Use of 6% Hydroxyethylstarch (130/0.4) in Cardiac Surgical Patients

Study Overview
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Brief Summary
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The purpose of this study is to evaluate the safety of a standard volume replacement called HES 130/0.4 (Voluven) during surgery on recovery. HES 130/0.4 (Voluven) may offer an alternative to pure fluid replacement solutions that are associated with problems after surgery including fluid overload and respiratory difficulties. The safety of HES 130/0.4 (Voluven) will be evaluated by examining its effects on kidney function, and coagulation parameters and platelet (part of the blood that help it clot) function. Participants will be randomized (like flipping a coin) to receive one of two possible volume replacements during surgery, if fluid volume decreases enough to need replacement with one of the fluids. The two possible volume replacements are Voluven (a starch-containing fluid) or human albumin 5% (a protein-containing solution). To examine kidney function, urine will be-sampled when the participant is put under general anesthesia, before surgical incision, within one hour of arrival to the ICU and 24 hours after completion of surgery. Two tubes (2 teaspoons) of blood (from an already established line) will be taken the morning of the surgery, within one hour of arrival to the ICU, 24 hours after surgery and every morning during the participants postoperative ICU stay. Additionally, health and recovery information will be recorded from the participant's medical record. We will phone participants around 90 days and one year after surgery to ask a few questions about one's health and recovery. We will also record blood sample analysis results from follow up appointments within the first year after surgery. If this analysis is not conducted at the Cleveland Clinic, with permission, we will obtain the results from a treating physician.

Official Title
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A Randomized Controlled Investigation of the Effects of 6% Hydroxyethylstarch 130/0.4 (Voluven) on Renal Function in Patients Having Aortic Valve Replacement With or Without Coronary Artery Bypass Grafting

Conditions
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Postoperative Kidney Injury

Intervention / Treatment
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* Drug: human albumin 5%
* Drug: HES 130/0.4 (Voluven)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age 50 - 85 years old Scheduled for elective aortic valve replacement with or without coronary artery bypass grafting with or without additional minor surgical procedure. Written, informed consent for participation in this investigation. Exclusion Criteria: Patients with renal failure with oliguria or anuria not related to hypovolemia. Patients receiving dialysis. Patients with preoperative renal insufficiency (Creatinine > 1.6 mg/dL) Anticipated deep hypothermic circulatory arrest Known hypersensitivity or allergy to hydroxyethyl starch or the excipients of hydroxyethyl starch Clinical conditions with volume overload (e.g., patients in pulmonary edema or congestive heart failure) Patients with severe hypernatremia or severe hyperchloremia Patients with intracranial bleeding Pregnant or breast feeding women Critically ill adult patients, including patients with sepsis, due to increased risk of mortality and renal replacement therapy, (e.g. patients who are hospitalized in the intensive care unit prior to surgery) Severe liver disease Pre-existing coagulation or bleeding disorders Any contraindications to proposed interventions.

Ages Eligible for Study
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Minimum Age: 40 Years
Maximum Age: 85 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: HES 130/0.4 (Voluven)<br>6% HES 130/0.4 during surgery | Drug: HES 130/0.4 (Voluven)<br> <br> |
| Active Comparator: human albumin 5%<br>human albumin 5% during surgery | Drug: human albumin 5%<br> <br> |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Urine Neutrophil Gelatinase-associated Lipocalin (NGAL) [Time Frame: 24 Hours After Surgery] [Designated as Safety Issue: Yes] | To assess the safety of HES 130/0.4 (Voluven) versus albumin 5% on renal function we will measure urinary concentrations of neutrophil gelatinase-associated lipocalin (NGAL), an important marker of renal function, measured at baseline (following anesthetic induction and prior to surgical incision), at one hour of arrival to intensive care unit (ICU), at 24 hours following completion of surgery. | 3 measurements in total from baseline to 24 hours after surgery: the first one is at baseline; the second one is at one hour of arrive to ICU and last one is at 24 hours after surgery | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Kidney Function | Postoperative kidney dysfunction using RIFLE diagnostic criteria was also assessed. Patients were assessed for risk for kidney dysfunction (RIFLE-R), injury to the kidney (RIFLE-I), failure of kidney function (RIFLE-F) using criteria based on only peak serum creatinine concentrations within the first seven postoperative days. Due to too few events, this outcome was redefined to risk (or worse) vs. no risk for this analysis. RIFLE classification criteria is listed below: Risk (RIFLE-R) Increase in serum creatinine x 1.5 from baseline Injury (RIFLE-I) Increase in serum creatinine x 2 from baseline Failure (RIFLE-F) Increase in serum creatinine x 3 from baseline Loss (RIFLE-L) Complete loss of kidney function > 4 weeks End stage (RIFLE-E) End-stage kidney failure > 3 months | within first 7 postoperative days | 
| Postop Urine IL-18 | Postop Urine IL-18 (interleukin-18) measured at 1 h of arrival to ICU | postoperative 1 hour | 
| Postop Urine IL-18 | Postoperative urine IL-18 (interleukin-18) measured at 24 hours after surgery | 24 hours after surgery |