Nephrotoxicity of hydroxyethyl starch solution.

Editor—Delayed graft function (DGF) after transplan-tation of cadaver kidneys is associated with poorer subsequent graft survival. 1 Fluid management during the donor operation can significantly modify the risk of DGF. Thus, in a blinded randomized trial of 69 kidney transplants from brain-dead donors, 2 volume loading with a mean of 2100 ml hydroxyethyl starch (HES) increased the incidence of DGF (P¼0.029). In the subset of patients with renal biopsies, osmotic nephrosis-like lesions were observed among all HES recipients, but none of the control group. Such lesions are consistent with HES deposition in renal tissue and have been found to persist as long as 10 yr after HES exposure. 3 In a recent study of 262 consecutive brain-dead donors, exposure to .750 ml HES was an independent risk factor for DGF, with an odds ratio (OR) of 1.80 and 95% confidence interval (CI) of 1.11 – 2.94. 4 It has been proposed that the molecular weight and substitution of HES solutions might be important determinants of adverse renal effects. For instance, it was suggested that the increased risk of DGF might reflect the particular HES solution used, which was 200 kDa in molecular weight and 0.62 in substitution (HES 200/0.62). 5 In a new retrospective study of 64 brain-dead donors enrolled over a time period of 8 yr, Blasco and colleagues 6 hypothesized that HES 130/0.4 might reduce renal dys-function in transplant recipients. Since case – controls were matched only at the donor patient level, and not the recipient, long-term differences in the recipients are hardly interpretable. More importantly, no difference in incidence of DGF could be detected between the groups receiving HES 130/0.4 and HES 200/0.62 (P¼0.27). Similarly, in a prior retrospective study of 109 brain-dead kidney donors, DGF incidence did not differ between donors receiving HES 200/0.5 vs HES 450/0.7 (P¼0.42). 5 Customarily defined as the need for dialysis within the first week, DGF is essentially acute renal failure (ARF) occurring within the specific context of renal transplantation. HES 200/0.62 administration has been shown to be an independent risk factor for ARF in a randomized trial of 129 patients with severe sepsis or septic shock (OR, 2.57; CI, 1.13 – 5.83). 7 Once again, it was speculated that the observed poor outcomes might be restricted to HES 200/0.62, but such has not proven to be the case. The newly reported Efficacy of Volume Substitution and Insulin Therapy in Severe …