Ascites als Komplikation hepatischer Speicherung von Hydroxyethylstärke (HES) bei Langzeitdialyse

Abstract

Three adult dialysis patients developed ascites after having received repeatedly the plasma substitute hydroxyethyl starch (HES 40/0.5). In two cases (total dose 180, and 330 g HES, respectively) the ascites was reversible after discontinuation of the HES administration. In the third case (total dose 915 g HES) the ascites could be controlled only by implantation of a Denver shunt. In this latter case it was shown by histological, electron microscopical, and biochemical findings that the ascites was caused by hepatic sinusoidal obstruction due to an extreme storage of HES in the sinusoidal lining cells. Additional storage was detected in hepatocytes, bile duct epithelia, endothelial cells, and fibroblasts in the portal tracts. Biochemically HES was found in liver tissue at a concentration of 4% (w/w). Although in renal impairment plasma clearance of HES is not significantly different from normal individuals, long-term administration of HES must be regarded inadvisable because of tissue storage which apparently is especially significant in this condition.

Histological and Immunohistochemical Investigations of Hydroxyethyl Starch Deposits in Rat Tissues

“…Other im munological effects have not yet been de scribed, although it seems likely that MZM are involved as antigen-presenting cells of thymus-independent antigens [26. 27], How ever, impairment of liver function evidenced by ascites formation as a complication of hepatic storage of HES has been reported in dialysis patients [15]. Only recently, interest was newly focused on pruritus as a side effect after HES infusion, occurring in 42% of pa tients in one study [4], However, in our histochemical study no mast cell degranulation or accumulation of inflammatory cells could be observed.…”

“…In HES-treated dogs, watersoluble periodic-acid-Schiff-positive granules could be detected in liver parenchymal cells, spleen and lymph node phagocytes and in proximal renal tubular cells [11], Vacuolized cells in lymph nodes of rats were reported after HES treatment. Analyzed by electron microscopy, these vacuoles appeared mainly empty, only marginal electron-dense material could be found [12], Human liver biopsies showed also vacuolized hepatocytes, sinusoi dal cells and bile duct epithelial cells as well as vacuolar endothelial cells with a foamy ap pearance [13][14][15].…”

“…Additionally, uptake of HES was detected by use of l4C-HES [1,11], by photometric measurement of polysaccha ride concentration [ 12], by the modified gly cogen determination [15] and immunodiffu sion [10], Furthermore, phagocytosis of HES by alveolar macrophages has been reported [17], Thus, it was concluded that the vacuoli zation within the different cells represents tis sue storage of HES. although there was only indirect proof.…”

A Systematic Review of the Comparative Safety of Colloids

“…18,40,55,96,101 Such deposition often has been described in association with pruritus. 55,96 Tissue deposits persist as long as 54 months after HES administration.…”

“…18 In 1 recent study, HES deposition in hepatic Kupffer cells was associated with worsening of hepatic dysfunction after HES infusion. 101 Pump priming with HES, as compared with albumin, during cardiac surgery has been found to increase levels of liver enzymes during and after cardiopulmonary bypass surgery.…”