Background: Hydroxyethyl starch (HES) solutions are used for perioperative fluid management. However, robust renal safety data in surgical patients are lacking. Methods: A meta-analysis was performed of randomised clinical trials comparing HES with non-HES control fluid in adult surgical patients. The endpoint was recourse to renal replacement therapy (RRT). Eligible trials were identified by multiple methods including computer database searches. Results: Fifteen randomised trials with a total of 4409 surgical patients were included. The Crystalloid versus Hydroxyethyl Starch Trial (CHEST) was the source for 65.1% of the included surgical patients. Eighty-three of the 2157 patients assigned to HES (3.8%) underwent RRT versus 56 of 2252 control patients (2.5%). HES significantly increased recourse to RRT, with a pooled relative risk (RR) of 1.44 and 95% confidence interval (95% CI) of 1.04-2.01. The absolute risk increase in recourse to RRT attributable to HES was 1.2% (95% CI: 0.1-2.2%), indicating a number needed to treat with HES of 85 to prompt RRT in one additional patient. In a subset of trials comparing HES 130/0.4 with crystalloid, the pooled RR for recourse to RRT (1.47; 95% CI: 1.02-2.12) coincided closely with the overall pooled RR of 1.44. In a subgroup analysis of data from CHEST, the RR for RRT was higher in surgical than non-surgical patients (ratio of RR: 1.19; 95% CI: 0.77-1.83); however, the difference was not significant (p = 0.43). Conclusions: HES increased recourse to RRT among surgical patients. There was no evidence that surgical patients are at lower risk for HES-induced acute kidney injury than non-surgical patients.