no, i will not change my current practice based on this study, this study’s results should be carefully interpreted despite its double-blinded RCT but its terminated early due to the safety concern with intervention in isotonic saline, a small sample size most from LD transplantation 48 /51 total numbers and from the single center so cant generalized the results, treatment of acidosis and hyperkalemia lack of algorithm, some of the patient received diuretics, where the two groups treated equally? What about the immunosuppression effects like CNI? ( may contribute to both acidosis and hyperkalemia, primary outcome on day 3 post-op while the patients received different types of fluids like half saline and 5% water
we need more studies with larger sample sizes and well-matched control groups from multiple centers to address such outcomes with longer follow up
yes, it changed my mind toward lactated ringer, we used it already but not that much, of course we used normal saline more, but now we can use LR safely more than NS
I would change and recommend changing, as this study, although small no. of patients was included, is supportive to the growing evidence of adverse effect linked to hyperchloremia and metabolic acidosis triggered by normal saline infusion.
Yes, based on this study LR is superior to NS in transplantation.
We usually use either half-NS or NS based on patients BP or electrolytes in transplantation.
Yes it’s change my mind regarding intravenous fluid in renal failure and renal transplant
lactate ringer’s are safe and superior to normal saline in transplant treatment because less effects on acid base balance and no metabolic acidosis or hyperchloremic risk.
Mohammed Sobair
2 years ago
Introduction:
Theoretically, the administration of large volumes of potassium-containing fluids such as lactated Ringer’s solution (LR) might cause hyperkalemia in patients with chronic renal failure And ESRD).
This concern was the most frequently cited reason for the use of NS during kidney transplantation in a one survey.
Evidence suggests that balanced salt-based solutions such as LR may offer clinical benefits over NS and NS-based solutions.
Although controversial, the administration of large volumes of NS is associated with the development of hyperchloremic metabolic acidosis, which may theoretically cause hyperkalemia through an extracellular shift of potassium ions.
Infusion of NS has also been associated with effects such as subjective mental changes and abdominal discomfort in healthy volunteers. Aim OF the study:
A randomized, blinded clinical trial to explore the effects of NS administration on graft function as reflected by the serum creatinine concentration on postoperative day (POD) 3.
Second outcome, including the serum potassium concentration and acid-base balance. Methods:
Eligible patients undergoing kidney transplantation were randomized in a prospective, double-blind fashion to receive either NS or LR for intraoperative fluid replacement during surgery for kidney transplantation. Results:
Fifty-four patients were enrolled and randomized to receive either NS or LR. Three patients were excluded after randomization because of a preoperative serum potassium level 5.5 mEq/L. There were 25 patients in the LR group and 26 patients in the NS group.
All 51 patients were included in the final analysis. Of note, a separate analysis of the data, which excluded the cadaveric transplant recipients, revealed no difference in overall study result.
Serum creatinine on POD 3 was 2.3 +_1.8 mg/dL in the NS group and 2.1 _+1.7 mg/dL in the LR group (P 0.7).
Graft loss occurred in two patients in the NS group and in one patient in the LR group.
Episodes of biopsy-proven rejection occurred in four patients who received NS and in two patients who received LR.
Serum creatinine was similar in both groups at all other time-points, and there were no significant differences in any other markers of renal function.
Median (range) postoperative length of stay was 6.3 (3–27) days in the NS group and 5.3 (3–13) days in the LR group (P 0.6).
Peak intraoperative potassium concentration was 5.1 _+0.6 mEq/L in the NS group and 5.1 +_1.1 mEq/L in the LR group.
The serum potassium concentration exceeded 6.0 mEq/L in 5 of 26 (19%) patients in the NS group and in no patients in the LR group.
Patients randomized to receive NS exhibited more metabolic acidosis during surgery than patients who were randomized to receive LR.
Serum chloride concentration at the end of surgery was 111 _+4 mEq/L in the NS group versus 106 _+4 in the LR group (P 0.0001). Discussion:
There was no significant difference between groups in the primary outcome measure of the serum creatinine on POD 3.
The study was terminated because of concerns for patient safety.
Results strongly suggest that the administration of large volumes of LR to patients undergoing kidney transplantation is safe and that LR may be superior to NS for IV fluid therapy in this set.
Metabolic acidosis requiring treatment occurred only in patients who received NS.
The choice of balanced salt-based solutions such as LR rather than NS-based solutions for IV fluid therapy averts the risk of IV fluid-induced hyperchloremic metabolic acidosis.
In this study, no patient who received LR required treatment for hyperkalemia.
However, it cannot be concluded from our findings that hyperkalemia never occurs in patients who receive LR during kidney transplant surgery.
Hyperkalemia may occur, for example, during the rapid infusion of large volumes of LR. However, our findings support our hypothesis that the risk of hyperkalemia may be more theoretical than real in patients undergoing uncomplicated kidney transplant surgery who are treated with potassium-containing, balanced salt-based solution.
The NS group revealed that postoperative urine output was larger in patients who were treated with sodium bicarbonate for metabolic acidosis.
In addition, serum creatinine was lower in these patients, and this effect was apparent at one week after surgery.
Limitations:
For logistical reasons only, 3 cadaveric donor kidney recipients were enrolled, with 48 of the 51 study patients undergoing living donor transplantation. Therefore, our results are strictly applicable only to patients undergoing living donor transplants.
A single-center investigation.
Factors such as surgical technique and the duration of surgery may differ among institute.
Lack of an algorithm for study fluid administration and for the treatment of acidosis and hyperkalemia.
level of evidence 1.
Sahar elkharraz
2 years ago
This study is A Randomized, Double-Blind Comparison of Lactated Ringer’s Solution and 0.9% NaCl During Renal Transplantation.
this article shows lactate ringer’s is safe treatment pre / intra and post operative therapy in kidney transplant and less risk of metabolic acidosis and hyperchloremic which develop by normal saline.
This study level 1
Nasrin Esfandiar
2 years ago
In spite of zero content of potassium in normal saline solution its safety regarding inducing hyperkalemia was tested in a randomized control trial in recipients of kidney transplantation. Other outcomes were acid-base disturbances and post-op serum creatinine. Totally, 51 patients were included (25 in LR group and 26 in NS group). There was no difference regarding serum creatinine or rejection in both groups. Five out of 26 recipients in NS group had potassium more than 6 mEq/L compared to no one in the other group. In addition, NS group showed more metabolic acidosis needing treatment (8 patients) compared to LR group (no patient). So, administration of high dose LR to TX patients is safe and superior to NS. The level of evidence is 1.
amiri elaf
2 years ago
II. A Randomized, Double-Blind Comparison of Lactated Ringer’s Solution and 0.9% NaCl During Renal TransplantationSummarise this article
The objective:
*To analyze the rule of normal saline (NS) administration on graft function as reflected by the serum creatinine concentration on postoperative day
*To identify the safety of the administration of lactated Ringer’s solution (LR) to patients undergoing KT through secondary end-points, including the serum potassium concentration and acid-base balance.
Introduction:
* (NS) or potassium-free fluids are recommended for IV fluid therapy during KT.
*Theoretically, the administration of large volumes
of potassium-containing fluids as (LR) might cause hyperkalemia in patients with (CRF) or (ESRD).
*LR may offer clinical benefits over NS and NS-based solutions and administration of large volumes of NS is associated with the development of hyperchloremic metabolic acidosis.
The methods:
*The study was approved by the IRB of the Columbia
Presbyterian Hospital of the New York Presbyterian
Hospital.
*Adults undergoing kidney transplantation were enrolled in a prospective, randomized, double-blind clinical trial of NS versus LR for intraoperative IV fluid therapy.
*The primary outcome measure was creatinine concentration on postoperative Day.
*The study was terminated for safety reasons after interim analysis of data from 51 patients. 48 patients(LDKT), and 3 (DDKT) patients.26 received NS, and 25 patients received LR.
* Exclusion criteria were age 18 yr old, a religious or ethical prohibition from the receipt of blood or blood products, or serum potassium level 5.5 mEq/L before surgery.
The result:
*No difference between groups in the primary conclusion measure.
* NS did not negatively affect renal function.
*LR was associated with minimal risk of hyperkalemia and acidosis compared with NS.
* LR may be a safe choice for IV fluid therapy and superior to NS in patients undergoing KT.
*The development of metabolic acidosis in association with the administration of large volumes of NS is a well-recognized phenomenon.
*I will change my practice by using RL because it is more safe and superior to NS.
What is the evidence provided by this article?
Level of evidence is level 1
Fatima AlTaher
2 years ago
In kidney transplantion, post operative fluid therapy is a critical issue to deal with as we need an ideal solution to maintain the graft perfusion with out or with minimal associated electrolytes and acid base disturbance. Theoritically, K containing solution administration after kidney transplantion may induce hyperkalemia, also using large volume of normal saline causes hypercholaremic metabolic acidosis that in turn causes hyperkalemia due to transcellular fluid shift.
in this randomized, blinded clinical study , the authors aimed to evaluate the superiority of lactated ringer Vs normal saline for post transplantion fluid management regarding post operative SCr (evaluated in day 3) , electrolytes specially hyperkalemia and acid base disturbance.
51 patients were included , 26 in the BS group and 25 in LR group . Kidney function indices and S Cr at POD 3 were similar in both groups.
Peak intraoperative K was around 5 in both groups, while hyperkalemia exceeding 6 was encountered in 26% of NS patients and 0% in LR group.
Metabolic acidosis was detected and treated by Na bicarbonate in 31% of NS patients and 0% in LR group
Cumulative UOP was larger in NS and serum Cr was lower in NS group compared to LR group Conclusion
LR solution is associated with less MA and hyperkalemia compared to NS as post transplant fluid therapy Limitation of the study
Only 3 cadaveric kidney transplant were included
Fluid therapy was changeable according to clinical circumstances and was not based on algorithmic approach
Level of evidence :1
Wael Jebur
2 years ago
A prospective double blinded study , conducted to test the impact of intra-operative and post operative normal saline vs balanced intravenous fluid on renal transplant outcome. As it was speculated, that normal saline fluid administration intra-operatively is linked to adverse allograft outcome
Renal allograft assessment via measurement of serum creatinine was performed on third post operative day.
25 allograft recipients were enrolled with Normal saline fluid therapy intra-operatively vs 26 patients received balanced salt fluid Ringer lactate.
There was no difference in primary outcome of serum creatinine on 3rd post operative day, however the study was terminated early , owing to significant adverse effect of metabolic acidosis in 8 patients (32%) and hyperkalemia in 5 patients (19%) in normal saline fluid limb.
The putative mechanisms for development of metabolic acidosis are dilution of bicarbonate concentration or increased secretion of bicarbonate to maintain the electroneutrality. Otherwise, reduction of the strong ion difference SID is most probable explanation,
hyperkalemia stemmed from ionic shift with exchange of intracellular K to H in the setting of metabolic acidosis inflicted by infusion of normal saline.
Rihab Elidrisi
2 years ago
This is RCT Trial done on 51 patients to compare the effect of iv fluid perioperative in renal transplant patients.
For safety reasons, the study was terminated and the data collected from 51 patients were analyzed. Of the 51 cases reviewed, 48 patients did live donors and 3 did cadaveric donor transplants, Of the 51, 26 got NS, and 25 got LR The result demonstrated: 1) There were not differences between the two groups’ outcomes. 2) 19% of the NS group and 0 % of the LR group has a potassium level greater than 6 mEq/L and treatment was given 3) 31% of the NS group vs 0 % of the LR group were treated for metabolic acidosis. Also, it was noted that NS never affected adversely the kidney function 4) Also it was noted that LR had less high K and acidosis when compared with NS
Conclusion: Normal saline does not compromise kidney function but increases metabolic acidosis and hyperkalemia risk compared to LR
Riham Marzouk
2 years ago
RCT compare the effect of normal saline-based intravenous solution and salt based intravenous solution.
Renal allograft recipients are already have preexisting metabolic acidosis and are prone to hyperkalemia.
Intravenous use of Normal saline in renal transplantation can cause hypercholeremia, which leads to metabolic acidosis and hyperkalemia; this is less occurred with salt-based intravenous solutions like lactated ringer, but hyperkalemia can happen with rapid infusion of lactated ringer, so lactated ringer can be used safely in renal transplant patients.
level of evidence is level I
RCT comparing the effect of using normal saline and lactated ringer on graft function and resulted in no difference and lactated ringer less in hyperkalemia and acidosis and may be safe to be used
Abdulrahman Ishag
2 years ago
The study type ;
A prospective, randomized, double-blind clinical trial.
The aim of study;
1-To explore the effects of NS administration on graft function as reflected by the serum creatinine concentration on postoperative day 3.
2-To determine the safety of the administration of lactated ringer solutions to patients undergoing kidney transplantation through secondary end-points, including the serum potassium concentration and acid-base balance.
The ethical approval;
The study was approved by the IRB of the Columbia Presbyterian Hospital of the New York Presbyterian Hospital.
The method ;
Adults undergoing kidney transplantation were enrolled in a prospective, randomized,
double-blind clinical trial of NS versus LR for intraoperative IV fluid therapy.
The population;
51 patients. Forty-eight patients underwent living donor kidney transplants, and three patients underwent cadaveric donor transplants. Twenty-six patients received NS, and 25 patients received LR.
Exclusion criteria ;
were age 18 yr old, a religious or ethical prohibition from the receipt of blood or blood products, or serum potassium level 5.5 mEq/L before surgery.
The result;
There was no difference between groups in the primary outcome measure.Normal saline did not adversely affect renal function. Lactated ringer solution was associated with less hyperkalemia and acidosis compared with NS. Lactated ringer solution may be a safe choice for IV fluid therapy in patients undergoing kidney transplantation.
The limitations;
Only, 3 cadaveric donor kidney recipients were enrolled, with 48 of the 51 study patients undergoing living donor transplantation.
The conclusion;
The study results demonstrate that NS is not detrimental to renal function in these patients. In addition, the administration of large volumes of LR to patients undergoing kidney transplantation seems safe and may be superior to NS for IV fluid therapy in these patients because it avoids the risk of metabolic acidosis and clinically significant hyperkalemia.
What is the evidence provided by this article?
Level I
Mohamad Habli
2 years ago
This article is a randomized, double-blind study that compared the outcomes of lactated Ringer’s solution versus 0.9% sodium chloride during renal transplantation.
26 N/S, 25 LR. Only 3 individuals received cadaveric kidneys. Baseline characteristics were comparable.
Restrictions:
Age below 18, religious or ethical objection to blood or blood products, or serum potassium >5.5 mEq/L before operation.
Primary outcome: Post-operative day 3 serum creatinine.
Secondary outcomes include:
Postoperative urine production, DGF, Incidence of rejection and graft loss, Intraoperative potassium, acid-base balance, blood loss, and transfusions, Hospital stay post-op.
Results:
The study groups had similar POD 3 serum creatinine. (p=0.7).
Two NS and one LR patients lost grafts.
Four NS and two LR patients experienced biopsy-proven rejection.
NS and LR groups had 6.3 (3–27) and 5.3 (3–13) postoperative days, respectively (P= 0.6).
5 of 26 (19%) NS patients and no LR patients had serum potassium levels above 6.0 mEq/L (P= 0.05).
Eight (31%) NS patients got sodium bicarbonate for metabolic acidosis, compared to no LR patients (P= 0.004).
The NS group had 111 +/-4 mEq/L serum chloride during surgery, while the LR group had 106 +/-4 (P= 0.0001).
Sodium bicarbonate-treated N/S patients had higher postoperative urine production and lower serum creatinine.
N/S required more blood transfusions, although not much.
Strengths: Randomized controlled, same anesthesia and intra-operative regimen, same team group (surgeon, anesthetist, nurses ..etc).
Limitations: Small number, mostly living donor kidney transplants, only 3 cadaveric transplants, single-center study, no standard methodology for fluid infusion, acidosis, and hyperkalemia management.
Conclusion: Normal saline does not compromise kidney function but increases metabolic acidosis and hyperkalemia risk compared to LR.
Thank you professor, definitely we will follow this. otherwise we used to use NS and half saline in patients post- operatively.
Marius Badal
2 years ago
Summarise this article
What is the evidence provided by this article?
The article is about a randomized, double-blind comparison of lactated ringer’s solution and 0.9% NaCl during renal transplantation. The patients were randomly given sodium chloride and the lactated ringer intra-op surgery for a kidney transplant.
There were criteria for exclusions and including:
1) The age of patient must not be less than 18 years old
2) Depending on the patient religious belief
3) Serum potassium level greater than 5.5 before surgery. The aim: of the study was to determine the safety of using lactated ringer vs normal saline during a kidney transplant.
The method that was used:
1) A study conducted to compare lactated ringer vs normal saline
2) The study was approved by the IRB of the Columbia Presbyterian Hospital of New York Presbyterian Hospital.
3) Patients consented and were randomized in a prospective and double-blind fashion to receive the solution during the surgery.
4) The parameter that was first measured was creatinine day 3 post-op.
5) For safety reasons, the study was terminated and the data collected from 51 patients were analyzed.
6) Of the 51 cases reviewed, 48 patients did live donors and 3 did cadaveric donor transplants,
7) Of the 51, 26 got NS, and 25 got LR
The result demonstrated:
1) There were not differences between the two groups’ outcomes.
2) 19% of the NS group and 0 % of the LR group has a potassium level greater than 6 mEq/L and treatment was given
3) 31% of the NS group vs 0 % of the LR group were treated for metabolic acidosis. Also, it was noted that NS never affected adversely the kidney function
4) Also it was noted that LR had less high K and acidosis when compared with NS
Study limitation:
1) It was a small group size
2) It was a single center where the study was conducted
3) There were no guidelines for the treatment of acidosis and high K
4) No documentation was made if patients had received diuretics
5) The donors were mostly live ones
Conclusion:
Between the two groups of solutions, it is likely that LR could be a safer solution to use during surgery due to less high K and acidosis. NS never adversely affects the kidneys and their function
The level of evidence is level 1
saja Mohammed
2 years ago
Summary this Double blinded RCT from Anesthesia & ANALGESIA Journal with an impact factor of 6.67 Summary Introduction
Normal saline is one of the traditional widely used and cheap resuscitation fluids in critically ill patients in emergencies, intraoperative and critical care units, and also in the perioperative period in kidney transplantation surgeries it’s a potassium-free preferred solution compared to lactated ringer fluids which usually avoided in ESRD due to the possible higher risk of hyperkalemia, however large volume of isotonic saline can cause hyperchloremic acidosis and rebound hyperkalemia due to high chloride content with reduction of the GFR and AKI with DGF. Clinical question/hypothesis of this trial Normal saline is detrimental to renal /graft function in kidney transplant recipients
Safety of ringer lactate fluid use intraoperative for patients undergoing kidney transplantation
Method, setting
This is a prospective double-blinded RCT from a single center in the US, separate randomization lists were generated for 2 transplant surgeons with blinded IVF bags intraoperative for both groups, and the clinician, staff as well
Postoperative IVF was the same for both groups with ml/ml IVF replacement of dextrose 5%/0.45% saline +20meq of sodium bicarbonate /L for diabetic patients alternating with dextrose 5%/0.45% saline and 0.45% saline +20meq/l sodium bicarbonate / l.( this can mask the results )
Blood samples at baseline then every 30 minutes monitoring acid-base balance and potassium level intraoperative with ABG
Any hyperkalemia with > 6.5meq/l will be treated
Inclusion criteria, all adults > 18 Years old Exclusion criteria
1. Those < 18 years
2. Religious or ethical prohibition for use of blood or blood products
3.Pre-operative potassium level > 5.5
Population, setting
51 kidney transplant recipients divide equally into two groups 25 patients with RL (intervention, and a control group of 25 with normal saline Outcome
1. primary outcome for intervention includes
* Serum creatinine level on day 3 after surgery
2. Secondary outcome
*Postoperative UOP volume
*Creatinine clearance
*Need for dialysis
*Incidence of biopsy-proven rejection and graft loss
* Intraoperative acid-base balance, blood loss, transfusion requirements
*Post-operative hospital stay duration
Results
For the primary outcome no difference between the two groups in serum creatinine level in post-operative D3
More hyperchloremic acidosis and hyperkalemia need intervention in the normal saline group, with 31% in the NS group treated with sodium bicarb for metabolic acidosis compared to non in the RL group.
