients. Various crystalloid and colloid solutions are available to correct hypovolemia. Some of them have been implicated in impairment of renal function. Infusion of large amounts of sodium chloride is associated with increased incidence of nausea, vomiting and hyperchloremic metabolic acidosis. While gelatins and HES are preferred colloids in patients with normal kidney function, there is some evidence that the latter are associated with impaired renal function in patients with pre-existing kidney disease. Any hyperoncotic colloid given in large amounts may decrease glomerular filtration, and should therefore be combined with crystalloids.

THE USE OF HYDROXYETHYL STARCH 200/0,5 AS PLASMA SUBTITUTES IS SAFE IN HYPOVOLEMIC PATIENTS AS INDICATED IN CHANGES OF N-ACETYL--GLUCOSAMINIDASE AND CREATININ SERUM PARAMETERS

Hydroxyethyl Starch (HES) is a compound that improves intravascular volume effectively and rapidly without causing tissue edema. However, HES also has renal safety profile which is still being debated. Based on clinical experience in Dr. Soetomo Hospital, the frequency of acute renal failure following HES 200/0.5 administration at a dose of less than 20 ml/kg (maximum dose) is very rare. The purpose of this study was to evaluate the effect of HES 200/0.5 at a dose of less than 20 ml/kg in patients undergoing surgery. N-acetyl-b-D-Glucosaminidase (NAG) per urine creatinine ratio and creatinine serum were used as main parameter to assess renal injury. This research was observational and prospective design in patients undergoing elective surgery at Gedung Bedah Pusat Terpadu, Dr. Soetomo Hospital, who requiring resuscitation therapy with HES 200/0.5 and met the inclusion and exclusion criteria. NAG was measured prior to surgery and 12 hours after administration of fluid therapy, while creatinine serum was observed before surgery and 48 hours after resuscitation. This study was conducted for three months, and obtained 50 subjects divided into 2 groups, crystalloid group and HES 200/0.5 group. Demographic and baseline characteristics did not differ between groups, except the total bleeding volume. Total bleeding in HES 200/0.5group was higher than crystalloid group (p <0.0001). The mean volume of fluid received in HES 200/0.5 group was 2042.0 ± 673.9 mL, higher when compared with that of crystalloid group (910.0 ± 592.0 ml). Doses of HES 200/0.5 received was 8.31 ± 4.86 ml/kg. Measurement of the of NAG/creatinine ratio and creatinine serum showed significant increase in both groups, but still within the normal range. In addition, the value of these two parameters did not differ between groups. In conclusion, HES 200/0.5 in a dose of less than 20 ml/kg is safe to use in patients who suffered from hypovolemic hemorrhage, without prior history of renal impairment.

Permanent renal failure induced by pentastarch

Background. Controversy exists with volume resuscitation using crystalloids or colloids. Renal dysfunction has been reported with some colloids and osmotic agents, but remains poorly defined. Patient. We report the case of a 67-year-old male who had normal kidney function at baseline and who developed anuric ARF in relation to the administration of >10 litres of 10% pentastarch. A renal biopsy confirmed hydropic changes in tubular cells compatible with colloid-induced damage. Conclusion. This case demonstrates that hydroxyethyl starch preparations may be associated with acute kidney injury, and one should carefully consider their use, especially in patients with pre-existing renal dysfunction. Osmotic tubular cell lesions may be long lasting and irreversible.

Osmotic nephrosis: acute kidney injury with accumulation of proximal tubular lysosomes due to administration of exogenous solutes

Osmotic nephrosis describes a morphological pattern with vacuolization and swelling of the renal proximal tubular cells. The term refers to a nonspecific histopathologic finding rather than defining a specific entity. Osmotic nephrosis can be induced by many different compounds, such as sucrose, hydroxyethyl starch, dextrans, and contrast media. It has a broad clinical spectrum that includes acute kidney injury and chronic kidney failure in rare cases. This article discusses the pathological characteristics, pathogenesis, and various clinical entities of osmotic nephrosis.

