title: 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.
abstract: OBJECTIVE
  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.
  
  
  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.
authors.affiliation: Medical Intensive Care Unit, ABC Medical School (FMABC), Santo André, Brazil; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil; Department of Intensive Care Medicine & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, The Netherlands. Electronic address: aryserpa@terra.com.br.
authors.forename: Ary
authors.initials: A
authors.lastname: Serpa Neto
authors.affiliation: Medical Intensive Care Unit, ABC Medical School (FMABC), Santo André, Brazil.
authors.forename: Denise P
authors.initials: DP
authors.lastname: Veelo
authors.affiliation: Medical Intensive Care Unit, ABC Medical School (FMABC), Santo André, Brazil.
authors.forename: Victor Galvão Moura
authors.initials: VG
authors.lastname: Peireira
authors.affiliation: Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.
authors.forename: Murillo Santucci Cesar
authors.initials: MS
authors.lastname: de Assunção
authors.affiliation: Medical Intensive Care Unit, ABC Medical School (FMABC), Santo André, Brazil.
authors.forename: José Antônio
authors.initials: JA
authors.lastname: Manetta
authors.affiliation: Medical Intensive Care Unit, ABC Medical School (FMABC), Santo André, Brazil.
authors.forename: Daniel Crepaldi
authors.initials: DC
authors.lastname: Espósito
authors.affiliation: Department of Intensive Care Medicine & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, The Netherlands.
authors.forename: Marcus J
authors.initials: MJ
authors.lastname: Schultz
mesh_terms: D058186:Acute Kidney Injury / Q000139:chemically induced*; D001803:Blood Transfusion / Q000706:statistics & numerical data; D003422:Critical Care; D016638:Critical Illness; D000077324:Crystalloid Solutions; D017052:Hospital Mortality; D006801:Humans; D006895:Hydroxyethyl Starch Derivatives / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D015994:Incidence; D007552:Isotonic Solutions / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D007902:Length of Stay; D010952:Plasma Substitutes / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D017582:Renal Replacement Therapy / Q000706:statistics & numerical data; D018805:Sepsis / Q000188:drug therapy* / Q000401:mortality / Q000628:therapy
chemical_list: D000077324:Crystalloid Solutions; D006895:Hydroxyethyl Starch Derivatives; D007552:Isotonic Solutions; D010952:Plasma Substitutes
keywords: Colloid; Crystalloid; Hydroxyethyl starch; Meta-analysis; Sepsis