Strength of the study 1. The first study to compare NS to RL in ESRD patients
2. Patients are equally randomized and have well-matched baseline characteristics, a double-blinded prospective design
However, I will take the conclusion of this study with precaution despite its double-blinded RCT but the conclusion regarding the primary outcome needs to be revisited, this study has many limitations but still, the data provided by this study can be used in better-designed multi-centers prospective future studies limitations: 1. small sample size, type 1 error
2. single center
3. most are for LD without information about the preemptive VS dialysis and duration of dialysis which can also contribute to the risk of hyperkalemia
medications including IS as might consider cofounder risk for hyperkalemia
the primary outcome after 48 hours when the patients already and another type of fluid that can mask the results
4. there is a safety concern and the trial was terminated early
What is the evidence provided by this article? LEVEL 1B evidence from a single randomized trial with narrow CI or even level 11 but not level 1 A ( cant be ) .
Abhijit Patil
2 years ago
Summary:
Introduction:
Normal saline (NS; 0.9% NaCl) is administered during kidney transplantation to avoid the risk of hyperkalemia associated with potassium-containing fluids.
Recent evidence suggests that NS may be associated with adverse effects as against with balanced-salt fluids, e.g., lactated Ringer’s solution (RL).
The authors hypothesize that NS is detrimental to renal function in kidney transplant recipients.
Material and methods:
Study Location: Presbyterian Hospital of the New York Presbyterian Hospital.
Study design: Adults undergoing kidney transplantation were enrolled
Prospective, randomized, double-blind clinical trial of NS versus RL for intraoperative IV fluid therapy.
The primary outcome: creatinine concentration on postoperative Day 3.
Results:
The study was terminated for safety reasons after interim analysis of data from 51 patients.
48 patients: living donor kidney transplants
3 patients underwent cadaveric donor transplants.
26 patients received NS
25 patients received RL
There was no difference between groups in the primary outcome measure.
5 (19%) patients in the NS group versus zero (0%) patients in the RL group had potassium concentrations >6 mEq/L and were treated for hyperkalemia (P = 0.05).
8 (31%) patients in the NS group versus zero (0%) patients in the RL group were treated for metabolic acidosis (P =0.004).
NS did not adversely affect renal function.
Conclusion
RL was associated with less hyperkalemia and acidosis compared with NS.
RL may be a safe choice for IV fluid therapy in patients undergoing kidney transplantation
At our institute:
During surgery we give, RL as intravenous fluid
During post-operative period, we alternate RL with NS, as urine output on day 1 is quite high and the amount of RL leads to increased lactate levels
This paper would definitely help in changing practice in kidney transplant patient.
Amit Sharma
2 years ago
Summarise this article
Normal saline and normal saline based solutions are preferred during kidney transplant surgery. In view of evidence suggesting association of adverse effects with normal saline, the study was conducted to compare kidney transplant outcomes with intraoperative use of Lactated Ringer’s solution with that of normal saline.
It was a prospective randomized, single-center, double-blind trial whereby the study participants were given either normal saline (NS) or Lactated Ringer’s (LR) solution intraoperatively. The study fluid was discontinued at the end of the surgery, after application of the surgical dressing. The primary outcome measure was creatinine concentration at post-operative day 3.
54 patients were enrolled and randomized but 3 patients were excluded. Out of 51 remaining patients, 25 patients received LR while 26 received NS. The study groups were similar with respect to baseline characteristics. The study was terminated early after the interim analysis of 51 patients, although it was planned to enroll 100 patients in the study, due to safety reasons.
The NS group had more metabolic acidosis during surgery with lower intraoperative pH, lower end of surgery pH, higher end of surgery serum chloride, lower intraoperative serum bicarbonate and lower end of surgery serum bicarbonate. The NS group required a greater number of blood transfusions. Serum creatinine was similar in both the groups at all time-points.
Peak intraoperative serum potassium was higher in the NS group with 19% patients in NS group having peak values more than 6 mEq/L, while none of the patients in LR group had serum potassium more than 6 mEq/L.
NS group patients who received treatment for acidosis had lower serum creatinine and higher cumulative post-operative urine output.
The study concluded that administering large volume of LR is safe in kidney transplantation, and is associated with less incidence of hyperkalemia and metabolic acidosis with no effect on graft function, in comparison with NS use.
Limitations of the study include small sample size, single-center study, only 3 cadaveric patients included, hence predominantly applicable to living donors, absence of a defined algorithm for study fluid administration and treatment of acidosis or hyperkalemia, the lack of clarity regarding use of diuretics in subjects.
What is the evidence provided by this article?
Level of evidence: Level 1
Assafi Mohammed
2 years ago
Summary of the article “A Randomized, Double-Blind Comparison of Lactated Ringer’s Solution and 0.9% NaCl During Renal Transplantation”
This is a prospective, double-blind study that has compared the effects of NS and LR as IV fluid therapy in kidney transplant recipients. Study’s result and outcome
1. There was no significant difference between groups in the primary outcome measure of the serum creatinine on POD 3.
2. The study was terminated because of concerns for patient safety.
3. The study’s results strongly suggest that the administration of large volumes of LR to patients undergoing kidney transplantation is safe and that LR may be superior to NS for IV fluid therapy in this setting.
4. The development of metabolic acidosis in association with the administration of large volumes of NS is a well-recognized phenomenon.
5. Hyperkalemia may occur, for example, during the rapid infusion of large volumes of LR. What is the evidence provided by this article?
This is a prospective double-blind study.
Level of evidence grade 2
Mohammad Alshaikh
2 years ago
Summarise this article Introduction: The N/S is the fluid usually used in fluid resuscitation in renal transplant in USA, this double blinded randomized controlled trial comparing N/S to Ringer lactate (LR), in one transplant center in US. A 51 patients randomized 26 patients received N/S, 25 patients received LR. Only 3 patients received cadaveric kidney, the base line characteristics were comparable among groups. Exclusion criteria: An 18 yr old, a religious or ethical prohibition from the receipt of blood or blood products, or serum potassium level >5.5 mEq/L before surgery. Primary outcomes: The serum creatinine concentration on POD 3. Secondary outcomes: Postoperative urine output, creatinine clearance, and requirement for dialysis. The incidence of biopsy-proven rejection and graft loss. Intraoperative acid-base balance, intraoperative potassium concentration, blood loss and transfusion requirements. Postoperative hospital length of stay. Results: Serum creatinine on POD 3 was comparable among the study groups. (p=0.7). Graft loss occurred in two patients in the NS group and in one patient in the LR group. Episodes of biopsy-proven rejection occurred in four patients who received NS and in two patients who received LR. Postoperative length of stay was 6.3 (3–27) days in the NS group and 5.3 (3–13) days in the LR group (P= 0.6). The serum potassium concentration exceeded 6.0 mEq/L in 5 of 26 (19%) patients in the NS group and in no patients in the LR group (P= 0.05). Metabolic acidosis was more among patients received N/S, eight (31%) patients in the NS group received sodium bicarbonate for the treatment of metabolic acidosis in comparison to No patients in the LR group (P= 0.004). Serum chloride concentration at the end of surgery was 111 +/- 4 mEq/L in the NS group versus 106 +/- 4 in the LR group (P= 0.0001). Postoperative urine output was larger, and postoperative serum creatinine was lower in N/S group whom received sodium bicarbonate. Blood transfusion requirement was more among N/S group but not statistically significant. Strength of the study: Randomized controlled, the same anesthetic and intra-operative protocol, and were managed by the same team group (surgeon, anesthetist, nurses ..etc). Limitations: Small number, most of the transplants are living donor kidney transplant only 3 cadaveric transplants, single center study, lack of standard protocol for fluid infusion, acidosis and hyperkalemia management. Conclusion: The use of normal saline is safe and has no deleterious effect on kidney function but has more risk for metabolic acidosis and hyperkalemia, than LR.
What is the evidence provided by this article? Level of evidence I – double blinded randomized controlled study.
Manal Malik
2 years ago
Summary of A Randomized, Double-Blind Comparison of Lactated Ringer’s Solution and 0.9% NaCl During Renal TransplantationIntroduction
The consensus of usage of balanced salt to based solution such as Lactate Ringer in kidney transplant surgery as may result in hyperkalaemia, so may of U.S kidney transplant centres used normal saline based solutions although there is some studies find that large volumes of normal saline is associated with the development of hyperchloremic metabolic acidosis and hyperkalaemia. This randomized blind clinical trial to explore the effects of NS administration on graft function as reflected by the serum creatinine concentration on postoperative day 3(POD). Secondary end point include the serum potassium concentration and acid base balance. Methods:
Eligible patients whom had kidney transplantation were randomized in a prospective double blind fashion to receive either NS or LR for interoperative fluid replacement during surgery for kidney transplantation. Exclusion criteria were:
1. Age < 18 years old
2. A religious or ethical prohibition from the recipient of blood or blood products.
3. Serum potassium >5.5 mEq/L before surgery.
Blood was sampled at baseline and every 30 min for the duration of surgery for measurement of serum potassium concentration and acid-base balance.
Informed the clinician if S.K exceed 6.5 mEq/L.
Serum creatinine concentration on POD3 is primary outcome measurement. Secondary outcomes:
1. Intraoperative acid-base balance
2. Intraoperative potassium concentration
3. Blood loss
4. Transfusion requirement
5. Postoperative hospital length of stay
31% (8 patients) in NS group received solution bicarbonate for the treatment of metabolic acidosis in comparison to NO of patients in LR group. Discussion:
There was no significant difference between group in primary outcome measure of the serum creatinine on POD3.
The study was terminated because of concern for patient safety.
Although, the result strongly suggests that given large volumes of LR to patients during kidney transplantation surgery is safe and may be superior to NS for IV fluid therapy.
Affection of renal function by IV fluid composition small difference but statistical insignificance.
Patients who were treated with sodium bicarbonate for metabolic acidosis in NS group, they had postoperative urine output large and lower serum creatinine, which was at one week after surgery. Limitations of this study:
1. Study results are applicable only to patients transplanted from living donor (48/5i)
2. Single-centre investigations
3. Lack of an a algorithm for study fluid administration and for the treatment of acidosis and hyperkalaemia
4. Some patients may have received diuretics in the days after surgery and this may affect urinary output. Summary:
This study is the first one to compare the effects of NS and LR in patients with ESRD
The result emphasized that NS is not detrimental to renal function in these patients.
Given large volume of LR to patients during kidney transplantation seems safe and may be superior to NS for IV fluid therapy, in these patients because it avoids the risk of metabolic acidosis and clinical significant hyperkalaemia.
What is the evidence provided by this article?
level 2
this study will affect my practise as I will give transplant, KI and CKD ringer lactate unless in exceptional situation which lead to cl loss ,I can give 0.9% saline.
mai shawky
2 years ago
Club 2; ringer vs normal saline Summary
· Normal saline is the preferred solution in CKD and renal transplant (to avoid hyperkalemia thought to occur with the administration of large amount of K containing ringer lactate).
· The primary outcome of the current study, was the kidney function (3 days post-operative) and 2ry outcomes were urine output, creatinine clearance, level of K and metabolic acidosis, incidence of acute rejection, graft function.
· The current study , a double blinded RCT, found that ringer lactate has lower incidence of hyperkalemia and acidosis compared to isotonic saline.
· However, many limitations as few number of cases (all are 51), single center study, unavailable chart delineating the fluid therapy in each patient, and the degree of acidosis and its treatment, rate and volume of fluid administration, in addition to the early termination of the study for fear of patient safety.
· patients who were treated with NAHCO3 for acidosis had higher urine output and lower creatinine (may be related to volume expansion by it).
· Conclusion:
o NS is not detrimental to renal function in kidney transplant patients.
o In addition, large volumes of LR to KT patients seems safe and may be superior to NS for IV fluid therapy to minimize the risk of metabolic acidosis and hyperkalemia.
Level of evidence: I, as it is RCT (but small small sample size)
we still use normal saline and half normal saline in pediatric kidney transplant recipients.
Rehab Fahmy
2 years ago
NS was frequently used in patients with AKI for fear of hyperkalemia induced by RL infusion ,this can be theoretically right but in this study they need to answer this question because on the other hand NS infusion can cause metabolic acidosis and further K shifts and hyperkalemia
Methedology:54 patients from Columbia Presbyterian Hospital of the New York Presbyterian Hospital. After written, informed consent was ob- tained, eligible patients undergoing kidney transplan- tation were randomized in a prospective, double-blind fashion to receive either NS (Table 1) or LR (Table 1) for intraoperative fluid replacement during surgery for kidney transplantation.
Urine output was replaced (milliliter for mil- liliter) with an IV infusion of dextrose 5%/0.45% NaCl +20 mEq/L of sodium bicarbonate/L. For diabetic patients, fluid replacement routinely consisted of alternating liters of dextrose 5%/0.45% NaCl and 0.45% NaCl +20 mEq/L of sodium bicarbonate. All patients received an additional 50 mL/h of either of these two solutions when appropriate.
Blood was sampled at baseline (after insertion of the intraarterial cannula) and every 30 min for the dura- tion of surgery for measurement of serum potassium concentration and acid-base balance). The treatment for hyperkalemia, metabolic acidosis, and any other metabolic derangements was at the discretion of the clinician.
The primary outcome measure was the serum creatinine concentration on POD 3. This timepoint was chosen because this is the minimum postoperative length of stay after kidney transplantation at their institution.
Secondary outcomes included postoperative urine output, creatinine clearance, and requirement for dialysis, along with the incidence of biopsy-proven rejection and graft loss. Others: intraoperative acid-base balance, intraoperative potassium concentration, blood loss and transfusion requirements, and postoperative hospital length of stay.
Results:
Fifty-four patients were enrolled and randomized to receive either NS or LR. Three patients were excluded after randomization because of a preoperative serum potassium level >5.5 mEq/L. There were 25 patients in the LR group and 26 patients in the NS group.
Patients randomized to receive NS e more metabolic acidosis during surgery than patients who were randomized to receive LR .Eight (31%) patients in the NS group received sodium bicarbonate for the treatment of metabolic acidosis in comparison to no patients in the LR group (P =0.004)). Serum chloride concentration at the end of sur- gery was 111 +/-4 mEq/L in the NS group versus 106 +/- 4 in the LR group (P=0.0001).
Of note, cumulative postoperative urine output was larger (Fig. 2A) and postoperative serum creatinine was lower .
In patients in the NS group who received treatment for acidosis compared with patients who received no treatment for acidosis. The serum chloride concentration in patients who received bicarbonate was 113 +/- 4 mEq/L versus 110 +/-4 mEq/L in patients who did not receive bicarbonate (P =0.1).
Urine flow rate (range) in the first 4 h after revas- cularization of the donor kidney was 400 +/-370 (130 – 1050) mL/h in patients treated for hyperkalemia and 370 +/-410 (0–1520) mL/h in NS-treated patients with no hyperkalemia (P =0.9).
One patient received treat- ment for both hyperkalemia and metabolic acidosis.
One patient in the NS group who received a transfusion of packed red blood cells was treated for hyperkalemia, and no patients who received blood transfusions were treated for metabolic acidosis.
Discussion:
This is the first study that has compared the effects of NS and LR as IV fluid therapy in kidney transplant
Few studies only addressed this issue ,but has reported the outcome on graft survival but here there was no significance on graft survival.
Limitation of the study:
1-single center only
2-No comment on lasix use post Op which may unmask the diuretic effect of NS
3-no spescific protocol for management of hyperkalemia and acidosis ,it was left to the clinician experience .
Conclusion:
RL is less in metabolic acidosis and hyperkalemia than NS use in post kidney transplantation post operative period.
Level of evidence 1 RCT
In my practice I was previously using ringer lactate but currently I am working in another center using D5%,0.45% Nacl
Hussam Juda
2 years ago
· Most kidney transplant centres prefer normal saline (NS) and NS-based for administration during kidney transplant surgery, as they want to avoid K+ containing fluids
· large volumes of NS is associated with the development of hyperchloremic metabolic acidosis, which may theoretically cause hyperkalemia through an extracellular shift of K+
· The use of balanced salt-based solutions in elderly surgical patients may be associated with better splanchnic perfusion than NS-based solutions
· This is a randomized, blinded clinical trial to explore the effects of NS administration on graft function as reflected by the serum creatinine concentration on postoperative day
· Also explore the safety of the administration of LR to patients undergoing kidney transplantation
Discussion
· This is the first study that has compared the effects of NS and LR as IV fluid therapy in kidney transplant recipients.
· There was no significant difference between groups primarily on serum creatinine on POD 3
· The results are strongly suggesting that the administration of large volumes of LR to patients undergoing kidney transplantation is safe and that LR may be superior to NS
· Metabolic acidosis requiring treatment occurred only in patients who received NS
· Giving balanced salt-based solutions such as LR for IV fluid therapy avoids the risk of IV fluid-induced hyperchloremic metabolic acidosis
· In this study, no patient who received LR required treatment for hyperkalemia
· A few small studies have suggested that the administration of NS may be detrimental to renal function
· Previous studies have suggested that hyperchloremia induced by large volume of NS may adversely affect kidney function, but this study findings against previous studies
Study limitations:
· Only 3 cadaveric donor kidney recipients were enrolled in this study, so the study applicable only to living donation transplant
· The study was a single-center investigation
· There is no algorithm for study fluid administration and for the treatment of acidosis and hyperkalemia
· some patients may have received diuretics in the days after surgery, and this may have influenced postoperative urinary output
What is the evidence provided by this article? 1
Will you change your practice based on this article?
Yes. I started today as I am on call.
What is your fluid management plan of your transplant programme?
Actually, I noticed that some patients with acute kidney injury, develop more progression as long as they are on normal saline. I have taken a decision to treat post renal patients with RL.
Huda Mazloum
2 years ago
● Normal saline (NS) or potassium-free fluids arerecommended for IV fluid therapy during kidney transplantation
● Evidence suggests that balanced salt-based solutions such as LR may offer clinical benefits over NS and NS-based solutions.
● Administration of large volumes of NS is associated with the development of hyperchloremic metabolic acidosis which cause hyperkalemia also associated with mental changes and abdominal discomfort
● randomized prospective, double-blind
study to receive either NS or LR for intraoperative fluid replacement during surgery for kidney transplantation
● Exclusion criteria were :
** age 18 yr old
** a religious or ethical prohibition from the receipt of blood or blood products
** serum potassium level5.5 mEq/L before surgery.
● There was no significant difference between groups in the primary outcome measure of the serum creatinine on POD 3. ● The study was terminated because of concerns for patient safety.
● The administration of large volumes of LR to patients undergoing kidney transplantation is safe and that LR may be superior to NS for IV fluid therapy in this setting
● The choice of balanced salt-based solutions such as LR rather than NS-based solutions for IV fluid therapy averts the risk of IV fluid-induced hyperchloremic metabolic acidosis.
● postoperative urine output was larger in
patients who were treated with sodium bicarbonate for metabolic acidosis. In addition, serum creatinine was lower in these patients
● limitations
** results are strictly applicable only to patients undergoing living donor transplants.
** study is a single-center investigation.
** Factors such as surgical technique and the duration of surgery may differ among institutions.
** lack of an algorithm for study fluid administration and for the treatment of acidosis and hyperkalemia.
** some patients may have received diuretics in the days after surgery, and this may have influenced postoperative urinary output.
