Hydroxyethyl Starch and Perioperative Complications: a Systematic Review and Meta-analysis.

Summary

Pooling 114 trials (13,951 patients), modern HES (130/0.4 or 130/0.42) did not increase acute kidney injury (RR 1.02 [0.91–1.16]) nor worsen perioperative creatinine change. Trial sequential analysis supported non-inferiority for creatinine change, and no meaningful increases were seen in adverse events or mortality. Most trials limited HES to <24 hours.

Key Findings

• Across 114 trials (13,951 patients), HES 130/0.4–0.42 did not increase AKI risk (RR 1.02 [0.91, 1.16]).
• Perioperative creatinine change was non-inferior with HES (mean difference −0.62 [−3.82, 2.57] µmol/L).
• No meaningful worsening of adverse events or mortality; nearly all trials limited HES to <24 h.

Clinical Implications

In surgical patients without critical illness, modern HES solutions (130/0.4–0.42) used for <24 hours appear renal-safe, supporting their selective use within goal-directed fluid therapy while continuing to avoid use in sepsis/critical illness per existing evidence.

Limitations

• Heterogeneity in surgical populations and fluid comparators; renal outcomes largely short-term
• Most trials restricted HES to <24 h, limiting extrapolation to prolonged use

Future Directions

Pragmatic, registry-embedded RCTs in contemporary ERAS pathways should compare HES versus crystalloids/albumin in defined subgroups (e.g., cardiac, baseline CKD), with standardized AKI definitions and long-term renal follow-up.