Comparison of the novel hydroxyethylstarch 130/0.4 and hydroxyethylstarch 200/0.6 in brain-dead donor resuscitation on renal function after transplantation

BACKGROUND

The renal effect of hydroxyethylstarch (HES) solutions remains controversial. We hypothesized that the use of HES with a mean molecular weight of 130 kDa would reduce renal dysfunctions in the recipients. Our study was aimed at comparing the effects of two fluid regimens (HES 130/0.4 or HES 200/0.6) used for the resuscitation of brain-dead donors on the rate of delayed graft function (DGF) and the serum creatinine levels post-transplantation.

METHODS

This retrospective matched-paired study was conducted in an intensive care unit of a university hospital. Case-controls were matched at the donor patient level as follows: gender, BMI, duration of ICU stay, serum creatinine levels, vasopressor, and volume of colloids. The organ donation from 64 brain-dead donors resulted in 115 transplants.

RESULTS

The renal function was similar among all donors. The characteristics of the recipients, including the cold ischaemia time, were similar. The rate of DGF was 22% in the donors treated with HES 130/0.4, compared with 33% in those treated with HES 200/0.6 (P=0.27). The serum creatinine levels at 1 month were 133 (38) micromol litre(-1) when the donors had been treated with HES 130/0.4 and 172 (83) micromol litre(-1) when they were treated with HES 200/0.6 (P=0.005). A difference was found 1 yr after transplantation [128 (36) vs147 (43) micromol litre(-1), P=0.05].

CONCLUSIONS

Using a modern, third-generation, rapidly degradable HES preparation with a low degree of substitution seems to be associated with a better effect on the renal function of recipients.

Effects of hydroxyethyl starch administration on renal function in critically ill patients

BACKGROUND

The influence of hydroxyethyl starch (HES) solutions on renal function is controversial. We investigated the effect of HES administration on renal function in critically ill patients enrolled in a large multicentre observational European study.

METHODS

All adult patients admitted to the 198 participating intensive care units (ICUs) during a 15-day period were enrolled. Prospectively collected data included daily fluid administration, urine output, sequential organ failure assessment (SOFA) score, serum creatinine levels, and the need for renal replacement therapy (RRT) during the ICU stay.

RESULTS

Of 3147 patients, 1075 (34%) received HES. Patients who received HES were older [mean (SD): 62 (SD 17) vs 60 (18) years, P = 0.022], more likely to be surgical admissions, had a higher incidence of haematological malignancy and heart failure, higher SAPS II [40.0 (17.0) vs 34.7 (16.9), P < 0.001] and SOFA [6.2 (3.7) vs 5.0 (3.9), P < 0.001] scores, and less likely to be receiving RRT (2 vs 4%, P < 0.001) than those who did not receive HES. The renal SOFA score increased significantly over the ICU stay independent of the type of fluid administered. Although more patients who received HES needed RRT than non-HES patients (11 vs 9%, P = 0.006), HES administration was not associated with an increased risk for subsequent RRT in a multivariable analysis [odds ratio (OR): 0.417, 95% confidence interval (CI): 0.05-3.27, P = 0.406]. Sepsis (OR: 2.03, 95% CI: 1.37-3.02, P < 0.001), cardiovascular failure (OR: 6.88, 95% CI: 4.49-10.56, P < 0.001), haematological cancer (OR: 2.83, 95% CI: 1.28-6.25, P = 0.01), and baseline renal SOFA scores > 1 (P < 0.01 for renal SOFA 2, 3, and 4 with renal SOFA = 0 as a reference) were all associated with a higher need for RRT.

CONCLUSIONS

In this observational study, haematological cancer, the presence of sepsis, cardiovascular failure, and baseline renal function as assessed by the SOFA score were independent risk factors for the subsequent need for RRT in the ICU. The administration of HES had no influence on renal function or the need for RRT in the ICU.