● NS is not detrimental to renal function
● administration of large volumes of LR to patients undergoing kidney transplantation seems safe and may be superior to NS for IV fluid therapy
Level 1
Introduction
Conventionally, normal saline (NS) or potassium-free fluids are used, recommended and preferred for intravenous fluid (IV) administration during renal transplantations. In theory, the concern is that the large volume of Ringer’s lactate (RL) may cause hyperkalemia due to its potassium content. This is a significant concern for patients with end-stage renal disease (ESRD). The use of NS may also cause hyperkalemia theoretically. Large volumes of NS may cause hyperchloremic metabolic acidosis which may lead to the extracellular shift of potassium. NS has also been implicated in causing mental state changes and abdominal discomfort in patients with no known comorbidities. A balanced salt-based solution may also improve splanchnic perfusion in the elderly.
In this context, the trial was designed to understand the effects of NS on renal transplant recipient graft function, by measuring serum creatinine levels on post-operative day 3 (POD3). The study also aimed to determine the safety of administering RL for patients undergoing renal transplant by assessing the serum potassium concentration and the acid-base balance.
Methods
The study was conducted at Columbia Presbyterian Hospital in New York. It was a randomized, prospective, double-blind study. Patients undergoing renal transplant, after consent was obtained, were either to receive NS or LR as the intraoperative IV fluid during surgery for the transplantation. Standardized anesthesia was used for both groups. Radial arterial cannula was inserted for all patients for sampling and blood pressure monitoring.
Exclusion criteria included:
Age less than 18 years
Religious, ethical prohibition to blood transfusion
Serum potassium levels more than 5.5mEq/L before surgery.
Post-operatively, urine output was replaced with an IV infusion of 5% dextrose/0.45% NaCl + 20mEq/L of sodium bicarbonate.
The primary outcome was the serum creatinine level on POD3.
Secondary outcomes included:
post-operative urine output
creatinine clearance
requirement for dialysis
incidence of graft loss (diagnosed with a biopsy).
Other secondary end points included intra-operative acid-base balance, intra-operative potassium levels, blood loss and post-operative length of hospital stay.
Results
Fifty four patients were enrolled and randomized for the study. Both groups received similar amounts of fluid intraoperatively. Serum creatinine was 2.3mg/dL in the NS group and 2.1mg/dL in the RL group, on POD3. Graft loos occurred in two patients in the NS group, and in one patient in the RL group. The peak potassium level intraoperatively was 5.1 +/- 0.6 mEq/L in the NS group, and 5.1 +/- 1.1 mEq/L in the RL group. The potassium level exceeded 6.0 mEq/L in 19% of the patients in the NS group, and no patients in the RL group. 31% of patients in the NS group developed metabolic acidosis and required sodium bicarbonate, and none of the patients in the RL group developed metabolic acidosis.
Discussion
There was no significant difference between the groups for the primary outcome of serum creatinine levels on POD3. The patients in the normal saline group had higher incidence of hyperkalemia and metabolic acidosis as compared to the RL group. The results showed that RL was safe to use for renal transplant patients. Administering large volumes of NS may worsen/cause metabolic acidosis, in patients with ESRD. It cannot be definitely concluded that hyperkalemia never occurs in patients receiving large volumes of RL, but the findings revealed that it may be more theoretical in patients undergoing uncomplicated renal transplantation.
Conclusion
RL is a safe fluid to use in the kidney transplant patients. It was not associated with graft dysfunction or hyperkalemia. NS has been associated with causing hyperchloremic metabolic acidosis and subsequent hyperkalemia due to the shift of potassium from the intracellular compartment to the extracellular compartment. Larger studies are needed to confirm these findings
The limitations of the study were:
1. Most of the patients underwent living donor transplant
2. It was a single-center investigation
3. The amount of fluid administration was dependent on the clinician
4. Some patients received diuretics post-operatively.
This is a randomized controlled trial – level 1 evidence
Summary of the article; Introduction; Most transplant centers recommend using normal saline and K free fluid for recipient during kidney transplantation, as grafted kidney may take time to start full function and to adapt to new environment and family. In this article we will show evidence of benefit of balanced solution (Lactated ringer) over 0.9 normal saline.
Infusion of large amount of 0.9 NS will cause extracellular shif and hyperkalemia, due to hyperchloremic metabolic acidosis. For this issue a randomized blined clinical article designed to explore the effects of NS on graft function and in the other hand the safety of using lactated ringer on graft function, on serum K level, and on acid-base status. Methods;
Study was done in Columbia Presbyterian Hospital of the in New York Presbyterian hospital.
Written informed consent was taken from eligible recipients, and randomized in to a prospective , double blind fashion, one group will receive NS, and the other LR.
Exclusion criteria was; recipient < 18 years, religious or ethical prohibition of recipient of blood or blood products, and the serum K >5.5 mg/dl.
Both group receive the regiment of Anesthesia.
Left kidney from living donor was taken (unless otherwise indicated) via a laparoscopic approach and flushed with ice cold LR, before shifted for implantation.
Cadaveric kidney was preserved using Euro-Collins or University of Wisconsin solution for the duration of transfer to the transplant center.
Graft was implanted to the either or left retroperitoneal space , with anastomosis to either right or left external or internal iliac artery.
Dopamine infusion was started for all recipients at 2 mic/kg/min until arrival to post anesthesia care.
Pre and post operative immunosuppressants was given according to the institutional guidelines, and all recipients receive triple therapy (Steroids/CNIs/MMF or SIR).
All IV fluid included in the study, before, during or after surgery, and it was same for all recipients, except for blood or blood products.
Urine output was replaced ml for ml with 5% dextrose/0.45%NS + 20 mEq/L NaBicarb/L, but for diabetic recipients was receive alternating regiment with or without NaBicarb.
Blood sample was withdrawing at start of canula insertion and every 30 min for Serum K, acid-base balance, and the clinician was informed if the serum k level exceed 6.5 mg/dl, and multiple sample can be taken independaple of the sampling protocol, and clinician treat any hyperkalemia or any acid-base imbalance.
The primary outcome measure was serum Cr at POD3.
Secondary outcomes included UOP, CrCL, and need for dialysis, along with incidence of biopsy proven rejection and graft loss, Intraoperative ( acid-base balance, Serum K, blood loss and transfusion, and postoperative length of stay).
Data was presented as mean +/- SD.
Sample size was of 100 in each group to ensure 80% power to detect the differences in S Cr, using a 2 group t-test.
Results;
54 recipients were randomized to receive either NS or LR.
3 patients were excluded b/c of a pre-op s K of >5.5 mEq/L.
there were 25 R with LR/ 26 R with NS, all included in the final analysis.
Cr on POD3 was 2.3+/-1.8 mg/dl in the NS group and 2.1+/-1.7 mg/dl in LR group.
graft loss occur in 2 recipients in NS group and in 1 recipients in LR group.
Biopsy proven rejection occured in 4 recipients in NS group ans in 2 recipeints in LR group.
S Cr was similar in other time points in both group.
LOS was 6.3 days in NS group compared with LR group which it was 5.3 days.
Peak intraoperative K was 5.1 +/- 0.6 mEq/l in the NS group and 5.1 +/- 1.1 mEq/l in the LR group.
S K level exceed 6.0 mEq/l in 5/26 recipients in NS group , while no recipients in the LR group.
Recipient in NS group show more metabolic acidosis during surgery compared to LR group.
8 recipients in NS group (with the lowest IP blood pH 7.28 +/-0.06 ) receive NaBicarb for the treatment of metabolic acidosis compared to no recipient (pH was 7.33 +/- 0.07) in LR group.
The Chloride concentration at the end of surgery was 111 +/- 4 mEq/l in the NS group vs 106 +/- 4 in the LR group.
S Cr was lower in NS group who receive treatment for NaBicarb, compared to NS group who were receive treatment for acidosis.
The serum Chloride was 113 +/- 4 mEq/l vs 110 +/- 4 mEq/l in patient who do not receive bicarbonate.
Discussion;
This is the first study that has compared the effect of NS vs LR in trasplanted recipients.
No significant difference between 2 group regarding S Cr in day 3 post operative.
Administration of huge amount of LR is safer, and LR is superior to NS for IV fluid therapy.
Metabolic acidosis is a recognized phenomenon in recipients receive NS.
Explanation of development of metabolic acidosis, may be due to dilution of bicarbonate, and hyperchloremia, whatever the cause , metabolic acidosis is of significant importance in transplanted recipients.
Fluid that use to manage patient with CKD, ESKD, and a perioperative period should be kept in mind the electrolyte disturbance (specially hyperkalemia) which is common in these group of patients, so it is important to minimize the risk of hyperkalemia.
In this study, no recipient treated for hyperkalemia in group receiving LR.
Hyperkalemia develop in NS group may be due to extracellular shift of K as a result of acute changes in blood hydrogen iron concentration, which is occur in association with hyperchloremic metabolic acidosis.
Within NS group, UOP was large in the metabolic acidosis treated with bicarbonate, and the s Cr was lower in the same group.
Limitation of the study;
For logistic reason, 3 cadaveric donor ,with 84 of the 51 living donation, therefore the result was confined only to the 48 recipients of living kidney donation.
Single center study.
Surgical procedures may be different among institutions.
Lack of the algorism for study fluid administration for the treatment of acidosis and hyperkalemia.
Some recipients receiving diuretics postoperatively and this is may affect UOP measurement.
This article greatly will affect my practice regarding not only transplanted patients, but also AKI, CKD as well as ESKD, and any patient should be individualized.
II. A Randomized, Double-Blind Comparison of Lactated Ringer’s Solution and 0.9% NaCl During Renal Transplantation
1. Summarise this article
This is a randomized prospective double-blind study. Patients were randomized to receive either NS or LR for intra-op fluid replacement during surgery for KTX. Exclusion criteria:
Age <18 year old
Religious or ethical prohibition from blood or blood products receipt.
Serum K+ level >5.5 mEq/L before surgery. Interventions Anesthesia induction:
IV midazolam, fentanyl, & propofol Anesthesia maintenance:
Isoflurane in air/O2 & fentanyl, with muscle
relaxants. Standard monitoring: recommendations of ASA used.
Radial arterial cannula after the induction of anesthesia for monitoring of systemic arterial BP & for blood sampling during surgery.
CVP at the discretion of the physician caring for the patient.
For LKD, the left kidney harvested via a laparoscopic approach.
The graft was flushed with ice cold LR before transfer to the OR for engrafting.
Cadaveric grafts were preserved with either Euro-Collins or University of Wisconsin solution.
The graft implanted in the R or L retroperitoneal space; vascular anastomoses to the R or L external or internal iliac artery & vein.
A dopamine infusion was started (D/C on arrival to the postanesthesia care unit). Ureteroneocystostomy by Leadbetter-Politano or Lich-Gregoir technique.
IS therapy according to institutional guidelines (triple therapy of tapering-dose steroids, a CNI, & either MMF or sirolimus). Goals:
To assess the impact of the interventions in actual clinical practice.
Study fluid used for all intra-op fluid replacement; blood or blood products were used if indicated.
All study personnel & clinicians were blinded to the fluid type.
Study fluid titrated to clinical end-points routinely used.
Study fluid was D/C at the end of surgery.
Post-op IV fluid therapy was the same for all patients & was given according to:
UOP (ml for ml) with an IV infusion of D 5%/0.45% NaCl +20 mEq/L of NaH2CO3/L.
For diabetics alternating liters of D5%/0.45% NaCl & 0.45% NaCl +20 mEq/L of NaH2CO3.
Additional 50 mL/h of either of these 2 solutions used for all when appropriate.
Serum K+ & ABG at baseline & every 30 min for the duration of surgery.
The treatment for hyperkalemia, metabolic acidosis, etc, at the discretion of the clinician. Primary outcome measure:
Serum creatinine concentration on POD 3 (the minimum post-op length of stay after KTX at the institution). Secondary outcomes:
UOP
Creatinine clearance
Requirement for dialysis
Incidence of BPAR & graft loss.
Intra-op acid-base balance
Intra-op K+ concentration
Blood loss & transfusion requirements
Post-op hospital length of stay. Results
The study terminated (for safety reasons) after analysis of data from 51 patients.
48 patients had LKD TX & 3 patients cadaveric donor TXs.
26 patients received NS, & 25 patients received LR. No difference between groups in the primary outcome measure.
5 (19%) patients in the NS group versus zero (0%) patients in LR group had K+ > 6 mEq/L & were
treated for hyperkalemia (P = 0.05).
8 (31%) patients in NS group versus zero (0%) patients in LR group were treated for metabolic acidosis (P = 0.004).
NS did not adversely affect renal function.
LR was associated with less hyperkalemia & acidosis compared with NS.
LR may be a safe choice for IV fluid therapy in patients undergoing KTX. Limitations
Results are strictly applicable only to patients undergoing LKD TXs.
Is is a single-center investigation. ////////////////////////// 2. What is the evidence provided by this article? Level I
Aim of the study: to determine the safety of the administration of LR to patients undergoing kidney transplantation.
Methods:
A prospective, randomized, double-blind clinical trial of NS versus LR for intraoperative IV fluid therapy.
After written informed consent was obtained, eligible patients undergoing kidney transplantation were randomized in a prospective, double-blind fashion to receive either NS or LR for intraoperative fluid replacement during surgery for kidney transplantation.
The primary outcome measure was creatinine concentration on a postoperative Day 3.
The study was terminated for safety reasons after interim analysis of data from 51 patients.
Forty-eight patients underwent living donor kidney transplants, and three patients underwent cadaveric donor transplants.
Twenty-six patients received NS, and 25 patients received LR.
Ethical Approval: The study was approved by the IRB of the Columbia Presbyterian Hospital of the New York Presbyterian Hospital.
Results:
There was no difference between groups in the primary outcome measure. Five (19%) patients in the NS group versus zero (0%) patients in the LR group had potassium concentrations >6 mEq/L and were treated for hyperkalemia.
Eight (31%) patients in the NS group versus zero (0%) patients in the LR group were treated for metabolic acidosis. NS did not adversely affect renal function.
LR was associated with less hyperkalemia and acidosis compared with NS.
Conclusion:
LR may be a safe choice for IV fluid therapy in patients undergoing kidney transplantation.
Limitations:
only 3 cadaveric donor kidney recipients were enrolled, with 48 of the 51 study patients undergoing living donor transplantation. Therefore, these results are applicable only to patients undergoing living donor transplants.
a single-center investigation.
small sample size ( 51 patients ).
lack of an algorithm for studying fluid administration and for the treatment of acidosis and hyperkalemia.
it is possible that some patients may have received diuretics in the days after surgery, and this may have influenced postoperative urinary output.
NS is the preferred IVF therapy during KT to avoid hyperkalemia. NS is associated with adverse metabolic effect and evidence suggests that balanced fluid such as LR may offer clinical benefits over NS and NS-based solutions.
Study goal:
Conduct a clinical effectiveness study, by assess the impact of the type of IVF during kidney transplantation.
Primary outcome:
Explore the effects of NS on graft function as reflected by the serum creatinine concentration on postoperative day 3(POD) 3.
Secondary outcomes:
Determine the safety of LR to patients undergoing KT through assessment of;
serum potassium and acid-base balance, blood loss and transfusion requirements, and postoperative hospital length of stay
Postoperative urine output, creatinine clearance, and requirement for dialysis, along with the incidence of biopsy-proven rejection and graft loss.
Methods: Design: prospective, double blinded randomized clinical trial. Population: Patient undergoing kidney transplantation randomized to either NS or LR for IVF during the surgery. Exclusion criteria: age <18 years old, a religious or ethical prohibition from the receipt of blood or blood products, or serum potassium level5.5 mEq/L before surgery.
Both groups received similar volumes of study fluid during surgery, and no patient received colloid during surgery
Results:
The study was terminated for safety reasons after interim analysis of data from 51 patients.
There were 25 patients in the LR group and 26 patients in the NS group.
Graft loss occurred in 2 patients in the NS group and in 1 patient in the LR group.
Episodes of biopsy-proven rejection occurred in 4 patients who received NS and in 2 patients who received LR.
Serum creatinine was similar in both groups at all other time-points
Median (range) postoperative LOS was 6.3 days in the NS group and 5.3 days in the LR group.
Potassium concentration was higher in NS group (19% treated vs no one in LR group)
Patients received NS exhibited more metabolic acidosis (31% treated for metabolic acidosis vs no one in LR group)
Serum chloride concentration at the end of surgery was 111 mEq/L in the NS group versus 106 in the LR group
Conclusion:
LR administration to patients undergoing kidney transplantation is safe and may be superior to NS.
LR was associated with less hyperkalemia and acidosis compared with NS.
NS did not adversely affect renal function.
Limitations:
Single center study.
Small sample size.
Study strictly applicable only to patients undergoing LD transplants, as number of DD recipients was only 3.
Lack of an algorithm for study fluid administration and for the treatment of acidosis and hyperkalemia
Thank you Agree regarding the limitations, well done
Ghalia sawaf
2 years ago
theoretically, lactated Ringer’s solution (LR) might cause hyperkalemia in patients with (ESRD).
This concern was the most frequently cited reason for the use of NS during kidney transplantation
However, administration of large volumes of NS is associated with the development of hyperchloremic metabolic acidosis which may theoretically cause hyperkalemia through an extracellular shift of potassium ions
Methods
The study is randomized prospective , blinded clinical trial
explore the effects of NS administration on graft function
as reflected by the serum creatinine concentration on postoperative day (POD)
at Columbia Presbyterian Hospital of the New York
This study aimed
To determine the safety of the administration of LR to patients undergoing kidney transplantation through secondary end-points, including the serum potassium concentration and acid-base balance.
Randomization was achieved by computer generation of random number lists, in blocks of four, and a closed envelope technique.
Separate randomization lists were compiled for the two surgeons
Exclusion criteria were
1. age 18 yr old,
2. a religious or ethical prohibition from the receipt of blood or blood products,
3. or serum potassium level 5.5 mEq/L before surgery.
Statistically
The investigational pharmacy completely covered each bag of study fluid with opaque tape to ensure blinding of all study personnel and clinicians to the fluid type.
Differences in continuous variables between the two groups were tested using t-tests or Mann-Whitney tests as appropriate.
Differences between categorical variables were tested using Fisher’s exact test.
A P value 0.05 (two-tailed) was considered to be significant.
Postoperative IV fluid therapy was the same for all patients and was administered according to the following institutional protocol.
The clinician caring for the patient was informed if serum potassium concentration exceeded 6.5 mEq/L
• The primary outcome measure
was the serum creatinine concentration on POD 3.
• Secondary outcomes included
postoperative urine output, creatinine clearance, and requirement for dialysis, along with the incidence of biopsy-proven rejection and graft loss.
• Other secondary outcomes
included intraoperative acid-base balance, intraoperative potassium concentration, blood loss and transfusion requirements, and postoperative hospital length of stay.
Sample size
was calculated to ensure sufficient statistical power to detect expected differences between fluids with respect to the primary outcome.
A planned interim safety analysis was conducted after 50 patients had been studied.
This analysis of safety data revealed statistically significant differences in safety related end-points (serum potassium concentrations and acid-base balance) in favor of the experimental therapy (LR). Therefore, it was decided to stop study enrollment at this time.
Results
• 54 patients were enrolled and randomized to receive either NS or LR.
• Three patients were excluded because of a preoperative serum potassium level 5.5 mEq/L.
• There were 25 patients in the LR group and 26 patients in the NS group..
• Both groups received similar volumes of study fluid during surgery, and no patient received colloid during surgery
• Seven units of packed red blood cells were administered in the NS group versus 3 U in the LR group.
Serum creatinine on POD 3 was 2.3+/- 1.8 mg/dL in the NS group and 2.1+/_ 1.7 mg/dL in the LR group (P 0.7).
Graft loss occurred in two patients in the NS group and in one patient in the LR group.
Episodes of biopsy-proven rejection occurred in four patients who received NS and in two patients who received LR.
Median (range) postoperative length of stay was 6.3 (3–27) days in the NS group and 5.3 (3–13) days in the LR group (P 0.6).
Peak intraoperative potassium concentration was 5.1- +/_0.6 mEq/L in the NS group and 5.1+/_1.1mEq/L in the LR group.
