Fluid resuscitation with hydroxyethyl starches in patients with sepsis is associated with an increased incidence of acute kidney injury and use of renal replacement therapy: a systematic review and meta-analysis of the literature

J Crit Care. 2014 Feb;29(1):185.e1-7. doi: 10.1016/j.jcrc.2013.09.031. Epub 2013 Oct 22.

Abstract

Purpose: Fluid resuscitation is a key intervention in sepsis, but the type of fluids used varies widely. The aim of this meta-analysis is to determine whether resuscitation with hydroxyethyl starches (HES) compared with crystalloids affects outcomes in patients with sepsis.

Materials and methods: Search of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials up to February 2013. Studies that compared resuscitation with HES versus crystalloids in septic patients, and reported incidence of acute kidney injury (AKI), renal replacement therapy (RRT), transfusion of red blood cell (RBC) or fresh frozen plasma and/or mortality. Three investigators independently extracted data into uniform risk ratio measures. The Grading of Recommendations Assessment, Development and Evaluation framework was used to determine the quality of the evidence.

Results: Ten trials (4624 patients) were included. An increased incidence of AKI (risk ratio [RR], 1.24 [95% Confidence Interval {CI}, 1.13-1.36], and need of RRT (RR, 1.36 [95% CI, 1.17-1.57]) was found in patients who received resuscitation with HES. Resuscitation with HES was also associated with increased transfusion of RBC (RR, 1.14 [95% CI, 1.01-1.93]), but not fresh frozen plasma (RR, 1.47 [95% CI, 0.97-2.24]). Furthermore, while intensive care unit mortality (RR, 0.74 [95% CI, 0.43-1.26]), and 28-day mortality (RR, 1.11 [95% CI, 0.96-1.28]) was not different, resuscitation with HES was associated with higher 90-day mortality (RR, 1.14 [95% CI, 1.04-1.26]).

Conclusions: Fluid resuscitation practice with HES as in the meta-analyzed studies is associated with increased an increase in AKI incidence, need of RRT, RBC transfusion, and 90-day mortality in patients with sepsis. Therefore, we favor the use of crystalloids over HES for resuscitation in patients with sepsis.

Keywords: Colloid; Crystalloid; Hydroxyethyl starch; Meta-analysis; Sepsis.

Publication types

  • Meta-Analysis
  • Review
  • Systematic Review

MeSH terms

  • Acute Kidney Injury / chemically induced*
  • Blood Transfusion / statistics & numerical data
  • Critical Care
  • Critical Illness
  • Crystalloid Solutions
  • Hospital Mortality
  • Humans
  • Hydroxyethyl Starch Derivatives / administration & dosage
  • Hydroxyethyl Starch Derivatives / adverse effects
  • Hydroxyethyl Starch Derivatives / therapeutic use*
  • Incidence
  • Isotonic Solutions / administration & dosage
  • Isotonic Solutions / adverse effects
  • Isotonic Solutions / therapeutic use*
  • Length of Stay
  • Plasma Substitutes / administration & dosage
  • Plasma Substitutes / adverse effects
  • Plasma Substitutes / therapeutic use*
  • Renal Replacement Therapy / statistics & numerical data
  • Sepsis / drug therapy*
  • Sepsis / mortality
  • Sepsis / therapy

Substances

  • Crystalloid Solutions
  • Hydroxyethyl Starch Derivatives
  • Isotonic Solutions
  • Plasma Substitutes