Perioperative Plasma-Lyte use reduces the incidence of renal replacement therapy and hyperkalaemia following renal transplantation when compared with 0.9% saline: a retrospective cohort study

Abstract

BackgroundKidney transplant recipients often receive large volumes of intravenous fluid replacement in the peri-operative period. Administration of 0.9% saline has previously been associated with acidosis, hyperkalaemia and acute kidney injury. The perioperative use of physiologically balanced replacement fluids may reduce the incidence of post-operative renal replacement therapy and hyperkalaemia.MethodsA retrospective review of consecutive renal transplants before and after a change in perioperative fluid prescription from 0.9% saline to Plasma-Lyte 148.ResultsA total of 97 patients were included in the study, 59 receiving exclusively 0.9% saline and 38 receiving exclusively Plasma-Lyte. Patients in the Plasma-Lyte group were less likely to require emergency postoperative dialysis than those receiving 0.9% saline [odds ratio (OR) 0.15 (95% confidence interval 0.03–0.48), P = 0.004], and these patients had more favourable biochemical parameters with less hyperkalaemia, less acidosis and better diuresis. Patients in the Plasma-Lyte group also had a shorter length of hospital stay (7 days versus 11 days; P < 0.0001) and better graft function at 3 months postoperatively (estimated glomerular filtration rate 51 versus 44 mL/min/1.73 m2; P = 0.03); however, there was no difference in graft function at 1 year.ConclusionsPlasma-Lyte in the perioperative period is safe in renal transplantation and is associated with a favourable biochemical profile, including a reduced incidence of hyperkalaemia, better diuresis and less frequent use of renal replacement therapy early after surgery. In patients receiving Plasma-Lyte, graft function was better at 3 months, but this difference did not persist up to 1 year after transplantation.

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

“…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.…”

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

“…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 ].…”

Another nail in the saline coffin

“…6 Noteworthy, this 5.5 mM increase in serum chloride concentration is comparable with the postoperative increase (from 107 to 112.5 mM) reported by Pfortmueller and colleagues. 1 Numerous publications have documented an association between administration of hyperchloraemic crystalloids (mostly normal saline) and various adverse outcomes, including increased incidence of renal replacement therapy, 7,8 AKI, 9 kidney graft dysfunction, 7 and mortality. 8,10,11 The overall evidence clearly provides a harm signal associated with hyperchloraemic crystalloid solutions without a comparable benefit signal, and supports the use of balanced instead of hyperchloraemic crystalloid solutions in most acute care patients.…”

“…Some argue that specific techniques 7,8 are going to face a decline in training opportunities. Fibre-optic intubation (FOI) is usually considered a last resource for difficult intubation, so a reduction in difficult intubation should lead to a reduced need for FOI.…”