The serum potassium concentration exceeded 6.0 mEq/L in (19%) patients in the NS group and in no patients in the LR group (P 0.05)
Patients randomized to receive NS exhibited more metabolic acidosis during surgery than patients who were randomized to receive LR
chloride concentration at the end of surgery was 111+/_ 4 mEq/L in the NS group versus 106 +/_4 in the LR group (P 0.0001).
Discussion
This is the first study that has compared the effects of NS and LR as IV fluid therapy in kidney transplant recipients.
There was no significant difference between groups in the primary outcome measure of the serum creatinine on POD 3.
The development of metabolic acidosis in association with the administration of large volumes of NS is a well-recognized phenomenon
In this study, metabolic acidosis requiring treatment occurred only in patients who received NS.
In this study, no patient who received LR required treatment for hyperkalemia. However, it cannot be concluded from our findings that hyperkalemia never occurs in patients who receive LR during kidney transplant surgery.
Small differences in postoperative markers of renal function were observed, but these differences were not clinically relevant and did not achieve statistical significant.
postoperative urine output was larger in patients who were treated with sodium bicarbonate for metabolic acidosis
The study is subject to a number of limitations.
only patients undergoing living donor transplants
. single-center investigation.
lack of an algorithm for study fluid administration and for the treatment of acidosis and hyperkalemia.
receiving diuretics in the days after surgery, and this may have influenced postoperative urinary output.
Level 1 high quality randomized trial prospective study
This study still not a guideline However it has the efforts to influence my practice
In our center we still use NS solution
II. A Randomized, Double-Blind Comparison of Lactated Ringer’s Solution and 0.9% NaCl During Renal Transplantation
Summarise this article
What is the evidence provided by this article?
——————————————————————————————————————-
Introduction
Normal saline is administered during kidney transplantation to avoid the risk of hyperkalemia associated with potassium-containing fluids.
Recent evidence suggests that NS may be associated with adverse effects that are not seen with balanced-salt fluids, e.g., lactated Ringer’s solution (LR).
Hypothesized that NS is detrimental to renal function in kidney transplant recipients.
The administration of large volumes of NS is associated with the development of hyperchloremic metabolic acidosis, which may theoretically cause hyperkalemia,effects as subjective mental changes and abdominal discomfort .
Use of balanced salt-based solutions in elderly surgical patients may be associated with better splanchnic perfusion than NS-based solutions.
Hence there is a need to critically look at these growing concerns and be able to come up with evidenced based decision on which fluid best suited patient undergoing kidney transplant.
Aim of the study
A randomized, blinded clinical to determine the safety of LR fluid for patient undergoing kidney transplantation.
And To explore the effect of use of normal saline on graft function.
Method
Randomized controlled , Double- Blind study for clinical trial of NS versus LR for intraoperative IV fluid therapy with following potassium and acid -base disturbance
48 patients underwent living donor kidney transplants, and
3 patients underwent cadaveric donor transplants.
26 of them use normal saline.
And 25 used LR solution.
Fluid used intraoperative were supplied by investigational pharmacy and covered so that surgeon is not aware.
Post operative fluid management was the same for all patient
The primary outcome was serum creatinine level at POD 3
The secondary outcome was post operative urine output, need for RRT, and creatinine clearance test .
Results
S.Creatinine on POD 3 was 2.3_+1.8 mg/dL in the NS group and 2.1_+1.7 mg/dL in the LR group and not significant.
Graft loss occurs in two patient who had normal saline and one in patient with LR
Median (range) postoperative length of stay was 6.3 (3–27) days in the NS group and 5.3 (3–13) days in the LR group.
Potassium concentration was 5.1_+ 0.6 mEq/L in the NS group and 5.1_+1.1 mEq/L in the LR group.
Patient in normal saline group had more metabolic acidosis than those in LR group.
All five patients in the NS group with serum potassium concentrations larger than 6mEq/L were treated for hyperkalemia.
31% of patient in normal saline group had metabolic acid correction with bicarbonates and none in LR group.
S.Chloride at the end of surgery was 111-+ 4 mEq/L in the NS group versus 106_+ 4 in the LR group and it was significant.
Discussion
There was no significant difference between groups in the primary outcome measure of the serum creatinine on POD 3.
Strongly suggest that the administration of large volumes of LR to patients undergoing kidney transplantation is safe and that LR may be superior to NS for IV fluid therapy in this setting.
Using LR instead of NS for iv fluid therapy in renal transplant cases lowers the risk of hyperchloremic acidosis .
Hyperkalemia is an important aspect in renal diseased cases therefore the iv fluids used for those cases are better to have lower K concentrartion , that is why LR was avoided for such cases but this study showed no hyperkalemia risk with the use of LR in kidney transplants.
Metabolic acidosis were more common ion normal saline group (31% of patients were treated form metabolic acidosis versus 0% in LR group).
Limitation of the study
Most of the donors are living donor (48).
3 cadaveric donor kidney.
Was a single center investigation.
The lack of algorithm for fluid administration, correction of hyperkalemia, and metabolic acidosis.
Finally, it is possible that some patients may have received diuretics in the days after surgery, and this may have influenced postoperative urinary output.
—————————————————————————————————————— What is the evidence provided by this article?
The level of evidence is 1
—————————————————————————————————————— Certainly, after this article, the use of Normal Saline will be reconsidered, patients will be monitored and the required examinations will be performed for them.
INTRODUCTION
Optimum fluid resuscitation is essential to maximise the outcomes in critically ill patients
Although CVP have been used for a long time, it is correlated to cardiac output and intravascular volume status
CVP
Historical use
Marik et al studied the relationship between CVP and the fluid status of the patients and concluded that CVP is an unreliable indicator of the fluid status and should not be used as a guide to fluid management
Cecconi et al recommended that CVP should not be used alone for evaluation and management unless in severe CHF or hypovolemia
CVP in the current practice
CVP still used in most clinical practice. For example, in Canada 89.2% of physicians use CVP in septic shock
Limitations in renal transplantation
CVP is not the ideal tool of measurement of fluid balance. It is affected by several factors:
1. Central venous blood volume
2. Compliance of central compartment
3. Tricuspid valve disease
4. Cardiac rhythm
5. Reference level of transducer (postion of the patient)
6. Intrathoracic pressure
Intraoperative factors that change the CVP reading:
1. The position of the patient is not always in flat supine position
2. Use of abdominal retractors (reduce venous return by pressing the viscera)
3. Positive pressure ventilation (PPV )
4. No intraoperative exact target of CVP
5. Determination of the normal CVP is difficult in dialysis patient
6. Central vein stenosis
7. Ageing, longstanding HTN and the use of medications affecting the peripheral vascular resistance (alpha blockers, beta blockers and calcium channel blockers)
POSSIBLE ALTERNATIVES FOR FLUID STATUS MONITORING
1. Intraoperative transesophageal Doppler (TED). When compared with CVP, TED was associated with a similar rate of immediate graft function and significant less amount of intraoperative intravenous fluids, and reduced incidence of postoperative fluid overload
CONCLUSION
CVP is not ideal for guiding fluid therapy in renal transplantation
Intraoperative factors like position and refractors affect the CVP
Other alternative devices should be used in renal transplantation for guiding fluid therapy (intraoperative and postoperative cardiac output monitoring devices)
What is the evidence provided by this article?
Level 5 (narrative review)
Normal saline (NS) is more preferred than lactated ringer (LR) in patients with renal impairment and kidney transplant recipients as it is potassium free and theoretically not associated with hyperkalemia, however, evidence suggest that NS is associated with hyperchloremic metabolic acidosis that lead to hyperkalemia.
The study aims to determine the effect of using NS on serum creatinine and to assess the safety of LR in kidney transplant recipients.
It was a randomized, double-blinded study, the primary outcome was serum creatinine on POD3, secondary outcome was serum potassium and acid base balance.
Patients were randomized to receive either NS or LR as fluid replacement intraoperatively.
Patients with serum potassium >5.5 preoperative were excluded.
The study was stopped because analysis of safety data revealed statistically significant differences in favor of LR regarding serum potassium and acid base balance.
The study showed no significant difference regarding serum creatinine on POD3 between the 2 groups.
Administration of large volumes of LR in kidney transplant recipients was safe and may be better than NS.
Patients receiving NS developed metabolic acidosis requiring treatment.
No patient who received LR required treatment for hyperkalemia but it still may occur with infusion of large volumes of LR. NS cause hyperchloremic metabolic acidosis that lead to hyperkalemia. The impact of type of IV fluid on kidney function was not significantly different in the 2 groups. Limitations:
Apply only to living donor transplants as included only 3 patients with deceased donor kidney transplantation.
Single center study.
Didn’t include an algorithm for fluid administration or for treatment of hyperkalemia and acidosis.
Conclusion:
NS has no adverse effect on kidney function, LR can be administered in large volumes safely in kidney transplant recipients and may be superior to NS.
A Randomized, Double-Blind Comparison of Lactated Ringer’s Solution and 0.9% NaCl During Renal Transplantation.
Normal saline is used more than Ringer lactate in patients with CKD, which is mainly to avoid hyperkalemia .
But, now there is evident that NS lead to Hyperchloremic metabolic acidosis which lead to extracellular shift of the potassium, this is the indication for this Randomized controlled trial between 0.9 % NaCl and RL post kidney transplant and their effects on graft function as reflected by the serum creatinine concentration on postoperative day (POD) 3. Methods.
Randomized controlled , Double- Blind study for clinical trial of NS versus LR for intraoperative IV fluid therapy with following potassium and acid -base disturbance and The primary outcome measure was creatinine concentration on postoperative Day 3.
because this is the minimum postoperative length of stay after kidney transplantation there.
Results:
=There were 25 patients in the LR group and 26 patients in the NS group.
=Both groups received similar volumes of study fluid during surgery, and no patient received colloid during surgery.
=Serum creatinine on POD 3 was 2.3 _ 1.8 mg/dL in the NS group and 2.1 _ 1.7 mg/dL in the LR group.
=Graft loss occurred in two patients in the NS group and in one patient in the LR group.
=The serum potassium concentration exceeded 6.0 mEq/L in 5 of 26 (19%) patients in the NS group and in no patients in the LR group.
=Metabolic acidosis is common than in NS group and group treated with sodium bicarbonate had good renal function that group who was not treated.
Discussion.
There was no significant difference between groups in the primary outcome measure of the serum creatinine on POD 3.Ringer lactate can be used safely postoperative and to avoid acidotic state caused by normal saline, regarding effects on renal functions the differences were not clinically relevant and did not achieve statistical significance .
No significant harmful effect on renal functions due to Hyperchloremia in this study.
Limitation points.
-Single center study.
-only 3 cadaveric kidney transplant and so data only reflected on living kidney transplant.
-Some patient received diuretics and so diuretic induced
changes in urine output would have masked an effect of NS on urine output. Level of evidence I.(Randomized controlled trial).
Introduction
The normal saline or potassium free solution has been used by most centers that do kidney transplantation despite attendant complication like hyperchloremic metabolic acidosis, effect on abdomen, and even immune systems. Also, the concern on the use of balanced salt-based solution like lactate ringer is the fear of hyperkalemia in kidney transplant patients. Hence there is a need to critically look at these growing concerns and be able to come up with evidenced based decision on which fluid best suited patient undergoing kidney transplant
Aim of the study
to determine the safety of LR fluid for patient undergoing kidney transplantation
to explore the effect of use of normal saline on graft function
Method
a randomized single Centre double blind trial
51 patients finally underwent kidney transplantation, 26 of them use normal saline and 25 used LR solution
fluid used intraoperative were supplied by investigational pharmacist and covered so that surgeon is not aware.
post operative fluid management was the same for all patient
primary outcome was serum creatinine level at POD 3
secondary outcome was post operative urine output, need for RRT, and creatinine clearance
Results
Serum creatinine on POD 3 was 2.3_+1.8 mg/dL in the NS group and 2.1_+1.7 mg/dL in the LR group and not significant
graft loss occurs in two patient who had normal saline and one in patient with LR
Median (range) postoperative length of stay was 6.3 (3–27) days in the NS group and 5.3 (3–13) days in the LR group
potassium concentration was 5.1_+ 0.6 mEq/L in the NS group and 5.1_+1.1 mEq/L in the LR group
Patient in normal saline group had more metabolic acidosis than those in LR group
31% of patient in normal saline group had metabolic acid correction with bicarbonates and none in LR group
Serum chloride concentration at the end of surgery was 111-+ 4 mEq/L in the NS group versus 106_+ 4 in the LR group and it was significant
Limitation of the study
most of the donors are living donor
is a single center study
lack of algorithm for fluid administration, correction of hyperkalemia, and acidosis
possible use of diuretic for some patient
Level of evidence is 1 because is a randomized trial
A randomized, blinded clinical study exploring the impact of NS on graft function as measured by blood creatinine on POD 3.
also tested the safety of LR in renal transplant patients by measuring serum potassium and acid-base balance.
Methods:
Eligible kidney transplant patients were randomly assigned NS or LR for intraoperative fluid replacement. Exclusion criteria:18 years old, religious or ethical ban from receiving blood or blood products, or serum potassium level 5.5 mEq/L before operation.
Results:
After analyzing 51individuals’ data, the trial was stopped for safety concerns. 48 individuals had kidney transplants from live donors and 3 from cadavers.
26 individuals got NS, 25 LR. Primary outcome measures didn’t vary across groups. Five (19%) NS patients vs zero (0%) LR patients were treated for hyperkalemia. 8 (31%) individuals in the NS group were treated for metabolic acidosis.
Discussion:
Serum creatinine on POD 3 didn’t vary between groups. Patient safety concerns halted the trial. Our data imply that high volumes of LR may be safer than NS for IV fluid treatment in renal transplant patients. In simple kidney transplant patients treated with potassium-containing, balanced salt-based solutions, hyperkalemia may be avoided. Hyperkalemia in NS-treated individuals develops via an extracellular shift of potassium produced by hyperchloremic metabolic acidosis.
Limitation:
– Applicable only to patients undergoing living donor transplants.
-Single-center investigation.
-Factors such as surgical technique and the duration of surgery may differ among institutions.
-A small number of participants.
Conclusion:
-NS does not impair renal function in these people. Large volumes of LR may be preferable to NS for IV fluid treatment in kidney transplant patients because it minimizes metabolic acidosis and hyperkalemia.
The most preferred intravenous fluids used in renal transplantation are normal saline and lactated ringers
There is a concern of hyperkalemia that can occur with large infusion of potassium containing IV fluid (LR); on the other hand infusion of normal saline can theoretically cause hyperchloremic metabolic acidosis which can in turn cause hyperkalemia and renal dysfunction
This is a prospective double-blind study (level of evidence II) evaluating 51 renal transplant recipients (48 living and 3 deceased donor transplantation) regarding the effect of intraoperative normal saline (26 patients) versus lactated ringers (25 patients) on serum creatinine, potassium at day 3 after transplantation and the need for treatment of hyperkalemia
The results
No difference between both groups in serum creatinine
Hyperkalemia was more frequent in normal saline group (19% had serum k > 6 and received treatment versus 0% in LR group)
Metabolic acidosis were more common ion normal saline group (31% of patients were treated form metabolic acidosis versus 0% in LR group)
Conclusion
Lactated ringers was more safe and associated with lower incidence of hyperkalemia and metabolic acidosis compared to normal saline but both had no effect on renal functions
K free fluids as normal saline are the preferred IV fluid therapy in kidney transplantation ,this was theoretically justified because K containing fluids can lead to hyperkalemia in CKD patients as Lactated ringer.
It was suggested that balanced solutions can be more beneficial than normal saline because infusion of large volumes normal saline can cause hyperchloremic acidosis which in turn causes hyperkalemia, also it was associated with mental changes.
Balanced solutions were associated with better splanchnic perfusion in elderly surgical cases.
This study is a blinded clinical trial to evaluate the effect of administration of normal saline on graft function by serum creatinine concentration checking on postoperative day 3 as well as assess the effect of using LR in renal transplant recipients with secondary endpoints as hyperkalemia . Methods
This double blind study compared recipients receiving prospectively normal saline with those receiving lactated ringer intraoperatively for kidney transplantation.
51 patients were included where 48 received living donor kidney transplants, and3 patients received cadaveric donor transplants.
26 cases were infused with NS, and 25 with LR.
Postoperative IV fluid therapy was the same for the 2 groups and was given according to the institution
protocol.
The primary outcome measure was the serum creatinine concentration on postoperative day 3.
Secondary outcomes were postoperative
urine output, creatinine clearance, and requirement
for dialysis, the incidence of biopsy-proven
rejection and graft loss, intraoperative acid-base balance, intraoperative K concentration, blood loss and transfusion requirements, and postoperative hospital stay. Results
7 units of packed red blood cells were taken by the NS group versus 3 U in the LR group.
Serum creatinine on POD 3 was mildly higher in
the NS group than in the LR group.
2 patients in the NSgroup had graft loss and one patient in the LR group.
Rejection occurred in 4 patients in NS and in two patients who received LR.
Serum potassium concentration was more than 6.0 mEq/L in19% of cases in the NS group and in no patients in the LR group.
Also NS group cases experienced more metabolic acidosis than LR group.
Serum Cl concentration was higher in NS group compared to LR group. Discussion
There was no significant difference between the 2 groups regarding the primary outcome measure of the
serum creatinine on POD 3.
The current results display that LR is superior over NS as IV fluid replacement in kidney transplantation cases.
NS lead to metabolic acidosis necessitating therapy , could be due to the dilution of bicarbonate by large volumes of buffer-free fluid or due to the hyperchloremia which lower the strong ion difference of the blood thereby causing metabolic acidosis.
Using LR instead of NS for iv fluid therapy in renal transplant cases lowers the risk of hyperchloremic acidosis .
Hyperkalemia is an important aspect in renal diseased cases therefore the iv fluids used for those cases are better to have lower K concentrartion , that is why LR was avoided for such cases but this study showed no hyperkalemia risk with the use of LR in kidney transplants .
In NS treated cases ,hyperkalemia can occur due to the change of H ion with hyperchloremic metabolic acidosis .
Postoperative urine output was larger in NS group treated with Na HCO3 for metabolic acidosis and had lower serum creatinine .
Previous studies opposing the current study used to mention that large volumes of NS can negatively affect renal function due to hyperchloremia.
The limitations were that those results were mostly applied on recipients of living donors as recipients from cadaveric donors were only 3 cases , and it was conducted in a single center, as well as absence of algorithm for fluid replacement , and for treatment of acidosis and hyperkalemia.
Some patients received postoperatively diuretics which is unlikely to have biased the effect of NS on the urinary output.
This study concluded that NS can be unharmful to renal function in kidney transplant recipients and LR can be safely used for those patients instead of NS to avoid hyperchloremic metabolic acidosis.
-level of evidence is 1
Thank you, Doaa Will you change your practice based on this article?
Nahla Allam
2 years ago
Introduction:
Ø Normal saline (NS) or potassium-free fluids are recommended for IV fluid therapy during kidney transplantation.
Ø Theoretically, administering large volumes of potassium-containing fluids such as lactated Ringer’s solution (LR) might cause hyperkalemia in patients with chronic renal failure and end-stage renal disease (ESRD).
Ø Evidence suggests that balanced salt-based solutions such as LR may offer clinical benefits over NS, and NS-based solutions administration of large volumes of NS is associated with the development of hyperchloremic metabolic acidosis
objectives :
Ø Determine the safety of the administration of LR to patients undergoing kidney transplantation through secondary end-points, including the serum potassium concentration and acid-base balance
Method:
It is A prospective, double-blind clinical trial of NS versus LR for intraoperative IV fluid therapy.
Exclusion criteria were age <18 yr old, a religious or ethical prohibition from recei
ving blood or blood products, or serum potassium level .>5.5 mEq/L before surgery.
