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Effect of Hydroxyethyl Starch Solution on Incidence of Acute Kidney Injury in Patients Suffering from Cerebral Vasospasm Following Aneurysmal Subarachnoid Hemorrhage
Kieninger M, Unbekannt D, Schneiker A, et al. Neurocrit Care 2017;26:34-40.
Study Question: What is the incidence of acute kidney injury (AKI) in patients receiving hydroxyethyl starch (HES) for aneurysmal subarachnoid hemorrhage (aSAH) with signs of delayed cerebral ischemia (DCI)?
Study Description: This single-center, retrospective study evaluated adult patients admitted to the neurosurgical ICU with aSAH from November 2008 to August 2013. Patients were included if they had signs of DCI detected via transcranial Doppler, computer tomographic angiography, or cerebral angiography and had received 6% HES 130/0.4 for at least two days. Exclusion criteria included preexisting impaired renal function, pregnancy, and patients in whom ICU therapy was being terminated. In addition to HES, patients received standard management of DCI, including nimodipine, magnesium, and elevated goal mean arterial pressure. The primary outcome was the incidence of AKI, as defined by Acute Kidney Injury Network criteria
Results: A total of 81 patients were included, with a mean age of 51 years (SD ±11.2) and mean ICU length of stay of 26.7 days (SD ±12.7). Most patients were classified as Hunt and Hess grade 1 aSAH (34.6%), with the second highest number of patients as grade 5 (21.0%). Patients received HES for a mean of 12.9 days (SD ±7.1). Overall, four patients developed AKIN criteria stage 1 (4.9%), with two of these patients achieving normal renal function before leaving the ICU. No patients met AKIN criteria stage 2 or 3 and no patients required renal replacement therapy. Four patients (4.9%) developed increases in serum creatinine after hospitalization. The only difference in characteristics among the patients with signs of renal failure was cumulative dose of norepinephrine, which was higher in patients without signs of renal failure (206.2, SD ±336.3 vs. 71.6 mg, SD ±66.6; p=0.005). There was no correlation between the amount of HES administered and incidence of AKI.
Conclusion: Critically ill aSAH patients receiving 6% HES 130/0.4 does not lead to a higher incidence of acute kidney injury.
Perspective: This study did not find a higher incidence of acute kidney injury in critically ill aSAH patients receiving HES, which correlates with other retrospective analyses in patients with aSAH. However, the small, retrospective design limits confidence in implementing the results, and the recommendation against HES use in critically ill patients limits the feasibility of a prospective study. As patients with aSAH often do not have long courses of sepsis or septic shock and are typically younger than patients in other HES trials, the results from this trial are not widely applicable outside of aSAH patients.