Resuscitation therapy with hydroxyethyl starch (HES) is most likely to lead to the development of acute kidney injury (AKI). This patient has septic shock and requires fluid resuscitation to prevent or limit multi-organ failure and reduce mortality. Repetitive fluid challenges are performed by giving a 500- to 1000-mL bolus of crystalloid over short intervals while assessing response to target central venous pressure. Most patients need 4 to 6 L of fluid in the first 6 hours, and a frequent error is underestimating the intravascular volume deficit and the amount of fluid required. The fluid input is typically greater than output owing to vasodilation and capillary leak. HES is a synthetic colloid that is associated with an increased risk of AKI, increased requirement of renal replacement therapy, a trend toward increased blood product transfusion, and increased mortality. HES accumulates in the proximal renal tubular epithelial cell, resulting in vacuolization and swelling of the proximal renal tubular cell, tubular obstruction and injury, and an osmotic nephrosis. As a result, the 2013 Surviving Sepsis Campaign recommends against using any HES in patients with severe sepsis.

Volume resuscitation can be achieved with either crystalloid or colloid solutions. The crystalloid solutions are lactated Ringer solution and 0.9% sodium chloride; the colloid solutions include albumin. Evidence from randomized trials and meta-analyses have found no convincing difference between using crystalloid solutions such as normal saline and lactated Ringer and albumin solutions in the treatment of severe sepsis or septic shock; however, colloid is far more expensive.