Data are presented as mean ± sd for continuous variables and percentages for categorical variables.
tested all data for normality using the method of Kolmogorov-Smirnov
Differences between categorical variables were tested using Fisher’s exact test. A P value ≤0.05 (two-tailed) was considered to be significant
Results
1-Fifty-four patients were enrolled and randomized to receive either NS or LR
2-Twenty-six patients received NS, and 25 patients received LR.
3-There was no difference between groups in the primary outcome measure.
4- Five (19%) patients in the NS group versus zero (0%) patients in the LR group had potassium concentrations >6 mEq/L and were treated for hyperkalemia (P= 0.05).
5-Eight (31%) patients in the NS group versus zero (0%) patients in the LR group were treated for metabolic acidosis (P = 0.004).
6-NS did not adversely affect renal function. LR was associated with less hyperkalemia and acidosis compared with NS.
Limitation :
1-single-center investigation
2-applicable only to patients undergoing living donor transplants
Conclusion :
The administration of large volumes of LR to patients undergoing kidney transplantation
seems safe and may be superior to NS for IV fluid therapy in these patients because it avoids the risk of metabolic acidosis and clinically significant hyperkalemia.
Thank you, Nahla Will you change your practice based on this article?
Zahid Nabi
2 years ago
What is best intravenous fluid in post kidney transplant period is still an unanswered question. Normal saline is frequently used and preferred over Ringer lactate in many transplant centers according to different surveys owing to apprehension of hyperkalmia associated with RL.
To address this issue a randomized, blinded clinical trial to explore the effects of NS administration on graft function as reflected by the serum creatinine concentration on postoperative day (POD) 3 was conducted in Presbyterian Hospital of the New York.
Adults undergoing kidney transplantation were enrolled in a prospective, randomized, double-blind clinical trial of NS versus LR for intraoperative IV fluid therapy.
The primary outcome measure was the serum cre- atinine concentration on POD 3.
Secondary outcomes included postoperative urine output,
creatinine clearance,
and requirement for dialysis, along with the incidence of biopsy-proven rejection and graft loss. Other secondary outcomes included intraoperative acid-base balance, intraoperative potassium concentration, blood loss and transfusion requirements, and postoperative hospital length of stay.
Fifty-four patients were enrolled and randomized to receive either NS or LR.
There were 25 patients in the LR group and 26 patients in the NS group.
All 51 patients were included in the final analysis.
The study groups were similar with regard to demographic factors
Both groups received similar volumes of study fluid during surgery, and no patient received colloid during sur- gery
Seven units of packed red blood cells were administered in the NS group versus 3 U in the LR group.
Serum creatinine on POD 3 was 2.3mg/dL and 1.8 mg/dL in the NS group and 2.1 mg/dLand 1.7 mg/dL in the LR group .
Graft loss occurred in two patients in the NS group and in one patient in the LR group. Episodes of biopsy-proven rejection occurred in four patients who received NS and in two patients who received LR.
Serum creatinine was similar in both groups at all other time-points, and there were no significant differences in any other markers of renal function.
CONCLUSION
There was no difference between groups in the primary outcome measure. Five (19%) patients in the NS group versus zero (0%) patients in the LR group had potassium concentrations more than 6 mEq/L and were treated for hyperkalemia Eight (31%) patients in the NS group versus zero (0%) patients in the LR group were treated for metabolic acidosis .
NS did not adversely affect renal function. LR was associated with less hyperkalemia and acidosis compared with NS.
LR may be a safe choice for IV fluid therapy in patients undergoing kidney transplantation.
Thank you, Zahid Will you change your practice based on this article?
Eusha Ansary
2 years ago
Summary:
· Normal saline is used during kidney transplantation to avoid the risk of hyperkalemia associated with potassium-containing fluids. But evidence suggests that normal saline infusion is associated with adverse effects like hyperchloremic metabolic acidosis, subjective mental changes and abdominal discomfort in healthy volunteers.
· The use of balanced salt-based solutions in elderly surgical patients may be associated with better splanchnic perfusion than normal saline.
· This prospective, randomized, double-blind clinical trial of NS versus LR for intraoperative IV fluid therapy in renal transplant patients.
· The study was terminated for safety reasons after interim analysis of data from 51 patients.
· In this study twenty-six patients received NS, and 25 patients received LR. There was no difference between groups in the primary outcome measure. Five (19%) patients in the NS group versus zero (0%) patients in the LR group had potassium concentrations more than 6 mEq/L and were treated for hyperkalemia. Eight (31%) patients in the NS group versus zero (0%) patients in the LR group were treated for metabolic acidosis.
· NS did not adversely affect renal function. LR was associated with less hyperkalemia and acidosis compared with NS.
· LR may be a safe choice for IV fluid therapy in patients undergoing kidney transplantation.
Hi Dr Ansary, I liked reading your summary and analysis, Will you change your practice based on this article? Ajay
Ben Lomatayo
2 years ago
Introduction;
NS is routinely given to transplant recipients due to fear of hyperkaemkia associated potassium containing fluids. However, recent evidence suggested harmful effects related to NS compared to balanced -salt solutions such as a RL
This study aimed at comparison of LR and NS during renal transplantation
Methodology;
After the approval of the study and consent, patients were randomized by computer system to either LR or NS
They excluded minors < 18, those with K >5.5 prior to surgery,and those who cannot received blood, or blood products due religious reasons.
48 participants received living donor KTx and 3 patients received deceased donor KTx
26 participants were given NS and 25 were RL
The primary outcome was SCr concentration on postoperative day 3
Results;
There was no difference in the primary outcome between the two groups
5 patients in NS had hyperkalemia (K > 6) compared to zero patient in RL group
NS group were treated for their hyperkalemia
NS group had more metabolic acidosis and they were treated for it
Non of the RL had metabolic acidosis
NS didn’t affect the renal function
Limitation;
small number of deceased donors KTx
Single center
Absence of study fluid, hyperkalemia, and acidosis management algorithm or protocol
Some patients were given diuretics after surgery
In summary; There was no difference in the primary between the two groups, and the RL seems to be better fluid than NS in terms of safety and adverse events
NS is the most common IV fluid used during transplantation surgery. Several evidence support the clinical benefit of RL over NS & NS based solutions because infusion of large volume of NS associated with hyperchloremic metabolic acidosis.
Method:
51 renal transplant recipient included in the study, & divided into 2 groups with double blind fashion to receive RL(25) or NS(26) for preoperative fluid replacement.
Exclusion criteria: age >18yr, S. potassium >5.5 meql/l & patient with religious or ethical prohibition from recipient blood or blood products.
Radial artery pressure cannula used routinely for all patients to monitor systemic blood pressure & for blood sampling during surgery.
All patients receive triple immunosuppression regime( steroids, MMF, CNI or mTOR-I).
Post surgery fluid was similar for all patients(glucose5%/0.45% NaCl+20meq/l sod bicarbonate).
Blood sample aspirated every 30 min during surgery to measure serum potassium & aside base.
Primary outcome of the study was S. Creat level on POD3.
Secondary outcome were post operative UOP, creatinine clearance, , requirement of dialysis, & biopsy-proven rejection & graft loss.
Result & discussion:
No significant difference found between 2 groups regarding serum creatinine at POD3.
The study strongly suggested that large volume of RL in kidney transplant surgery is safe & superior to NS.
Metabolic acidosis that need treatment only found in patients receive NS.
Use of balanced salt-based solution can avoid IV fluid use associated hyperchloremic metabolic acidosis.
It was found that no patient develop hyperkalemia need treatment when they receive RL & this support that RL use increase risk of hyperkalemia may be more theoretical than real.
Insignificant difference found in post operative markers of renal function.
Patient treated with sodium bicarbonate show more UOP & lower serum creatinine at first week post transplant.
The study result didn’t support that serum hyperchloremia result from infusion of large volume of NS.
Study limitations:
Only 3 DDT recipient included in the study make it more applicable for LDT recipients.
Single center study.
Absence of algorithm for fluid infusion & treatment of acidosis & hyperkalemia.
Some patient receive diuretics & this may affect UOP result.
Thank you, All
Will you change your practice based on this article?
What is your fluid management plan of your transplant programme?
Yes this study result will affect my practise I will use RL in transplant ,AKI and CKD unless certain few condition need 0.9%
Yes, already discussed the issue with our anesthesia team to change the fluid management of our patients.
we will start using LR for fluid managament.
The protocol in our transplant unit involves use of Plasma-Lyte
no, i will not change my current practice based on this study, this study’s results should be carefully interpreted despite its double-blinded RCT but its terminated early due to the safety concern with intervention in isotonic saline, a small sample size most from LD transplantation 48 /51 total numbers and from the single center so cant generalized the results, treatment of acidosis and hyperkalemia lack of algorithm, some of the patient received diuretics, where the two groups treated equally? What about the immunosuppression effects like CNI? ( may contribute to both acidosis and hyperkalemia, primary outcome on day 3 post-op while the patients received different types of fluids like half saline and 5% water
we need more studies with larger sample sizes and well-matched control groups from multiple centers to address such outcomes with longer follow up
Need to discuss the issue with the anaesthetist as we usually use NS for transplant patients.
yes. From the study the better choice is using LR
yes, it changed my mind toward lactated ringer, we used it already but not that much, of course we used normal saline more, but now we can use LR safely more than NS
I would change and recommend changing, as this study, although small no. of patients was included, is supportive to the growing evidence of adverse effect linked to hyperchloremia and metabolic acidosis triggered by normal saline infusion.
Yes, based on this study LR is superior to NS in transplantation.
We usually use either half-NS or NS based on patients BP or electrolytes in transplantation.
Yes it’s change my mind regarding intravenous fluid in renal failure and renal transplant
lactate ringer’s are safe and superior to normal saline in transplant treatment because less effects on acid base balance and no metabolic acidosis or hyperchloremic risk.
Introduction:
Theoretically, the administration of large volumes of potassium-containing fluids such as lactated Ringer’s solution (LR) might cause hyperkalemia in patients with chronic renal failure And ESRD).
This concern was the most frequently cited reason for the use of NS during kidney transplantation in a one survey.
Evidence suggests that balanced salt-based solutions such as LR may offer clinical benefits over NS and NS-based solutions.
Although controversial, the administration of large volumes of NS is associated with the development of hyperchloremic metabolic acidosis, which may theoretically cause hyperkalemia through an extracellular shift of potassium ions.
Infusion of NS has also been associated with effects such as subjective mental changes and abdominal discomfort in healthy volunteers.
Aim OF the study:
A randomized, blinded clinical trial to explore the effects of NS administration on graft function as reflected by the serum creatinine concentration on postoperative day (POD) 3.
Second outcome, including the serum potassium concentration and acid-base balance.
Methods:
Eligible patients undergoing kidney transplantation were randomized in a prospective, double-blind fashion to receive either NS or LR for intraoperative fluid replacement during surgery for kidney transplantation.
Results:
Fifty-four patients were enrolled and randomized to receive either NS or LR. Three patients were excluded after randomization because of a preoperative serum potassium level 5.5 mEq/L. There were 25 patients in the LR group and 26 patients in the NS group.
All 51 patients were included in the final analysis. Of note, a separate analysis of the data, which excluded the cadaveric transplant recipients, revealed no difference in overall study result.
Serum creatinine on POD 3 was 2.3 +_1.8 mg/dL in the NS group and 2.1 _+1.7 mg/dL in the LR group (P 0.7).
Graft loss occurred in two patients in the NS group and in one patient in the LR group.
Episodes of biopsy-proven rejection occurred in four patients who received NS and in two patients who received LR.
Serum creatinine was similar in both groups at all other time-points, and there were no significant differences in any other markers of renal function.
Median (range) postoperative length of stay was 6.3 (3–27) days in the NS group and 5.3 (3–13) days in the LR group (P 0.6).
Peak intraoperative potassium concentration was 5.1 _+0.6 mEq/L in the NS group and 5.1 +_1.1 mEq/L in the LR group.
The serum potassium concentration exceeded 6.0 mEq/L in 5 of 26 (19%) patients in the NS group and in no patients in the LR group.
Patients randomized to receive NS exhibited more metabolic acidosis during surgery than patients who were randomized to receive LR.
Serum chloride concentration at the end of surgery was 111 _+4 mEq/L in the NS group versus 106 _+4 in the LR group (P 0.0001).
Discussion:
There was no significant difference between groups in the primary outcome measure of the serum creatinine on POD 3.
The study was terminated because of concerns for patient safety.
Results strongly suggest that the administration of large volumes of LR to patients undergoing kidney transplantation is safe and that LR may be superior to NS for IV fluid therapy in this set.
Metabolic acidosis requiring treatment occurred only in patients who received NS.
The choice of balanced salt-based solutions such as LR rather than NS-based solutions for IV fluid therapy averts the risk of IV fluid-induced hyperchloremic metabolic acidosis.
In this study, no patient who received LR required treatment for hyperkalemia.
However, it cannot be concluded from our findings that hyperkalemia never occurs in patients who receive LR during kidney transplant surgery.
Hyperkalemia may occur, for example, during the rapid infusion of large volumes of LR. However, our findings support our hypothesis that the risk of hyperkalemia may be more theoretical than real in patients undergoing uncomplicated kidney transplant surgery who are treated with potassium-containing, balanced salt-based solution.
The NS group revealed that postoperative urine output was larger in patients who were treated with sodium bicarbonate for metabolic acidosis.
In addition, serum creatinine was lower in these patients, and this effect was apparent at one week after surgery.
Limitations:
For logistical reasons only, 3 cadaveric donor kidney recipients were enrolled, with 48 of the 51 study patients undergoing living donor transplantation. Therefore, our results are strictly applicable only to patients undergoing living donor transplants.
A single-center investigation.
Factors such as surgical technique and the duration of surgery may differ among institute.
Lack of an algorithm for study fluid administration and for the treatment of acidosis and hyperkalemia.
level of evidence 1.
This study is A Randomized, Double-Blind Comparison of Lactated Ringer’s Solution and 0.9% NaCl During Renal Transplantation.
this article shows lactate ringer’s is safe treatment pre / intra and post operative therapy in kidney transplant and less risk of metabolic acidosis and hyperchloremic which develop by normal saline.
This study level 1
In spite of zero content of potassium in normal saline solution its safety regarding inducing hyperkalemia was tested in a randomized control trial in recipients of kidney transplantation. Other outcomes were acid-base disturbances and post-op serum creatinine. Totally, 51 patients were included (25 in LR group and 26 in NS group). There was no difference regarding serum creatinine or rejection in both groups. Five out of 26 recipients in NS group had potassium more than 6 mEq/L compared to no one in the other group. In addition, NS group showed more metabolic acidosis needing treatment (8 patients) compared to LR group (no patient). So, administration of high dose LR to TX patients is safe and superior to NS.
The level of evidence is 1.
II. A Randomized, Double-Blind Comparison of Lactated Ringer’s Solution and 0.9% NaCl During Renal TransplantationSummarise this article
The objective:
*To analyze the rule of normal saline (NS) administration on graft function as reflected by the serum creatinine concentration on postoperative day
*To identify the safety of the administration of lactated Ringer’s solution (LR) to patients undergoing KT through secondary end-points, including the serum potassium concentration and acid-base balance.
Introduction:
* (NS) or potassium-free fluids are recommended for IV fluid therapy during KT.
*Theoretically, the administration of large volumes
of potassium-containing fluids as (LR) might cause hyperkalemia in patients with (CRF) or (ESRD).
*LR may offer clinical benefits over NS and NS-based solutions and administration of large volumes of NS is associated with the development of hyperchloremic metabolic acidosis.
The methods:
*The study was approved by the IRB of the Columbia
Presbyterian Hospital of the New York Presbyterian
Hospital.
*Adults undergoing kidney transplantation were enrolled in a prospective, randomized, double-blind clinical trial of NS versus LR for intraoperative IV fluid therapy.
*The primary outcome measure was creatinine concentration on postoperative Day.
*The study was terminated for safety reasons after interim analysis of data from 51 patients. 48 patients(LDKT), and 3 (DDKT) patients.26 received NS, and 25 patients received LR.
* Exclusion criteria were age 18 yr old, a religious or ethical prohibition from the receipt of blood or blood products, or serum potassium level 5.5 mEq/L before surgery.
The result:
*No difference between groups in the primary conclusion measure.
* NS did not negatively affect renal function.
*LR was associated with minimal risk of hyperkalemia and acidosis compared with NS.
* LR may be a safe choice for IV fluid therapy and superior to NS in patients undergoing KT.
*The development of metabolic acidosis in association with the administration of large volumes of NS is a well-recognized phenomenon.
*I will change my practice by using RL because it is more safe and superior to NS.
What is the evidence provided by this article?
Level of evidence is level 1
In kidney transplantion, post operative fluid therapy is a critical issue to deal with as we need an ideal solution to maintain the graft perfusion with out or with minimal associated electrolytes and acid base disturbance. Theoritically, K containing solution administration after kidney transplantion may induce hyperkalemia, also using large volume of normal saline causes hypercholaremic metabolic acidosis that in turn causes hyperkalemia due to transcellular fluid shift.
in this randomized, blinded clinical study , the authors aimed to evaluate the superiority of lactated ringer Vs normal saline for post transplantion fluid management regarding post operative SCr (evaluated in day 3) , electrolytes specially hyperkalemia and acid base disturbance.
51 patients were included , 26 in the BS group and 25 in LR group . Kidney function indices and S Cr at POD 3 were similar in both groups.
Peak intraoperative K was around 5 in both groups, while hyperkalemia exceeding 6 was encountered in 26% of NS patients and 0% in LR group.
Metabolic acidosis was detected and treated by Na bicarbonate in 31% of NS patients and 0% in LR group
Cumulative UOP was larger in NS and serum Cr was lower in NS group compared to LR group
Conclusion
LR solution is associated with less MA and hyperkalemia compared to NS as post transplant fluid therapy
Limitation of the study
Only 3 cadaveric kidney transplant were included
Fluid therapy was changeable according to clinical circumstances and was not based on algorithmic approach
Level of evidence :1
A prospective double blinded study , conducted to test the impact of intra-operative and post operative normal saline vs balanced intravenous fluid on renal transplant outcome. As it was speculated, that normal saline fluid administration intra-operatively is linked to adverse allograft outcome
Renal allograft assessment via measurement of serum creatinine was performed on third post operative day.
25 allograft recipients were enrolled with Normal saline fluid therapy intra-operatively vs 26 patients received balanced salt fluid Ringer lactate.
There was no difference in primary outcome of serum creatinine on 3rd post operative day, however the study was terminated early , owing to significant adverse effect of metabolic acidosis in 8 patients (32%) and hyperkalemia in 5 patients (19%) in normal saline fluid limb.
The putative mechanisms for development of metabolic acidosis are dilution of bicarbonate concentration or increased secretion of bicarbonate to maintain the electroneutrality. Otherwise, reduction of the strong ion difference SID is most probable explanation,
hyperkalemia stemmed from ionic shift with exchange of intracellular K to H in the setting of metabolic acidosis inflicted by infusion of normal saline.
This is RCT Trial done on 51 patients to compare the effect of iv fluid perioperative in renal transplant patients.
For safety reasons, the study was terminated and the data collected from 51 patients were analyzed. Of the 51 cases reviewed, 48 patients did live donors and 3 did cadaveric donor transplants, Of the 51, 26 got NS, and 25 got LR
The result demonstrated:
1) There were not differences between the two groups’ outcomes.
2) 19% of the NS group and 0 % of the LR group has a potassium level greater than 6 mEq/L and treatment was given
3) 31% of the NS group vs 0 % of the LR group were treated for metabolic acidosis. Also, it was noted that NS never affected adversely the kidney function
4) Also it was noted that LR had less high K and acidosis when compared with NS
Conclusion: Normal saline does not compromise kidney function but increases metabolic acidosis and hyperkalemia risk compared to LR
RCT compare the effect of normal saline-based intravenous solution and salt based intravenous solution.
Renal allograft recipients are already have preexisting metabolic acidosis and are prone to hyperkalemia.