Effects of hydroxyethylstarch and gelatin on renal function in severe sepsis: a multicentre randomised study

BACKGROUND

Hydroxyethylstarch used for volume restoration in brain-dead kidney donors has been associated with impaired kidney function in the transplant recipients. We undertook a multicentre randomised study to assess the frequency of acute renal failure (ARF) in patients with severe sepsis or septic shock treated with hydroxyethylstarch or gelatin.

METHODS

Adults with severe sepsis or septic shock were enrolled prospectively in three intensive-care units in France. They were randomly assigned 6% hydroxyethylstarch (200 kDa, 0.60-0.66 substitution) or 3% fluid-modified gelatin. The primary endpoint was ARF (a two-fold increase in serum creatinine from baseline or need for renal replacement therapy). Analyses were by intention to treat.

FINDINGS

129 patients were enrolled over 18 months. Severity of illness and serum creatinine (median 143 [IQR 88-203] vs 114 [91-175] micromol/L) were similar at baseline in the hydroxyethylstarch and gelatin groups. The frequencies of ARF (27/65 [42%] vs 15/64 [23%], p=0.028) and oliguria (35/62 [56%] vs 23/63 [37%], p=0.025) and the peak serum creatinine concentration (225 [130-339] vs 169 [106-273] micromol/L, p=0.04) were significantly higher in the hydroxyethylstarch group than in the gelatin group. In a multivariate analysis, risk factors for acute renal failure included mechanical ventilation (odds ratio 4.02 [95% CI 1.37-11.8], p=0.013) and use of hydroxyethylstarch (2.57 [1.13-5.83], p=0.026).

INTERPRETATIONS

The use of this preparation of hydroxyethylstarch as a plasma-volume expander is an independent risk factor for ARF in patients with severe sepsis or septic shock.

Propylene glycol-induced proximal renal tubular cell injury

Propylene glycol is a solvent that is used in many oral, injectable, and topical medications. Although uncommon, acute renal failure has been attributed to propylene glycol. The mechanism of propylene glycol-mediated renal injury is unknown. We report a case of acute renal failure in a 16-year-old boy given large doses of pentobarbital and phenobarbital, both of which are solubilized with propylene glycol. A renal biopsy showed proximal renal tubular cell swelling and vacuole formation. The data from this case suggest that the reversible acute renal failure caused by propylene glycol is attributable to proximal renal tubular cell injury.

[Can hydroxyethylamidon be used during intensive care of brain-dead organ donors?]

In France, most of the kidney grafts are obtained from brain dead organ donors. Brain death induces numerous changes, especially in haemodynamic status, requiring the infusion of large volumes of fluid. The aim of this study was to evaluate the effect of hydroxyethyl starch (HES) on the organ donors and the kidney graft function in recipients. We compared two groups of brain dead organ donors and the kidney grafts, differing by the infused solutions: either a combination of HES (Elohes, Biosedra) and 4% human albumin solutions (HES group), or albumin alone in the control group (Albumin group). In the two groups, sex-ratio, age, cause of brain death and duration of therapy were similar. Fluid requirements were identical in the two groups: respectively 2,211 +/- 1,512 mL in the Albumin group vs 2,452 +/- 1,094 mL in the HES group (p = 0.17). However, the volume of albumin was significantly decreased in the HES group: 711 +/- 822 mL (p = 0.0001). Therefore the cost was lower in the latter: 638 +/- 633 vs 1766 +/- 788 FF. The coagulation status was not significantly different between the two groups. Amylasemia was higher in the HES group, but the difference was not significant. In the Albumin group, urinary output increased, but not significantly and creatinemia was decreased: 113.9 +/- 62 vs 131.5 +/- 44 mumol.L-1 (p < 0.05). The two groups of recipients were also similar for sex-ratio, age, kind of graft, cause of the chronic renal failure and ischaemia times.(ABSTRACT TRUNCATED AT 250 WORDS)