Influence of volume therapy with a modern hydroxyethylstarch preparation on kidney function in cardiac surgery patients with compromised renal function: a comparison with human albumin

OBJECTIVE

There is continuing concern about the influence of hydroxyethylstarch on renal function in patients with compromised kidney function.

DESIGN

Prospective, randomized, single-center study.

SETTING

University-affiliated hospital.

PATIENTS

Fifty patients undergoing elective, first-time coronary artery bypass grafting using cardiopulmonary bypass with a preoperative serum creatinine between 1.5 and 2.5 mg/dL.

INTERVENTIONS

According to a prospective, randomized sequence, the patients received either hydroxyethylstarch with a low molecular weight (mean molecular weight 130 kD) and a low molar substitution (0.4) (6% hydroxyethylstarch 130/0.4) (n = 25) or 5% human albumin (n = 25). Volume was added to the priming (500 mL) and given perioperatively until the second postoperative day to keep pulmonary artery occlusion pressure or central venous pressure between 12 and 14 mm Hg.

MEASUREMENTS AND MAIN RESULTS

Serum creatinine and cystatin plasma levels were measured from arterial blood samples. From urine specimens, N-acetyl-beta-D-glucosaminidase, glutathione transferase-alpha, and neutrophil gelatinase-associated lipocalin were measured. Measurements were performed after induction of anesthesia, at the end of surgery, 5 hrs after surgery, and on the first and second postoperative days. A follow-up after discharge from the hospital (60 days) was also done. Similar amounts of hydroxyethylstarch and albumin were infused. Serum creatinine, glomerular filtration rate, and cystatin C plasma levels were without significant differences between the groups. Concentrations of kidney-specific proteins were elevated at baseline and increased significantly after surgery without showing group differences. Urinary levels of neutrophil gelatinase-associated lipocalin increased more in the albumin- than in the hydroxyethylstarch-treated patients. None of the patients developed acute renal failure requiring renal replacement therapy during the hospital stay and thereafter.

CONCLUSIONS

A hydroxyethylstarch preparation with a low molecular weight and a low molar substitution given in cardiac surgery patients with preoperative compromised kidney function did not negatively influence kidney integrity compared with a human albumin-based volume replacement strategy.

Influence of different volume replacement strategies on inflammation and endothelial activation in the elderly undergoing major abdominal surgery

OBJECTIVE

Adequate restoration of intravascular volume remains an important maneuver in the management of the surgical patient. Influence of different volume replacement regimens on inflammation/endothelial activation in elderly surgical patients was assessed.

DESIGN

Prospective, randomized study.

SETTING

Surgical intensive care unit of a university-affiliated hospital.

PATIENTS

Sixty-six patients >65 years undergoing major abdominal surgery.

INTERVENTIONS

Ringer's lactate (RL; n=22), normal saline solution (NS; n=22) or a low-molecular HES (mean molecular weight 130 kD) with a low degree of substitution (0.4; HES 130/0.4; n=22) were administered after induction of anesthesia until the 1st postoperative day (POD) to keep central venous pressure between 8-12 mmHg.

MEASUREMENTS AND RESULTS

C-reactive protein, interleukins (IL-6, IL-8), adhesion molecules [endothelial leukocyte adhesion molecule-1 (ELAM-1) and intercellular adhesion molecule-1 (ICAM-1)] were measured prior to volume therapy at the end of surgery, 5 h after surgery and at the morning of the 1st POD. RL patients received 10,150+/-1,660 ml of RL, NS patients 10,220+/-1,770 ml of NS and the HES-treated group 2,850+/-300 ml of HES 130/0.4 and 2,810+/-350 ml of RL. Hemodynamics were similar in all groups. CRP, IL-6 and IL-8 plasma levels increased significantly higher in both crystalloid groups (IL-6 in the NS group: increase to 407+/-33 pg/ml; RL: increase to 377+/-35 pg/dl) than in the HES-130 treated group (IL-6: increase to 197+/-20 pg/dl). Plasma levels of ELAM-1 and ICAM remained almost unchanged in the HES 130-, but significantly increased in the RL- and NS-treated patients.

CONCLUSIONS

In elderly patients, markers of inflammation and endothelial injury and activation were significantly higher after crystalloid- than after HES 130/0.4-based volume replacement regimens.

Endothelial nitric oxide synthase gene polymorphism and elite endurance athlete status: the Genathlete study

In the Genathlete study, we examined the contribution of three polymorphisms in the endothelial nitric oxide synthase (NOS3) gene to discriminate elite endurance athletes (EEA) from sedentary controls (SC). The EEA group included a total of 316 Caucasian males with a VO2max >75 mL/kg. The SC group comprised 299 unrelated sedentary Caucasian males who had VO2max values below 50 mL/kg. The polymerase chain reaction technique was used to amplify a microsatellite (CA)(n) repeat in intron 13, a 27 bp repeat in intron 4 and a third fragment in exon 7 containing the Glu298Asp SNP. No difference was found between the EEA and SC groups for the 27 bp repeat and the Glu298Asp polymorphism. Chi-square analysis of the overall allelic distribution of the (CA)(n) repeat revealed no significant difference between the two groups (P=0.135). However, comparing carriers and non-carriers for the most common (CA)(n) repeat alleles, we found significant differences between SC and EEA, with more EEA subjects carrying the 164 bp allele (P=0.007). In summary, we found suggestive evidence that the 164 bp allele of the (CA)(n) repeat in intron 13 is associated with EEA status and may account for some of the differences between EEA and SC.

Prevention of Atrial Fibrillation after Coronary Artery Bypass Graft Surgery Using a Potassium-Magnesium-Aspartate Solution (Inzolen®)

BACKGROUND

Atrial fibrillation (AFIB) following cardiac surgery is a frequent complication. The purpose of this study was to evaluate the efficacy of a potassium-magnesium-aspartate solution (Inzolen) for the prevention of AFIB.

METHODS

In a randomised, prospective, double-blinded study, we studied 88 patients undergoing elective coronary artery bypass graft surgery (CABG). After surgery, patients were allocated randomly to one of two groups. Group A (n = 43) received a potassium-magnesium-aspartate solution (Inzolen), group B (n = 45) received potassium chloride; both solutions were administered continuously for 48 hours to keep the potassium serum levels between 4.5 and 5.5 mmol/l. Patients were observed for 5 days postoperatively and the incidence of atrial fibrillation was noted. At the end of surgery (T0), 4 h (T1), 24 h (T2), 48 h (T3), and 120 h (T4) postoperatively, magnesium and potassium serum levels were measured.

RESULTS

The two groups did not differ significantly with regard to demographics and perioperative data. No significant difference in the incidence of postoperative atrial fibrillation was seen (group A: 41.9 % vs. group B 31.1 %; P = 0.53). In group A, the magnesium serum levels were significantly higher at T1 (1.15 +/- 0.18 vs. 0.87 +/- 0.11 mmol/l), T2 (1.24 +/- 0.22 vs. 0.82 +/- 0.10 mmol/l) and T3 (1.15 +/- 0.18 vs. 0.81 +/- 0.20 mmol/l) compared to group B, whereas potassium levels were similar in the two groups throughout the study period.

CONCLUSIONS

The use of a potassium-magnesium-aspartate solution (Inzolen) showed no significant difference in potassium chloride for the prophylaxis of postoperative atrial fibrillation secondary to CABG.