Effects of intraoperative and early postoperative normal saline or Plasma-Lyte 148® on hyperkalaemia in deceased donor renal transplantation: a double-blind randomized trial

Weinberg, Laurence; Harris, L.; Bellomo, Rinaldo; Ierino, Frank; Story, David A; Eastwood, Glenn M; Collins, Michael G.; Чурилов, Леонид; Mount, Peter F.

doi:10.1093/bja/aex163

Cited by 59 publications

(61 citation statements)

References 30 publications

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“…Clinicians tend to use saline in diabetic patients and patients with renal dysfunction to avoid hyperkalemiaalthough patients given saline actually have more hyperkalemia, hyperchloremia, and acidosis. 27 Saline is presumed to be safe when mixed with packed erythrocytes. However, lactated Ringer's solution can also be safely mixed with packed erythrocytes without provoking clot formation.…”

Section: Discussionmentioning

confidence: 99%

Saline versus Lactated Ringer’s Solution

et al. 2020

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Background: Both saline and lactated Ringer's solutions are commonly given to surgical patients. However, hyperchloremic acidosis consequent to saline administration may provoke complications. The authors therefore tested the primary hypothesis that a composite of in-hospital mortality and major postoperative complications is less common in patients given lactated Ringer's solution than normal saline. Methods:The authors conducted an alternating cohort controlled trial in which adults having colorectal and orthopedic surgery were given either lactated Ringer's solution or normal saline in 2-week blocks between September 2015 and August 2018. The primary outcome was a composite of in-hospital mortality and major postoperative renal, respiratory, infectious, and hemorrhagic complications. The secondary outcome was postoperative acute kidney injury.results: Among 8,616 qualifying patients, 4,187 (49%) were assigned to lactated Ringer's solution, and 4,429 (51%) were assigned to saline. Each group received a median 1.9 l of fluid. The primary composite of major complications was observed in 5.8% of lactated Ringer's versus 6.1% of normal saline patients, with estimated average relative risk across the components of the composite of 1.16 (95% CI, 0.89 to 1.52; P = 0.261). The secondary outcome, postoperative acute kidney injury, Acute Kidney Injury Network stage I-III versus 0, occurred in 6.6% of lactated Ringer's patients versus 6.2% of normal saline patients, with an estimated relative risk of 1.18 (99.3% CI, 0.99 to 1.41; P = 0.009, significance criterion of 0.007). Absolute differences between the treatment groups for each outcome were less than 0.5%, an amount that is not clinically meaningful.conclusions: In elective orthopedic and colorectal surgery patients, there was no clinically meaningful difference in postoperative complications with lactated Ringer's or saline volume replacement. Clinicians can reasonably use either solution intraoperatively. (ANESTHESIOLOGY 2020; 132:614-24) What We Already Know about This Topic • Infusion of large volumes of saline causes hyperchloremic metabolic acidosis • A recent Cochrane review based on 18 small trials reported that major morbidity and mortality were comparable with perioperative saline or lactated Ringer's use What This Article Tells Us That is New• In a large single-center alternating cohort trial of patients having elective colorectal or orthopedic surgery, there was no clinically meaningful difference in the risk of a composite of in-hospital mortality and major postoperative complications including renal, respiratory, infectious, and hemorrhagic complications A bout 51 million inpatient surgeries were performed in the United States in 2010, based on National Hospital Discharge Survey. 1 Nearly all surgeries require intravenous crystalloid fluids for drug administration and vascular volume repletion. Saline (0.9% sodium chloride; "normal saline") is a commonly used crystalloid, but it has a much higher chloride concentration than human plasma, and is thus u...

