Hydroxyethyl starch and acute kidney injury in orthotopic liver transplantation: a single-center retrospective review

Anesth Analg. 2015 Mar;120(3):619-626. doi: 10.1213/ANE.0000000000000374.


Background: Acute kidney injury (AKI) is a frequent complication of orthotopic liver transplantation (OLT). Hepatic failure pathophysiology and intraoperative events contribute to AKI after OLT. Colloids are routinely used to maintain intravascular volume during OLT. Recent evidence has implicated 6% hydroxyethyl starch (HES) (130/0.4) with AKI in critically ill patients.

Methods: We performed a retrospective cross-sectional analysis of electronic anesthesia records, surgical dictations, and perioperative laboratory results. Postoperative AKI incidence was determined by RIFLE (Risk Injury Failure Loss End-Stage) criteria. AKI was staged into Risk, Injury, and Failure based on change in serum creatinine from preoperative baseline to peak level by postoperative day 7. Uni- and multivariate analysis was used to evaluate the association between type of intraoperative colloid administered and AKI.

Results: One hundred seventy-four adult patients underwent OLT and had complete records for review. Of these, 50 received only 5% albumin, 25 received both 5% albumin and HES, and 99 received only HES. Albumin-only, albumin and HES, and HES-only groups were otherwise homogeneous based on patient characteristics and intraoperative variables. There was a statistically significant linear-by-linear association between type of colloid(s) administered and AKI (Rifle Criteria-Injury Stage). Patients administered HES were 3 times more likely to develop AKI within 7 days after OLT compared with albumin (adjusted odds ratio 2.94, 95% confidence interval, 1.13-7.7, P = 0.027). The linear trend between colloidal use (5% albumin only versus albumin/HES versus HES only, ranked ordering) and "injury" was statistically significant (P = 0.048). A propensity-matched analysis also showed a significant difference in the incidence of AKI between the patients receiving albumin compared with HES (P = 0.044).

Conclusions: Patients receiving 6% HES (130/0.4) likely had an increased odds of AKI compared with patients receiving 5% albumin during OLT. These retrospective findings are consistent with recent clinical trials that found an association between 6% HES (130/0.4) and renal injury in critically ill patients.

Publication types

  • Comparative Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Acute Kidney Injury / blood
  • Acute Kidney Injury / chemically induced*
  • Acute Kidney Injury / diagnosis
  • Adult
  • Aged
  • Albumins / adverse effects*
  • Biomarkers / blood
  • Creatinine / blood
  • Cross-Sectional Studies
  • Female
  • Fluid Therapy / adverse effects*
  • Fluid Therapy / methods
  • Humans
  • Hydroxyethyl Starch Derivatives / adverse effects*
  • Linear Models
  • Liver Transplantation / adverse effects*
  • Logistic Models
  • Male
  • Middle Aged
  • Multivariate Analysis
  • Odds Ratio
  • Plasma Substitutes / adverse effects*
  • Propensity Score
  • Retrospective Studies
  • Risk Factors
  • South Carolina
  • Time Factors
  • Treatment Outcome


  • Albumins
  • Biomarkers
  • Hydroxyethyl Starch Derivatives
  • Plasma Substitutes
  • Creatinine