Intravenous use of Normal saline in renal transplantation can cause hypercholeremia, which leads to metabolic acidosis and hyperkalemia; this is less occurred with salt-based intravenous solutions like lactated ringer, but hyperkalemia can happen with rapid infusion of lactated ringer, so lactated ringer can be used safely in renal transplant patients.
level of evidence is level I
RCT comparing the effect of using normal saline and lactated ringer on graft function and resulted in no difference and lactated ringer less in hyperkalemia and acidosis and may be safe to be used
The study type ;
A prospective, randomized, double-blind clinical trial.
The aim of study;
1-To explore the effects of NS administration on graft function as reflected by the serum creatinine concentration on postoperative day 3.
2-To determine the safety of the administration of lactated ringer solutions to patients undergoing kidney transplantation through secondary end-points, including the serum potassium concentration and acid-base balance.
The ethical approval;
The study was approved by the IRB of the Columbia Presbyterian Hospital of the New York Presbyterian Hospital.
The method ;
Adults undergoing kidney transplantation were enrolled in a prospective, randomized,
double-blind clinical trial of NS versus LR for intraoperative IV fluid therapy.
The population;
51 patients. Forty-eight patients underwent living donor kidney transplants, and three patients underwent cadaveric donor transplants. Twenty-six patients received NS, and 25 patients received LR.
Exclusion criteria ;
were age 18 yr old, a religious or ethical prohibition from the receipt of blood or blood products, or serum potassium level 5.5 mEq/L before surgery.
The result;
There was no difference between groups in the primary outcome measure.Normal saline did not adversely affect renal function. Lactated ringer solution was associated with less hyperkalemia and acidosis compared with NS. Lactated ringer solution may be a safe choice for IV fluid therapy in patients undergoing kidney transplantation.
The limitations;
Only, 3 cadaveric donor kidney recipients were enrolled, with 48 of the 51 study patients undergoing living donor transplantation.
The conclusion;
The study results demonstrate that NS is not detrimental to renal function in these patients. In addition, the administration of large volumes of LR to patients undergoing kidney transplantation seems safe and may be superior to NS for IV fluid therapy in these patients because it avoids the risk of metabolic acidosis and clinically significant hyperkalemia.
What is the evidence provided by this article?
Level I
This article is a randomized, double-blind study that compared the outcomes of lactated Ringer’s solution versus 0.9% sodium chloride during renal transplantation.
26 N/S, 25 LR. Only 3 individuals received cadaveric kidneys. Baseline characteristics were comparable.
Restrictions:
Age below 18, religious or ethical objection to blood or blood products, or serum potassium >5.5 mEq/L before operation.
Primary outcome: Post-operative day 3 serum creatinine.
Secondary outcomes include:
Postoperative urine production, DGF, Incidence of rejection and graft loss, Intraoperative potassium, acid-base balance, blood loss, and transfusions, Hospital stay post-op.
Results:
The study groups had similar POD 3 serum creatinine. (p=0.7).
Two NS and one LR patients lost grafts.
Four NS and two LR patients experienced biopsy-proven rejection.
NS and LR groups had 6.3 (3–27) and 5.3 (3–13) postoperative days, respectively (P= 0.6).
5 of 26 (19%) NS patients and no LR patients had serum potassium levels above 6.0 mEq/L (P= 0.05).
Eight (31%) NS patients got sodium bicarbonate for metabolic acidosis, compared to no LR patients (P= 0.004).
The NS group had 111 +/-4 mEq/L serum chloride during surgery, while the LR group had 106 +/-4 (P= 0.0001).
Sodium bicarbonate-treated N/S patients had higher postoperative urine production and lower serum creatinine.
N/S required more blood transfusions, although not much.
Strengths: Randomized controlled, same anesthesia and intra-operative regimen, same team group (surgeon, anesthetist, nurses ..etc).
Limitations: Small number, mostly living donor kidney transplants, only 3 cadaveric transplants, single-center study, no standard methodology for fluid infusion, acidosis, and hyperkalemia management.
Conclusion: Normal saline does not compromise kidney function but increases metabolic acidosis and hyperkalemia risk compared to LR.
Thank you professor, definitely we will follow this. otherwise we used to use NS and half saline in patients post- operatively.
The article is about a randomized, double-blind comparison of lactated ringer’s solution and 0.9% NaCl during renal transplantation. The patients were randomly given sodium chloride and the lactated ringer intra-op surgery for a kidney transplant.
There were criteria for exclusions and including:
1) The age of patient must not be less than 18 years old
2) Depending on the patient religious belief
3) Serum potassium level greater than 5.5 before surgery.
The aim: of the study was to determine the safety of using lactated ringer vs normal saline during a kidney transplant.
The method that was used:
1) A study conducted to compare lactated ringer vs normal saline
2) The study was approved by the IRB of the Columbia Presbyterian Hospital of New York Presbyterian Hospital.
3) Patients consented and were randomized in a prospective and double-blind fashion to receive the solution during the surgery.
4) The parameter that was first measured was creatinine day 3 post-op.
5) For safety reasons, the study was terminated and the data collected from 51 patients were analyzed.
6) Of the 51 cases reviewed, 48 patients did live donors and 3 did cadaveric donor transplants,
7) Of the 51, 26 got NS, and 25 got LR
The result demonstrated:
1) There were not differences between the two groups’ outcomes.
2) 19% of the NS group and 0 % of the LR group has a potassium level greater than 6 mEq/L and treatment was given
3) 31% of the NS group vs 0 % of the LR group were treated for metabolic acidosis. Also, it was noted that NS never affected adversely the kidney function
4) Also it was noted that LR had less high K and acidosis when compared with NS
Study limitation:
1) It was a small group size
2) It was a single center where the study was conducted
3) There were no guidelines for the treatment of acidosis and high K
4) No documentation was made if patients had received diuretics
5) The donors were mostly live ones
Conclusion:
Between the two groups of solutions, it is likely that LR could be a safer solution to use during surgery due to less high K and acidosis. NS never adversely affects the kidneys and their function
The level of evidence is level 1
Summary
this Double blinded RCT from Anesthesia & ANALGESIA Journal with an impact factor of 6.67
Summary
Introduction
Normal saline is one of the traditional widely used and cheap resuscitation fluids in critically ill patients in emergencies, intraoperative and critical care units, and also in the perioperative period in kidney transplantation surgeries it’s a potassium-free preferred solution compared to lactated ringer fluids which usually avoided in ESRD due to the possible higher risk of hyperkalemia, however large volume of isotonic saline can cause hyperchloremic acidosis and rebound hyperkalemia due to high chloride content with reduction of the GFR and AKI with DGF.
Clinical question/hypothesis of this trial
Normal saline is detrimental to renal /graft function in kidney transplant recipients
Safety of ringer lactate fluid use intraoperative for patients undergoing kidney transplantation
Method, setting
This is a prospective double-blinded RCT from a single center in the US, separate randomization lists were generated for 2 transplant surgeons with blinded IVF bags intraoperative for both groups, and the clinician, staff as well
Postoperative IVF was the same for both groups with ml/ml IVF replacement of dextrose 5%/0.45% saline +20meq of sodium bicarbonate /L for diabetic patients alternating with dextrose 5%/0.45% saline and 0.45% saline +20meq/l sodium bicarbonate / l.( this can mask the results )
Blood samples at baseline then every 30 minutes monitoring acid-base balance and potassium level intraoperative with ABG
Any hyperkalemia with > 6.5meq/l will be treated
Inclusion criteria, all adults > 18 Years old
Exclusion criteria
1. Those < 18 years
2. Religious or ethical prohibition for use of blood or blood products
3.Pre-operative potassium level > 5.5
Population, setting
51 kidney transplant recipients divide equally into two groups 25 patients with RL (intervention, and a control group of 25 with normal saline
Outcome
1. primary outcome for intervention includes
* Serum creatinine level on day 3 after surgery
2. Secondary outcome
*Postoperative UOP volume
*Creatinine clearance
*Need for dialysis
*Incidence of biopsy-proven rejection and graft loss
* Intraoperative acid-base balance, blood loss, transfusion requirements
*Post-operative hospital stay duration
Results
For the primary outcome no difference between the two groups in serum creatinine level in post-operative D3
More hyperchloremic acidosis and hyperkalemia need intervention in the normal saline group, with 31% in the NS group treated with sodium bicarb for metabolic acidosis compared to non in the RL group.
Strength of the study
1. The first study to compare NS to RL in ESRD patients
2. Patients are equally randomized and have well-matched baseline characteristics, a double-blinded prospective design
However, I will take the conclusion of this study with precaution despite its double-blinded RCT but the conclusion regarding the primary outcome needs to be revisited, this study has many limitations but still, the data provided by this study can be used in better-designed multi-centers prospective future studies
limitations:
1. small sample size, type 1 error
2. single center
3. most are for LD without information about the preemptive VS dialysis and duration of dialysis which can also contribute to the risk of hyperkalemia
medications including IS as might consider cofounder risk for hyperkalemia
the primary outcome after 48 hours when the patients already and another type of fluid that can mask the results
4. there is a safety concern and the trial was terminated early
What is the evidence provided by this article?
LEVEL 1B evidence from a single randomized trial with narrow CI or even level 11 but not level 1 A ( cant be ) .
Summary:
Introduction:
Material and methods:
Results:
Conclusion
At our institute:
During surgery we give, RL as intravenous fluid
During post-operative period, we alternate RL with NS, as urine output on day 1 is quite high and the amount of RL leads to increased lactate levels
This paper would definitely help in changing practice in kidney transplant patient.
Normal saline and normal saline based solutions are preferred during kidney transplant surgery. In view of evidence suggesting association of adverse effects with normal saline, the study was conducted to compare kidney transplant outcomes with intraoperative use of Lactated Ringer’s solution with that of normal saline.
It was a prospective randomized, single-center, double-blind trial whereby the study participants were given either normal saline (NS) or Lactated Ringer’s (LR) solution intraoperatively. The study fluid was discontinued at the end of the surgery, after application of the surgical dressing. The primary outcome measure was creatinine concentration at post-operative day 3.
54 patients were enrolled and randomized but 3 patients were excluded. Out of 51 remaining patients, 25 patients received LR while 26 received NS. The study groups were similar with respect to baseline characteristics. The study was terminated early after the interim analysis of 51 patients, although it was planned to enroll 100 patients in the study, due to safety reasons.
The NS group had more metabolic acidosis during surgery with lower intraoperative pH, lower end of surgery pH, higher end of surgery serum chloride, lower intraoperative serum bicarbonate and lower end of surgery serum bicarbonate. The NS group required a greater number of blood transfusions. Serum creatinine was similar in both the groups at all time-points.
Peak intraoperative serum potassium was higher in the NS group with 19% patients in NS group having peak values more than 6 mEq/L, while none of the patients in LR group had serum potassium more than 6 mEq/L.
NS group patients who received treatment for acidosis had lower serum creatinine and higher cumulative post-operative urine output.
The study concluded that administering large volume of LR is safe in kidney transplantation, and is associated with less incidence of hyperkalemia and metabolic acidosis with no effect on graft function, in comparison with NS use.
Limitations of the study include small sample size, single-center study, only 3 cadaveric patients included, hence predominantly applicable to living donors, absence of a defined algorithm for study fluid administration and treatment of acidosis or hyperkalemia, the lack of clarity regarding use of diuretics in subjects.
Level of evidence: Level 1
Summary of the article
“A Randomized, Double-Blind Comparison of Lactated Ringer’s Solution and 0.9% NaCl During Renal Transplantation”
This is a prospective, double-blind study that has compared the effects of NS and LR as IV fluid therapy in kidney transplant recipients.
Study’s result and outcome
1. There was no significant difference between groups in the primary outcome measure of the serum creatinine on POD 3.
2. The study was terminated because of concerns for patient safety.
3. The study’s results strongly suggest that the administration of large volumes of LR to patients undergoing kidney transplantation is safe and that LR may be superior to NS for IV fluid therapy in this setting.
4. The development of metabolic acidosis in association with the administration of large volumes of NS is a well-recognized phenomenon.
5. Hyperkalemia may occur, for example, during the rapid infusion of large volumes of LR.
What is the evidence provided by this article?
This is a prospective double-blind study.
Level of evidence grade 2
Summarise this article
Introduction:
The N/S is the fluid usually used in fluid resuscitation in renal transplant in USA, this double blinded randomized controlled trial comparing N/S to Ringer lactate (LR), in one transplant center in US.
A 51 patients randomized 26 patients received N/S, 25 patients received LR. Only 3 patients received cadaveric kidney, the base line characteristics were comparable among groups.
Exclusion criteria:
An 18 yr old, a religious or ethical prohibition from the receipt of blood or blood products, or serum potassium level >5.5 mEq/L before surgery.
Primary outcomes:
The serum creatinine concentration on POD 3.
Secondary outcomes:
Postoperative urine output, creatinine clearance, and requirement for dialysis.
The incidence of biopsy-proven rejection and graft loss.
Intraoperative acid-base balance, intraoperative potassium concentration, blood loss and transfusion requirements.
Postoperative hospital length of stay.
Results:
Serum creatinine on POD 3 was comparable among the study groups. (p=0.7).
Graft loss occurred in two patients in the NS group and in one patient in the LR group.
Episodes of biopsy-proven rejection occurred in four patients who received NS and in two patients who received LR.
Postoperative length of stay was 6.3 (3–27) days in the NS group and 5.3 (3–13) days in the LR group (P= 0.6).
The serum potassium concentration exceeded 6.0 mEq/L in 5 of 26 (19%) patients in the NS group and in no patients in the LR group (P= 0.05).
Metabolic acidosis was more among patients received N/S, eight (31%) patients in the NS group received sodium bicarbonate for the treatment of metabolic acidosis in comparison to No patients in the LR group (P= 0.004).
Serum chloride concentration at the end of surgery was 111 +/- 4 mEq/L in the NS group versus 106 +/- 4 in the LR group (P= 0.0001).
Postoperative urine output was larger, and postoperative serum creatinine was lower in N/S group whom received sodium bicarbonate.
Blood transfusion requirement was more among N/S group but not statistically significant.
Strength of the study:
Randomized controlled, the same anesthetic and intra-operative protocol, and were managed by the same team group (surgeon, anesthetist, nurses ..etc).
Limitations:
Small number, most of the transplants are living donor kidney transplant only 3 cadaveric transplants, single center study, lack of standard protocol for fluid infusion, acidosis and hyperkalemia management.
Conclusion:
The use of normal saline is safe and has no deleterious effect on kidney function but has more risk for metabolic acidosis and hyperkalemia, than LR.
What is the evidence provided by this article?
Level of evidence I – double blinded randomized controlled study.
Summary of A Randomized, Double-Blind Comparison of Lactated Ringer’s Solution and 0.9% NaCl During Renal TransplantationIntroduction
The consensus of usage of balanced salt to based solution such as Lactate Ringer in kidney transplant surgery as may result in hyperkalaemia, so may of U.S kidney transplant centres used normal saline based solutions although there is some studies find that large volumes of normal saline is associated with the development of hyperchloremic metabolic acidosis and hyperkalaemia. This randomized blind clinical trial to explore the effects of NS administration on graft function as reflected by the serum creatinine concentration on postoperative day 3(POD). Secondary end point include the serum potassium concentration and acid base balance.
Methods:
Eligible patients whom had kidney transplantation were randomized in a prospective double blind fashion to receive either NS or LR for interoperative fluid replacement during surgery for kidney transplantation.
Exclusion criteria were:
1. Age < 18 years old
2. A religious or ethical prohibition from the recipient of blood or blood products.
3. Serum potassium >5.5 mEq/L before surgery.
Blood was sampled at baseline and every 30 min for the duration of surgery for measurement of serum potassium concentration and acid-base balance.
Informed the clinician if S.K exceed 6.5 mEq/L.
Serum creatinine concentration on POD3 is primary outcome measurement.
Secondary outcomes:
1. Intraoperative acid-base balance
2. Intraoperative potassium concentration
3. Blood loss
4. Transfusion requirement
5. Postoperative hospital length of stay
31% (8 patients) in NS group received solution bicarbonate for the treatment of metabolic acidosis in comparison to NO of patients in LR group.
Discussion:
There was no significant difference between group in primary outcome measure of the serum creatinine on POD3.
The study was terminated because of concern for patient safety.
Although, the result strongly suggests that given large volumes of LR to patients during kidney transplantation surgery is safe and may be superior to NS for IV fluid therapy.
Affection of renal function by IV fluid composition small difference but statistical insignificance.
Patients who were treated with sodium bicarbonate for metabolic acidosis in NS group, they had postoperative urine output large and lower serum creatinine, which was at one week after surgery.
Limitations of this study:
1. Study results are applicable only to patients transplanted from living donor (48/5i)
2. Single-centre investigations
3. Lack of an a algorithm for study fluid administration and for the treatment of acidosis and hyperkalaemia
4. Some patients may have received diuretics in the days after surgery and this may affect urinary output.
Summary:
This study is the first one to compare the effects of NS and LR in patients with ESRD
The result emphasized that NS is not detrimental to renal function in these patients.
Given large volume of LR to patients during kidney transplantation seems safe and may be superior to NS for IV fluid therapy, in these patients because it avoids the risk of metabolic acidosis and clinical significant hyperkalaemia.
level 2
this study will affect my practise as I will give transplant, KI and CKD ringer lactate unless in exceptional situation which lead to cl loss ,I can give 0.9% saline.
Club 2; ringer vs normal saline
Summary
· Normal saline is the preferred solution in CKD and renal transplant (to avoid hyperkalemia thought to occur with the administration of large amount of K containing ringer lactate).
· The primary outcome of the current study, was the kidney function (3 days post-operative) and 2ry outcomes were urine output, creatinine clearance, level of K and metabolic acidosis, incidence of acute rejection, graft function.
· The current study , a double blinded RCT, found that ringer lactate has lower incidence of hyperkalemia and acidosis compared to isotonic saline.
· However, many limitations as few number of cases (all are 51), single center study, unavailable chart delineating the fluid therapy in each patient, and the degree of acidosis and its treatment, rate and volume of fluid administration, in addition to the early termination of the study for fear of patient safety.
· patients who were treated with NAHCO3 for acidosis had higher urine output and lower creatinine (may be related to volume expansion by it).
· Conclusion:
o NS is not detrimental to renal function in kidney transplant patients.
o In addition, large volumes of LR to KT patients seems safe and may be superior to NS for IV fluid therapy to minimize the risk of metabolic acidosis and hyperkalemia.
Level of evidence: I, as it is RCT (but small small sample size)
we still use normal saline and half normal saline in pediatric kidney transplant recipients.
NS was frequently used in patients with AKI for fear of hyperkalemia induced by RL infusion ,this can be theoretically right but in this study they need to answer this question because on the other hand NS infusion can cause metabolic acidosis and further K shifts and hyperkalemia
Methedology:54 patients from Columbia Presbyterian Hospital of the New York Presbyterian Hospital. After written, informed consent was ob- tained, eligible patients undergoing kidney transplan- tation were randomized in a prospective, double-blind fashion to receive either NS (Table 1) or LR (Table 1) for intraoperative fluid replacement during surgery for kidney transplantation.
Urine output was replaced (milliliter for mil- liliter) with an IV infusion of dextrose 5%/0.45% NaCl +20 mEq/L of sodium bicarbonate/L. For diabetic patients, fluid replacement routinely consisted of alternating liters of dextrose 5%/0.45% NaCl and 0.45% NaCl +20 mEq/L of sodium bicarbonate. All patients received an additional 50 mL/h of either of these two solutions when appropriate.
Blood was sampled at baseline (after insertion of the intraarterial cannula) and every 30 min for the dura- tion of surgery for measurement of serum potassium concentration and acid-base balance). The treatment for hyperkalemia, metabolic acidosis, and any other metabolic derangements was at the discretion of the clinician.
The primary outcome measure was the serum creatinine concentration on POD 3. This timepoint was chosen because this is the minimum postoperative length of stay after kidney transplantation at their institution.