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Section: Discussionmentioning

confidence: 99%

Saline versus Lactated Ringer’s Solution

et al. 2020

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“…Elomel Isoton, which has been used in a trial of deceased donor transplant recipients, is similar to Plasmalyte, except that acetate is the sole buffer (Plasmalyte contains both acetate and gluconate buffers); however, it is not currently licensed in Australia and New Zealand. Plasmalyte is licensed in Australia, New Zealand, and many other countries, is readily available and already in use at many centers, and was recently evaluated for safety and potential efficacy in a small trial involving deceased donor kidney transplant recipients [29]. Thus, Plasmalyte was selected as the experimental low-chloride crystalloid fluid therapy for this trial.…”

Section: Interventions Explanation For the Choice Of Comparators {6b}mentioning

confidence: 99%

“…The effect size, or minimum clinically important difference, was determined by considering that a relative risk (RR) reduction of approximately 25% (RR of 0.75) for the incidence of the primary outcome would be both clinically meaningful and within the range of biological plausibility for the association between DGF and Plasmalyte versus 0.9% saline. The latter is based on trends observed in (1) the Weinberg trial [29]: RR of dialysis within 48 h posttransplant of 0.78 (95% confidence interval (CI) 0.47 to 1.28) and (2) a recently published before-and-after nonrandomized interventional study [39]: RR for dialysis within 48 h of 0.3 (95% CI 0.10 to 0.97; adjusted odds ratio 0.14; 95% CI 0.03 to 0.48), as the most current and relevant data available. A sample size of 722 participants (361 per group) will have 80% power at a 5% two-sided significance level to show an estimated absolute difference between the groups of 10% (41% versus 31%), with an estimated overall incidence of DGF of 36% and RR for Plasmalyte versus 0.9% saline of 0.76.…”

Section: Sample Size {14}mentioning

confidence: 99%

Study Protocol for Better Evidence for Selecting Transplant Fluids (BEST-Fluids): a pragmatic, registry-based, multi-center, double-blind, randomized controlled trial evaluating the effect of intravenous fluid therapy with Plasma-Lyte 148 versus 0.9% saline on delayed graft function in deceased donor kidney transplantation

Collins

Fahim

Pascoe

et al. 2020

Trials

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Background: Delayed graft function, the requirement for dialysis due to poor kidney function post-transplant, is a frequent complication of deceased donor kidney transplantation and is associated with inferior outcomes and higher costs. Intravenous fluids given during and after transplantation may affect the risk of poor kidney function after transplant. The most commonly used fluid, isotonic sodium chloride (0.9% saline), contains a high chloride concentration, which may be associated with acute kidney injury, and could increase the risk of delayed graft function. Whether using a balanced, low-chloride fluid instead of 0.9% saline is safe and improves kidney function after deceased donor kidney transplantation is unknown.

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“…The finding of significantly more hyperkalemia with 0.9% saline than lactated Ringers (containing 4 mmol/l potassium) was corroborated in two further studies in adult kidney transplant recipients [ 60 , 61 ]. PlasmaLyte (containing 5 mmol/l potassium) has also been shown to reduce the risk of hyperkalemia relative to potassium-free 0.9% saline in adults with end-stage kidney disease undergoing transplantation [ 62 , 63 ]. Although no pediatric data are available, these findings are noteworthy because pediatric transplant recipients receive large volumes of intravenous crystalloid to maintain allograft perfusion perioperatively [ 64 ].…”

Section: The Case For Abandoning 09% Salinementioning

confidence: 99%

Ab-normal saline in abnormal kidney function: risks and alternatives

Hayes

2018

Pediatr Nephrol

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Intravenous 0.9% saline has saved countless lives since it was introduced over a century ago. It remains the most widespread crystalloid in both adult and pediatric practice. However, in recent years, evidence of deleterious effects is accruing. These include increased mortality, acute kidney injury (AKI), metabolic acidosis, and coagulopathy. The predominant cause for these sequelae appears to be the excess chloride concentration of 0.9% saline relative to plasma. This has led to development of balanced isotonic solutions such as PlasmaLyte. This review summarizes current evidence for adverse effects of chloride-rich intravenous fluid and considers whether 0.9% saline should still be used in 2018 or abandoned as a historical treatment in favor of balanced crystalloid solutions.

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Effects of intraoperative and early postoperative normal saline or Plasma-Lyte 148® on hyperkalaemia in deceased donor renal transplantation: a double-blind randomized trial

Abstract: Australian New Zealand Clinical Trials Registry: ACTRN12612000023853.

Cited by 59 publications

References 30 publications

Saline versus Lactated Ringer’s Solution

Saline versus Lactated Ringer’s Solution

Ab-normal saline in abnormal kidney function: risks and alternatives

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