Hydroxyethylstarch as a risk factor for acute renal failure: is a change of clinical practice indicated?

Hypovolaemia is extremely common among surgical and intensive care patients. The best strategy for volume replacement therapy has been the focus of debate for several years. The lack of acceptance of hydroxyethylstarch (HES) for volume replacement therapy is most likely due to reports of abnormal coagulation and to recently published studies indicating negative effects of HES on renal function. All HES solutions are not created equal - they widely differ with regard to their physicochemical characteristics (concentration, mean molecular weight (Mw), degree of substitution [DS], C2/C6-substitution ratio). These differences have important consequences for adverse effects such as alterations in the coagulation process and on kidney function. Conflicting results about the effects of different HES solutions on renal function may also be due to varying clinical protocols, selection of patients, and different criteria for volume replacement. Theoretical and documented hazards are associated with each kind of volume replacement therapy. There appears to be no reason to banish modern HES preparations with a low or medium Mw (e.g. 70, 130 or 200 kD) and a low DS (0.4 or 0.5) in patients without pre-existing kidney dysfunction. In patients with known renal dysfunction (e.g. plasma creatinine level >3 mg/dl), all HES preparations should be used cautiously and other volume replacement regimens (e.g. gelatins) should be considered since no convincing data are yet available for the latest generation of HES (Mw 130; DS 0.4).