Secondary outcomes included postoperative urine output, creatinine clearance, and requirement for dialysis, along with the incidence of biopsy-proven rejection and graft loss. Others: intraoperative acid-base balance, intraoperative potassium concentration, blood loss and transfusion requirements, and postoperative hospital length of stay.
Results:
Fifty-four patients were enrolled and randomized to receive either NS or LR. Three patients were excluded after randomization because of a preoperative serum potassium level >5.5 mEq/L. There were 25 patients in the LR group and 26 patients in the NS group.
Patients randomized to receive NS e more metabolic acidosis during surgery than patients who were randomized to receive LR .Eight (31%) patients in the NS group received sodium bicarbonate for the treatment of metabolic acidosis in comparison to no patients in the LR group (P =0.004)). Serum chloride concentration at the end of sur- gery was 111 +/-4 mEq/L in the NS group versus 106 +/- 4 in the LR group (P=0.0001).
Of note, cumulative postoperative urine output was larger (Fig. 2A) and postoperative serum creatinine was lower .
In patients in the NS group who received treatment for acidosis compared with patients who received no treatment for acidosis. The serum chloride concentration in patients who received bicarbonate was 113 +/- 4 mEq/L versus 110 +/-4 mEq/L in patients who did not receive bicarbonate (P =0.1).
Urine flow rate (range) in the first 4 h after revas- cularization of the donor kidney was 400 +/-370 (130 – 1050) mL/h in patients treated for hyperkalemia and 370 +/-410 (0–1520) mL/h in NS-treated patients with no hyperkalemia (P =0.9).
One patient received treat- ment for both hyperkalemia and metabolic acidosis.
One patient in the NS group who received a transfusion of packed red blood cells was treated for hyperkalemia, and no patients who received blood transfusions were treated for metabolic acidosis.
Discussion:
This is the first study that has compared the effects of NS and LR as IV fluid therapy in kidney transplant
Few studies only addressed this issue ,but has reported the outcome on graft survival but here there was no significance on graft survival.
Limitation of the study:
1-single center only
2-No comment on lasix use post Op which may unmask the diuretic effect of NS
3-no spescific protocol for management of hyperkalemia and acidosis ,it was left to the clinician experience .
Conclusion:
RL is less in metabolic acidosis and hyperkalemia than NS use in post kidney transplantation post operative period.
Level of evidence 1 RCT
In my practice I was previously using ringer lactate but currently I am working in another center using D5%,0.45% Nacl
· Most kidney transplant centres prefer normal saline (NS) and NS-based for administration during kidney transplant surgery, as they want to avoid K+ containing fluids
· large volumes of NS is associated with the development of hyperchloremic metabolic acidosis, which may theoretically cause hyperkalemia through an extracellular shift of K+
· The use of balanced salt-based solutions in elderly surgical patients may be associated with better splanchnic perfusion than NS-based solutions
· This is a randomized, blinded clinical trial to explore the effects of NS administration on graft function as reflected by the serum creatinine concentration on postoperative day
· Also explore the safety of the administration of LR to patients undergoing kidney transplantation
Discussion
· This is the first study that has compared the effects of NS and LR as IV fluid therapy in kidney transplant recipients.
· There was no significant difference between groups primarily on serum creatinine on POD 3
· The results are strongly suggesting that the administration of large volumes of LR to patients undergoing kidney transplantation is safe and that LR may be superior to NS
· Metabolic acidosis requiring treatment occurred only in patients who received NS
· Giving balanced salt-based solutions such as LR for IV fluid therapy avoids the risk of IV fluid-induced hyperchloremic metabolic acidosis
· In this study, no patient who received LR required treatment for hyperkalemia
· A few small studies have suggested that the administration of NS may be detrimental to renal function
· Previous studies have suggested that hyperchloremia induced by large volume of NS may adversely affect kidney function, but this study findings against previous studies
Study limitations:
· Only 3 cadaveric donor kidney recipients were enrolled in this study, so the study applicable only to living donation transplant
· The study was a single-center investigation
· There is no algorithm for study fluid administration and for the treatment of acidosis and hyperkalemia
· some patients may have received diuretics in the days after surgery, and this may have influenced postoperative urinary output
What is the evidence provided by this article? 1
Will you change your practice based on this article?
Yes. I started today as I am on call.
What is your fluid management plan of your transplant programme?
Actually, I noticed that some patients with acute kidney injury, develop more progression as long as they are on normal saline. I have taken a decision to treat post renal patients with RL.
● Normal saline (NS) or potassium-free fluids arerecommended for IV fluid therapy during kidney transplantation
● Evidence suggests that balanced salt-based solutions such as LR may offer clinical benefits over NS and NS-based solutions.
● Administration of large volumes of NS is associated with the development of hyperchloremic metabolic acidosis which cause hyperkalemia also associated with mental changes and abdominal discomfort
● randomized prospective, double-blind
study to receive either NS or LR for intraoperative fluid replacement during surgery for kidney transplantation
● Exclusion criteria were :
** age 18 yr old
** a religious or ethical prohibition from the receipt of blood or blood products
** serum potassium level5.5 mEq/L before surgery.
● There was no significant difference between groups in the primary outcome measure of the serum creatinine on POD 3. ● The study was terminated because of concerns for patient safety.
● The administration of large volumes of LR to patients undergoing kidney transplantation is safe and that LR may be superior to NS for IV fluid therapy in this setting
● The choice of balanced salt-based solutions such as LR rather than NS-based solutions for IV fluid therapy averts the risk of IV fluid-induced hyperchloremic metabolic acidosis.
● postoperative urine output was larger in
patients who were treated with sodium bicarbonate for metabolic acidosis. In addition, serum creatinine was lower in these patients
● limitations
** results are strictly applicable only to patients undergoing living donor transplants.
** study is a single-center investigation.
** Factors such as surgical technique and the duration of surgery may differ among institutions.
** lack of an algorithm for study fluid administration and for the treatment of acidosis and hyperkalemia.
** some patients may have received diuretics in the days after surgery, and this may have influenced postoperative urinary output.
● NS is not detrimental to renal function
● administration of large volumes of LR to patients undergoing kidney transplantation seems safe and may be superior to NS for IV fluid therapy
Level 1
Thank you
Introduction
Conventionally, normal saline (NS) or potassium-free fluids are used, recommended and preferred for intravenous fluid (IV) administration during renal transplantations. In theory, the concern is that the large volume of Ringer’s lactate (RL) may cause hyperkalemia due to its potassium content. This is a significant concern for patients with end-stage renal disease (ESRD). The use of NS may also cause hyperkalemia theoretically. Large volumes of NS may cause hyperchloremic metabolic acidosis which may lead to the extracellular shift of potassium. NS has also been implicated in causing mental state changes and abdominal discomfort in patients with no known comorbidities. A balanced salt-based solution may also improve splanchnic perfusion in the elderly.
In this context, the trial was designed to understand the effects of NS on renal transplant recipient graft function, by measuring serum creatinine levels on post-operative day 3 (POD3). The study also aimed to determine the safety of administering RL for patients undergoing renal transplant by assessing the serum potassium concentration and the acid-base balance.
Methods
The study was conducted at Columbia Presbyterian Hospital in New York. It was a randomized, prospective, double-blind study. Patients undergoing renal transplant, after consent was obtained, were either to receive NS or LR as the intraoperative IV fluid during surgery for the transplantation. Standardized anesthesia was used for both groups. Radial arterial cannula was inserted for all patients for sampling and blood pressure monitoring.
Exclusion criteria included:
Post-operatively, urine output was replaced with an IV infusion of 5% dextrose/0.45% NaCl + 20mEq/L of sodium bicarbonate.
The primary outcome was the serum creatinine level on POD3.
Secondary outcomes included:
Other secondary end points included intra-operative acid-base balance, intra-operative potassium levels, blood loss and post-operative length of hospital stay.
Results
Fifty four patients were enrolled and randomized for the study. Both groups received similar amounts of fluid intraoperatively. Serum creatinine was 2.3mg/dL in the NS group and 2.1mg/dL in the RL group, on POD3. Graft loos occurred in two patients in the NS group, and in one patient in the RL group. The peak potassium level intraoperatively was 5.1 +/- 0.6 mEq/L in the NS group, and 5.1 +/- 1.1 mEq/L in the RL group. The potassium level exceeded 6.0 mEq/L in 19% of the patients in the NS group, and no patients in the RL group. 31% of patients in the NS group developed metabolic acidosis and required sodium bicarbonate, and none of the patients in the RL group developed metabolic acidosis.
Discussion
There was no significant difference between the groups for the primary outcome of serum creatinine levels on POD3. The patients in the normal saline group had higher incidence of hyperkalemia and metabolic acidosis as compared to the RL group. The results showed that RL was safe to use for renal transplant patients. Administering large volumes of NS may worsen/cause metabolic acidosis, in patients with ESRD. It cannot be definitely concluded that hyperkalemia never occurs in patients receiving large volumes of RL, but the findings revealed that it may be more theoretical in patients undergoing uncomplicated renal transplantation.
Conclusion
RL is a safe fluid to use in the kidney transplant patients. It was not associated with graft dysfunction or hyperkalemia. NS has been associated with causing hyperchloremic metabolic acidosis and subsequent hyperkalemia due to the shift of potassium from the intracellular compartment to the extracellular compartment. Larger studies are needed to confirm these findings
The limitations of the study were:
1. Most of the patients underwent living donor transplant
2. It was a single-center investigation
3. The amount of fluid administration was dependent on the clinician
4. Some patients received diuretics post-operatively.
This is a randomized controlled trial – level 1 evidence
Thank you, see my question above.
Summary of the article;
Introduction;
Most transplant centers recommend using normal saline and K free fluid for recipient during kidney transplantation, as grafted kidney may take time to start full function and to adapt to new environment and family.
In this article we will show evidence of benefit of balanced solution (Lactated ringer) over 0.9 normal saline.
Infusion of large amount of 0.9 NS will cause extracellular shif and hyperkalemia, due to hyperchloremic metabolic acidosis.
For this issue a randomized blined clinical article designed to explore the effects of NS on graft function and in the other hand the safety of using lactated ringer on graft function, on serum K level, and on acid-base status.
Methods;
Results;
Discussion;
Limitation of the study;
This article greatly will affect my practice regarding not only transplanted patients, but also AKI, CKD as well as ESKD, and any patient should be individualized.
Level of evidence ((I)) randomize trial.
Thank you, Kamal for your reflection
II. A Randomized, Double-Blind Comparison of Lactated Ringer’s Solution and 0.9% NaCl During Renal Transplantation
1. Summarise this article
This is a randomized prospective double-blind study. Patients were randomized to receive either NS or LR for intra-op fluid replacement during surgery for KTX.
Exclusion criteria:
Age <18 year old
Religious or ethical prohibition from blood or blood products receipt.
Serum K+ level >5.5 mEq/L before surgery.
Interventions
Anesthesia induction:
IV midazolam, fentanyl, & propofol
Anesthesia maintenance:
Isoflurane in air/O2 & fentanyl, with muscle
relaxants.
Standard monitoring: recommendations of ASA used.
Radial arterial cannula after the induction of anesthesia for monitoring of systemic arterial BP & for blood sampling during surgery.
CVP at the discretion of the physician caring for the patient.
For LKD, the left kidney harvested via a laparoscopic approach.
The graft was flushed with ice cold LR before transfer to the OR for engrafting.
Cadaveric grafts were preserved with either Euro-Collins or University of Wisconsin solution.
The graft implanted in the R or L retroperitoneal space; vascular anastomoses to the R or L external or internal iliac artery & vein.
A dopamine infusion was started (D/C on arrival to the postanesthesia care unit). Ureteroneocystostomy by Leadbetter-Politano or Lich-Gregoir technique.
IS therapy according to institutional guidelines (triple therapy of tapering-dose steroids, a CNI, & either MMF or sirolimus).
Goals:
To assess the impact of the interventions in actual clinical practice.
Study fluid used for all intra-op fluid replacement; blood or blood products were used if indicated.
All study personnel & clinicians were blinded to the fluid type.
Study fluid titrated to clinical end-points routinely used.
Study fluid was D/C at the end of surgery.
Post-op IV fluid therapy was the same for all patients & was given according to:
UOP (ml for ml) with an IV infusion of D 5%/0.45% NaCl +20 mEq/L of NaH2CO3/L.
For diabetics alternating liters of D5%/0.45% NaCl & 0.45% NaCl +20 mEq/L of NaH2CO3.
Additional 50 mL/h of either of these 2 solutions used for all when appropriate.
Serum K+ & ABG at baseline & every 30 min for the duration of surgery.
The treatment for hyperkalemia, metabolic acidosis, etc, at the discretion of the clinician.
Primary outcome measure:
Serum creatinine concentration on POD 3 (the minimum post-op length of stay after KTX at the institution).
Secondary outcomes:
UOP
Creatinine clearance
Requirement for dialysis
Incidence of BPAR & graft loss.
Intra-op acid-base balance
Intra-op K+ concentration
Blood loss & transfusion requirements
Post-op hospital length of stay.
Results
The study terminated (for safety reasons) after analysis of data from 51 patients.
48 patients had LKD TX & 3 patients cadaveric donor TXs.
26 patients received NS, & 25 patients received LR. No difference between groups in the primary outcome measure.
5 (19%) patients in the NS group versus zero (0%) patients in LR group had K+ > 6 mEq/L & were
treated for hyperkalemia (P = 0.05).
8 (31%) patients in NS group versus zero (0%) patients in LR group were treated for metabolic acidosis (P = 0.004).
NS did not adversely affect renal function.
LR was associated with less hyperkalemia & acidosis compared with NS.
LR may be a safe choice for IV fluid therapy in patients undergoing KTX.
Limitations
Results are strictly applicable only to patients undergoing LKD TXs.
Is is a single-center investigation.
//////////////////////////
2. What is the evidence provided by this article?
Level I
Thank you, see my question above.
Aim of the study: to determine the safety of the administration of LR to patients undergoing kidney transplantation.
Methods:
A prospective, randomized, double-blind clinical trial of NS versus LR for intraoperative IV fluid therapy.
After written informed consent was obtained, eligible patients undergoing kidney transplantation were randomized in a prospective, double-blind fashion to receive either NS or LR for intraoperative fluid replacement during surgery for kidney transplantation.
The primary outcome measure was creatinine concentration on a postoperative Day 3.
The study was terminated for safety reasons after interim analysis of data from 51 patients.
Forty-eight patients underwent living donor kidney transplants, and three patients underwent cadaveric donor transplants.
Twenty-six patients received NS, and 25 patients received LR.
Ethical Approval: The study was approved by the IRB of the Columbia Presbyterian Hospital of the New York Presbyterian Hospital.
Results:
There was no difference between groups in the primary outcome measure. Five (19%) patients in the NS group versus zero (0%) patients in the LR group had potassium concentrations >6 mEq/L and were treated for hyperkalemia.
Eight (31%) patients in the NS group versus zero (0%) patients in the LR group were treated for metabolic acidosis. NS did not adversely affect renal function.
LR was associated with less hyperkalemia and acidosis compared with NS.
Conclusion:
LR may be a safe choice for IV fluid therapy in patients undergoing kidney transplantation.
Limitations:
Level of evidence:
Level 1 ( prospective randomized trial ).
I liked reading your summary, limitations of study and your conclusions.
Ajay
thank you porf. Sharma
NS is the preferred IVF therapy during KT to avoid hyperkalemia. NS is associated with adverse metabolic effect and evidence suggests that balanced fluid such as LR may offer clinical benefits over NS and NS-based solutions.
Study goal:
Conduct a clinical effectiveness study, by assess the impact of the type of IVF during kidney transplantation.
Primary outcome:
Explore the effects of NS on graft function as reflected by the serum creatinine concentration on postoperative day 3(POD) 3.
Secondary outcomes:
Determine the safety of LR to patients undergoing KT through assessment of;
serum potassium and acid-base balance, blood loss and transfusion requirements, and postoperative hospital length of stay
Postoperative urine output, creatinine clearance, and requirement for dialysis, along with the incidence of biopsy-proven rejection and graft loss.
Methods:
Design: prospective, double blinded randomized clinical trial.
Population: Patient undergoing kidney transplantation randomized to either NS or LR for IVF during the surgery.
Exclusion criteria: age <18 years old, a religious or ethical prohibition from the receipt of blood or blood products, or serum potassium level5.5 mEq/L before surgery.
Both groups received similar volumes of study fluid during surgery, and no patient received colloid during surgery
Results:
The study was terminated for safety reasons after interim analysis of data from 51 patients.
There were 25 patients in the LR group and 26 patients in the NS group.
Graft loss occurred in 2 patients in the NS group and in 1 patient in the LR group.
Episodes of biopsy-proven rejection occurred in 4 patients who received NS and in 2 patients who received LR.
Serum creatinine was similar in both groups at all other time-points
Median (range) postoperative LOS was 6.3 days in the NS group and 5.3 days in the LR group.
Potassium concentration was higher in NS group (19% treated vs no one in LR group)
Patients received NS exhibited more metabolic acidosis (31% treated for metabolic acidosis vs no one in LR group)
Serum chloride concentration at the end of surgery was 111 mEq/L in the NS group versus 106 in the LR group
Conclusion:
LR administration to patients undergoing kidney transplantation is safe and may be superior to NS.
LR was associated with less hyperkalemia and acidosis compared with NS.
NS did not adversely affect renal function.
Limitations:
Single center study.
Small sample size.
Study strictly applicable only to patients undergoing LD transplants, as number of DD recipients was only 3.
Lack of an algorithm for study fluid administration and for the treatment of acidosis and hyperkalemia
Level of evidence: level 1
Thank you
Agree regarding the limitations, well done
theoretically, lactated Ringer’s solution (LR) might cause hyperkalemia in patients with (ESRD).
This concern was the most frequently cited reason for the use of NS during kidney transplantation
However, administration of large volumes of NS is associated with the development of hyperchloremic metabolic acidosis which may theoretically cause hyperkalemia through an extracellular shift of potassium ions
Methods
This study aimed
To determine the safety of the administration of LR to patients undergoing kidney transplantation through secondary end-points, including the serum potassium concentration and acid-base balance.
Randomization was achieved by computer generation of random number lists, in blocks of four, and a closed envelope technique.
Separate randomization lists were compiled for the two surgeons
Exclusion criteria were
1. age 18 yr old,
2. a religious or ethical prohibition from the receipt of blood or blood products,
3. or serum potassium level 5.5 mEq/L before surgery.
Statistically
Postoperative IV fluid therapy was the same for all patients and was administered according to the following institutional protocol.
The clinician caring for the patient was informed if serum potassium concentration exceeded 6.5 mEq/L
• The primary outcome measure
was the serum creatinine concentration on POD 3.
• Secondary outcomes included
postoperative urine output, creatinine clearance, and requirement for dialysis, along with the incidence of biopsy-proven rejection and graft loss.
• Other secondary outcomes
included intraoperative acid-base balance, intraoperative potassium concentration, blood loss and transfusion requirements, and postoperative hospital length of stay.
Sample size
Serum creatinine on POD 3 was 2.3+/- 1.8 mg/dL in the NS group and 2.1+/_ 1.7 mg/dL in the LR group (P 0.7).
Graft loss occurred in two patients in the NS group and in one patient in the LR group.
Episodes of biopsy-proven rejection occurred in four patients who received NS and in two patients who received LR.
Median (range) postoperative length of stay was 6.3 (3–27) days in the NS group and 5.3 (3–13) days in the LR group (P 0.6).
Peak intraoperative potassium concentration was 5.1- +/_0.6 mEq/L in the NS group and 5.1+/_1.1mEq/L in the LR group.
The serum potassium concentration exceeded 6.0 mEq/L in (19%) patients in the NS group and in no patients in the LR group (P 0.05)
Patients randomized to receive NS exhibited more metabolic acidosis during surgery than patients who were randomized to receive LR
chloride concentration at the end of surgery was 111+/_ 4 mEq/L in the NS group versus 106 +/_4 in the LR group (P 0.0001).
Discussion
The development of metabolic acidosis in association with the administration of large volumes of NS is a well-recognized phenomenon
In this study, metabolic acidosis requiring treatment occurred only in patients who received NS.
In this study, no patient who received LR required treatment for hyperkalemia. However, it cannot be concluded from our findings that hyperkalemia never occurs in patients who receive LR during kidney transplant surgery.
Small differences in postoperative markers of renal function were observed, but these differences were not clinically relevant and did not achieve statistical significant.
postoperative urine output was larger in patients who were treated with sodium bicarbonate for metabolic acidosis
The study is subject to a number of limitations.
Level 1 high quality randomized trial prospective study
This study still not a guideline However it has the efforts to influence my practice
In our center we still use NS solution
Thank you, see my question above.
II. A Randomized, Double-Blind Comparison of Lactated Ringer’s Solution and 0.9% NaCl During Renal Transplantation
——————————————————————————————————————-
Introduction
Aim of the study
Method
Results
Discussion
Limitation of the study
——————————————————————————————————————
What is the evidence provided by this article?
The level of evidence is 1
——————————————————————————————————————
Certainly, after this article, the use of Normal Saline will be reconsidered, patients will be monitored and the required examinations will be performed for them.
Thank you
Thanks alot our Prof.Halawa
Summarise this article
INTRODUCTION
Optimum fluid resuscitation is essential to maximise the outcomes in critically ill patients
Although CVP have been used for a long time, it is correlated to cardiac output and intravascular volume status
CVP
Historical use
Marik et al studied the relationship between CVP and the fluid status of the patients and concluded that CVP is an unreliable indicator of the fluid status and should not be used as a guide to fluid management
Cecconi et al recommended that CVP should not be used alone for evaluation and management unless in severe CHF or hypovolemia
CVP in the current practice
CVP still used in most clinical practice. For example, in Canada 89.2% of physicians use CVP in septic shock
Limitations in renal transplantation
CVP is not the ideal tool of measurement of fluid balance. It is affected by several factors:
1. Central venous blood volume
2. Compliance of central compartment
3. Tricuspid valve disease
4. Cardiac rhythm
5. Reference level of transducer (postion of the patient)
6. Intrathoracic pressure
Intraoperative factors that change the CVP reading:
1. The position of the patient is not always in flat supine position
2. Use of abdominal retractors (reduce venous return by pressing the viscera)
3. Positive pressure ventilation (PPV )
4. No intraoperative exact target of CVP
5. Determination of the normal CVP is difficult in dialysis patient
6. Central vein stenosis
7. Ageing, longstanding HTN and the use of medications affecting the peripheral vascular resistance (alpha blockers, beta blockers and calcium channel blockers)
POSSIBLE ALTERNATIVES FOR FLUID STATUS MONITORING
1. Intraoperative transesophageal Doppler (TED). When compared with CVP, TED was associated with a similar rate of immediate graft function and significant less amount of intraoperative intravenous fluids, and reduced incidence of postoperative fluid overload
2. Stroke volume variation (SVV)
3. lithium dilution technology (e.g., LiDCOplusTM machine) and arterial pulse wave analysis (e.g., FloTrac/VigileoTM)
CONCLUSION
CVP is not ideal for guiding fluid therapy in renal transplantation
Intraoperative factors like position and refractors affect the CVP
Other alternative devices should be used in renal transplantation for guiding fluid therapy (intraoperative and postoperative cardiac output monitoring devices)
What is the evidence provided by this article?
Level 5 (narrative review)
Thank you, but it is not a narrative review. Please read the title and see the methodology.
Level 1 (randomized trial)
Normal saline (NS) is more preferred than lactated ringer (LR) in patients with renal impairment and kidney transplant recipients as it is potassium free and theoretically not associated with hyperkalemia, however, evidence suggest that NS is associated with hyperchloremic metabolic acidosis that lead to hyperkalemia.
The study aims to determine the effect of using NS on serum creatinine and to assess the safety of LR in kidney transplant recipients.
It was a randomized, double-blinded study, the primary outcome was serum creatinine on POD3, secondary outcome was serum potassium and acid base balance.
Patients were randomized to receive either NS or LR as fluid replacement intraoperatively.
Patients with serum potassium >5.5 preoperative were excluded.
The study was stopped because analysis of safety data revealed statistically significant differences in favor of LR regarding serum potassium and acid base balance.
The study showed no significant difference regarding serum creatinine on POD3 between the 2 groups.
Administration of large volumes of LR in kidney transplant recipients was safe and may be better than NS.
Patients receiving NS developed metabolic acidosis requiring treatment.
No patient who received LR required treatment for hyperkalemia but it still may occur with infusion of large volumes of LR.
NS cause hyperchloremic metabolic acidosis that lead to hyperkalemia.
The impact of type of IV fluid on kidney function was not significantly different in the 2 groups.
Limitations:
Apply only to living donor transplants as included only 3 patients with deceased donor kidney transplantation.
Single center study.
Didn’t include an algorithm for fluid administration or for treatment of hyperkalemia and acidosis.
Conclusion:
NS has no adverse effect on kidney function, LR can be administered in large volumes safely in kidney transplant recipients and may be superior to NS.
Level of evidence 1 (Randomized trial)
Thank you
A Randomized, Double-Blind Comparison of Lactated
Ringer’s Solution and 0.9% NaCl During
Renal Transplantation.
Normal saline is used more than Ringer lactate in patients with CKD, which is mainly to avoid hyperkalemia .
But, now there is evident that NS lead to Hyperchloremic metabolic acidosis which lead to extracellular shift of the potassium, this is the indication for this Randomized controlled trial between 0.9 % NaCl and RL post kidney transplant and their effects on graft function as reflected by the serum creatinine concentration on postoperative day (POD) 3.
Methods.
Randomized controlled , Double- Blind study for clinical trial of NS versus LR for intraoperative IV fluid therapy with following potassium and acid -base disturbance and The primary outcome measure was creatinine concentration on postoperative Day 3.
because this is the minimum postoperative length of stay after kidney transplantation there.
Results:
=There were 25 patients in the LR group and 26 patients in the NS group.
=Both groups received similar volumes of study fluid during surgery, and no patient received colloid during surgery.
=Serum creatinine on POD 3 was 2.3 _ 1.8 mg/dL in the NS group and 2.1 _ 1.7 mg/dL in the LR group.
=Graft loss occurred in two patients in the NS group and in one patient in the LR group.
=The serum potassium concentration exceeded 6.0 mEq/L in 5 of 26 (19%) patients in the NS group and in no patients in the LR group.
=Metabolic acidosis is common than in NS group and group treated with sodium bicarbonate had good renal function that group who was not treated.
Discussion.
There was no significant difference between groups in the primary outcome measure of the serum creatinine on POD 3.Ringer lactate can be used safely postoperative and to avoid acidotic state caused by normal saline, regarding effects on renal functions the differences were not clinically relevant and did not achieve statistical significance .
No significant harmful effect on renal functions due to Hyperchloremia in this study.
Limitation points.
-Single center study.
-only 3 cadaveric kidney transplant and so data only reflected on living kidney transplant.
-Some patient received diuretics and so diuretic induced
changes in urine output would have masked an effect of NS on urine output.
Level of evidence I.(Randomized controlled trial).
Thank you.
SUMMARY
Introduction
The normal saline or potassium free solution has been used by most centers that do kidney transplantation despite attendant complication like hyperchloremic metabolic acidosis, effect on abdomen, and even immune systems. Also, the concern on the use of balanced salt-based solution like lactate ringer is the fear of hyperkalemia in kidney transplant patients. Hence there is a need to critically look at these growing concerns and be able to come up with evidenced based decision on which fluid best suited patient undergoing kidney transplant
Aim of the study
Method
Results
Limitation of the study
Level of evidence is 1 because is a randomized trial
Thank you.
Aim of the study:
A randomized, blinded clinical study exploring the impact of NS on graft function as measured by blood creatinine on POD 3.
also tested the safety of LR in renal transplant patients by measuring serum potassium and acid-base balance.
Methods:
Eligible kidney transplant patients were randomly assigned NS or LR for intraoperative fluid replacement. Exclusion criteria:18 years old, religious or ethical ban from receiving blood or blood products, or serum potassium level 5.5 mEq/L before operation.
Results:
After analyzing 51individuals’ data, the trial was stopped for safety concerns. 48 individuals had kidney transplants from live donors and 3 from cadavers.
26 individuals got NS, 25 LR. Primary outcome measures didn’t vary across groups. Five (19%) NS patients vs zero (0%) LR patients were treated for hyperkalemia. 8 (31%) individuals in the NS group were treated for metabolic acidosis.
Discussion:
Serum creatinine on POD 3 didn’t vary between groups. Patient safety concerns halted the trial. Our data imply that high volumes of LR may be safer than NS for IV fluid treatment in renal transplant patients. In simple kidney transplant patients treated with potassium-containing, balanced salt-based solutions, hyperkalemia may be avoided. Hyperkalemia in NS-treated individuals develops via an extracellular shift of potassium produced by hyperchloremic metabolic acidosis.
Limitation:
– Applicable only to patients undergoing living donor transplants.
-Single-center investigation.
-Factors such as surgical technique and the duration of surgery may differ among institutions.
-A small number of participants.
Conclusion:
-NS does not impair renal function in these people. Large volumes of LR may be preferable to NS for IV fluid treatment in kidney transplant patients because it minimizes metabolic acidosis and hyperkalemia.
Level of evidence I
Thank you.
Aim of study:
The most preferred intravenous fluids used in renal transplantation are normal saline and lactated ringers
There is a concern of hyperkalemia that can occur with large infusion of potassium containing IV fluid (LR); on the other hand infusion of normal saline can theoretically cause hyperchloremic metabolic acidosis which can in turn cause hyperkalemia and renal dysfunction
This is a prospective double-blind study (level of evidence II) evaluating 51 renal transplant recipients (48 living and 3 deceased donor transplantation) regarding the effect of intraoperative normal saline (26 patients) versus lactated ringers (25 patients) on serum creatinine, potassium at day 3 after transplantation and the need for treatment of hyperkalemia
The results
Conclusion
Limitation
Thank you.
-Summary
K free fluids as normal saline are the preferred IV fluid therapy in kidney transplantation ,this was theoretically justified because K containing fluids can lead to hyperkalemia in CKD patients as Lactated ringer.
It was suggested that balanced solutions can be more beneficial than normal saline because infusion of large volumes normal saline can cause hyperchloremic acidosis which in turn causes hyperkalemia, also it was associated with mental changes.
Balanced solutions were associated with better splanchnic perfusion in elderly surgical cases.
This study is a blinded clinical trial to evaluate the effect of administration of normal saline on graft function by serum creatinine concentration checking on postoperative day 3 as well as assess the effect of using LR in renal transplant recipients with secondary endpoints as hyperkalemia .
Methods
This double blind study compared recipients receiving prospectively normal saline with those receiving lactated ringer intraoperatively for kidney transplantation.
51 patients were included where 48 received living donor kidney transplants, and3 patients received cadaveric donor transplants.
26 cases were infused with NS, and 25 with LR.
Postoperative IV fluid therapy was the same for the 2 groups and was given according to the institution
protocol.
The primary outcome measure was the serum creatinine concentration on postoperative day 3.
Secondary outcomes were postoperative
urine output, creatinine clearance, and requirement
for dialysis, the incidence of biopsy-proven
rejection and graft loss, intraoperative acid-base balance, intraoperative K concentration, blood loss and transfusion requirements, and postoperative hospital stay.
Results
7 units of packed red blood cells were taken by the NS group versus 3 U in the LR group.
Serum creatinine on POD 3 was mildly higher in
the NS group than in the LR group.
2 patients in the NSgroup had graft loss and one patient in the LR group.
Rejection occurred in 4 patients in NS and in two patients who received LR.
Serum potassium concentration was more than 6.0 mEq/L in19% of cases in the NS group and in no patients in the LR group.
Also NS group cases experienced more metabolic acidosis than LR group.
Serum Cl concentration was higher in NS group compared to LR group.
Discussion
There was no significant difference between the 2 groups regarding the primary outcome measure of the
serum creatinine on POD 3.
The current results display that LR is superior over NS as IV fluid replacement in kidney transplantation cases.
NS lead to metabolic acidosis necessitating therapy , could be due to the dilution of bicarbonate by large volumes of buffer-free fluid or due to the hyperchloremia which lower the strong ion difference of the blood thereby causing metabolic acidosis.
Using LR instead of NS for iv fluid therapy in renal transplant cases lowers the risk of hyperchloremic acidosis .
Hyperkalemia is an important aspect in renal diseased cases therefore the iv fluids used for those cases are better to have lower K concentrartion , that is why LR was avoided for such cases but this study showed no hyperkalemia risk with the use of LR in kidney transplants .
In NS treated cases ,hyperkalemia can occur due to the change of H ion with hyperchloremic metabolic acidosis .
Postoperative urine output was larger in NS group treated with Na HCO3 for metabolic acidosis and had lower serum creatinine .
Previous studies opposing the current study used to mention that large volumes of NS can negatively affect renal function due to hyperchloremia.
The limitations were that those results were mostly applied on recipients of living donors as recipients from cadaveric donors were only 3 cases , and it was conducted in a single center, as well as absence of algorithm for fluid replacement , and for treatment of acidosis and hyperkalemia.
Some patients received postoperatively diuretics which is unlikely to have biased the effect of NS on the urinary output.
This study concluded that NS can be unharmful to renal function in kidney transplant recipients and LR can be safely used for those patients instead of NS to avoid hyperchloremic metabolic acidosis.
-level of evidence is 1
Thank you, Doaa
Will you change your practice based on this article?
Introduction:
Ø Normal saline (NS) or potassium-free fluids are recommended for IV fluid therapy during kidney transplantation.
Ø Theoretically, administering large volumes of potassium-containing fluids such as lactated Ringer’s solution (LR) might cause hyperkalemia in patients with chronic renal failure and end-stage renal disease (ESRD).
Ø Evidence suggests that balanced salt-based solutions such as LR may offer clinical benefits over NS, and NS-based solutions administration of large volumes of NS is associated with the development of hyperchloremic metabolic acidosis
objectives :
Ø Determine the safety of the administration of LR to patients undergoing kidney transplantation through secondary end-points, including the serum potassium concentration and acid-base balance
Method:
It is A prospective, double-blind clinical trial of NS versus LR for intraoperative IV fluid therapy.
Exclusion criteria were age <18 yr old, a religious or ethical prohibition from recei
ving blood or blood products, or serum potassium level .>5.5 mEq/L before surgery.
Data are presented as mean ± sd for continuous variables and percentages for categorical variables.
tested all data for normality using the method of Kolmogorov-Smirnov
Differences between categorical variables were tested using Fisher’s exact test. A P value ≤0.05 (two-tailed) was considered to be significant
Results
1-Fifty-four patients were enrolled and randomized to receive either NS or LR
2-Twenty-six patients received NS, and 25 patients received LR.
3-There was no difference between groups in the primary outcome measure.
4- Five (19%) patients in the NS group versus zero (0%) patients in the LR group had potassium concentrations >6 mEq/L and were treated for hyperkalemia (P= 0.05).
5-Eight (31%) patients in the NS group versus zero (0%) patients in the LR group were treated for metabolic acidosis (P = 0.004).
6-NS did not adversely affect renal function. LR was associated with less hyperkalemia and acidosis compared with NS.
Limitation :
1-single-center investigation
2-applicable only to patients undergoing living donor transplants
Conclusion :
The administration of large volumes of LR to patients undergoing kidney transplantation
seems safe and may be superior to NS for IV fluid therapy in these patients because it avoids the risk of metabolic acidosis and clinically significant hyperkalemia.
level 1
Thank you, Nahla
Will you change your practice based on this article?
What is best intravenous fluid in post kidney transplant period is still an unanswered question. Normal saline is frequently used and preferred over Ringer lactate in many transplant centers according to different surveys owing to apprehension of hyperkalmia associated with RL.
To address this issue a randomized, blinded clinical trial to explore the effects of NS administration on graft function as reflected by the serum creatinine concentration on postoperative day (POD) 3 was conducted in Presbyterian Hospital of the New York.
Adults undergoing kidney transplantation were enrolled in a prospective, randomized, double-blind clinical trial of NS versus LR for intraoperative IV fluid therapy.
The primary outcome measure was the serum cre- atinine concentration on POD 3.
Secondary outcomes included postoperative urine output,
creatinine clearance,
and requirement for dialysis, along with the incidence of biopsy-proven rejection and graft loss. Other secondary outcomes included intraoperative acid-base balance, intraoperative potassium concentration, blood loss and transfusion requirements, and postoperative hospital length of stay.
Fifty-four patients were enrolled and randomized to receive either NS or LR.
There were 25 patients in the LR group and 26 patients in the NS group.
All 51 patients were included in the final analysis.
The study groups were similar with regard to demographic factors
Both groups received similar volumes of study fluid during surgery, and no patient received colloid during sur- gery
Seven units of packed red blood cells were administered in the NS group versus 3 U in the LR group.
Serum creatinine on POD 3 was 2.3mg/dL and 1.8 mg/dL in the NS group and 2.1 mg/dLand 1.7 mg/dL in the LR group .
Graft loss occurred in two patients in the NS group and in one patient in the LR group. Episodes of biopsy-proven rejection occurred in four patients who received NS and in two patients who received LR.
Serum creatinine was similar in both groups at all other time-points, and there were no significant differences in any other markers of renal function.
CONCLUSION
There was no difference between groups in the primary outcome measure. Five (19%) patients in the NS group versus zero (0%) patients in the LR group had potassium concentrations more than 6 mEq/L and were treated for hyperkalemia Eight (31%) patients in the NS group versus zero (0%) patients in the LR group were treated for metabolic acidosis .
NS did not adversely affect renal function. LR was associated with less hyperkalemia and acidosis compared with NS.
LR may be a safe choice for IV fluid therapy in patients undergoing kidney transplantation.
Level of evidence 1
Thank you, Zahid
Will you change your practice based on this article?
Summary:
· Normal saline is used during kidney transplantation to avoid the risk of hyperkalemia associated with potassium-containing fluids. But evidence suggests that normal saline infusion is associated with adverse effects like hyperchloremic metabolic acidosis, subjective mental changes and abdominal discomfort in healthy volunteers.
· The use of balanced salt-based solutions in elderly surgical patients may be associated with better splanchnic perfusion than normal saline.
· This prospective, randomized, double-blind clinical trial of NS versus LR for intraoperative IV fluid therapy in renal transplant patients.
· The study was terminated for safety reasons after interim analysis of data from 51 patients.
· In this study twenty-six patients received NS, and 25 patients received LR. There was no difference between groups in the primary outcome measure. Five (19%) patients in the NS group versus zero (0%) patients in the LR group had potassium concentrations more than 6 mEq/L and were treated for hyperkalemia. Eight (31%) patients in the NS group versus zero (0%) patients in the LR group were treated for metabolic acidosis.
· NS did not adversely affect renal function. LR was associated with less hyperkalemia and acidosis compared with NS.
· LR may be a safe choice for IV fluid therapy in patients undergoing kidney transplantation.
Level of evidence: 1
Hi Dr Ansary,
I liked reading your summary and analysis, Will you change your practice based on this article?
Ajay
Hi Dr Ben,
I liked reading your summary and analysis, Will you change your practice based on this article?
Ajay
Absolutely prof
NS is the most common IV fluid used during transplantation surgery. Several evidence support the clinical benefit of RL over NS & NS based solutions because infusion of large volume of NS associated with hyperchloremic metabolic acidosis.
Method:
Result & discussion:
Study limitations:
Level of evidence is 1
Hi Dr Ban,
I liked reading your summary and analysis, Will you change your practice based on this article?
Ajay
Of course I will use balanced solution more than NS during transplantation surgery.