IV. Effects of intraoperative and early postoperative normal saline or Plasma-Lyte - 148 on hyperkalaemia in deceased donor renal transplantation: a double-blind randomized trial
plasmalytes fluid is more physiological compared to isotonic saline, with less chloride and less sodium but potassium 5mmol/l, magnesium 3mmol/l, calcium 1.5mmol, and more cost, $12 /1liter of osmolytes compared to$2 /liter for isotonic saline and $4 / l for RL
so it is a more costly fluid but more physiologically balanced IVF
The protocol in our transplant unit involves using Plasma-Lyte.
Plasma-Lyte is costlier than normal saline, but the overall benefits with a balanced solution like Plasma-Lyte tilt the balance towards its use over normal saline.
PL is more expensive than NS. But it is more physiologic than NS.
Mohammed Sobair
2 years ago
INTRODUCTION:
Hyperkalemia is a common complication of kidney transplantation, occurring in 25–40% of recipients. Although the outcomes of severe postoperative hyperkalemia in kidney transplantation are not well studied, adverse consequences of hyperkalemia in this setting include significant hemodynamic and neurological effects that result in respiratory paralysis or cardiac arrest if not treated urgently.
Administration of saline in renal transplantation is associated with hyperchloremic metabolic acidosis, but the effect of normal saline (NS) on the risk of hyperkalemia or postoperative graft function is uncertain. Methods.
A double-blinded randomized trial comparing the effects of intraoperative and early postoperative NS or acetate-buffered crystalloid solution (Plasma-Lyte 148 on hyperkalemia, the need for hyperkalemia treatment, acid–base status, and graft function in patients
Compared NS with Plasma-Lyte 148VR (PL) given during surgery and for 48 h after surgery in patients undergoing deceased donor renal transplantation. Outcome:
The primary outcome was hyperkalemia within 48 h after surgery. Secondary outcomes were need for hyperkalemia treatment, change in acid–base status, and graft function. Results.
Between September 2012 and April 2015, the trial was conducted at Austin Hospital, a university teaching hospital in Melbourne with expertise in renal transplantation.
Twenty-five subjects were randomized to NS and 24 to PL. The incidence of hyperkalemia in the first 48 h after surgery was higher in the NS group; 20 patients (80%) vs 12 patients (50%) in the PL group (risk difference: 0.3; 95% confidence interval: 0.05, 0.55; P¼0.037).
The mean (SD) peak serum potassium was NS 6.1 (0.8) compared with PL 5.4 (0.9) mmol litre1 (P¼0.009). Sixteen participants (64%) in the NS group required treatment for hyperkalemia compared with five (21%) in the PL group (P¼0.004). Participants receiving NS were more acidemia [pH 7.32 (0.06) vs 7.39 (0.05), P¼0.001] and had higher serum chloride concentrations (107 vs 101 mmol litre1. Conclusions.
Compared with PL, participants receiving NS had a greater incidence of hyperkalemia and hyperchloremia and were more acidemia. These biochemical differences were not associated with adverse clinical outcome.
level of evidence 1
Ghalia sawaf
2 years ago
Methods
The trial was prospectively registered with the Australian New Zealand Clinical Trials Registry.
Between September 2012 and April 2015,
the trial was conducted at Austin Hospital, in Melbourne
1. Exclusion criteria included preoperative hyperkalaemia >6.0mmol litre
2. that was not corrected before transplantation,
3. pregnancy,
4. chronic liver disease (liver function tests >1.5 times normal value),
5. known allergic reaction to study solutions,
6. and patients undergoing multi-organ transplantation.
A statistician generated a computerised randomization sequence of 50 allocation codes, 25 for each group.
Independent research staff sealed the allocation codes into sequentially numbered opaque envelopes.
The sequence was decoded after data analysis.
The study was completely blinded to the trial fluid intervention.
Baxter Healthcare provided either NS or PL as 1000ml identical blinded carrier solution containers.
The PL contained
1. sodium (140mmol litre1),
2. potassium (5mmol litre1),
3. magnesium (3mmol litre1),
4. chloride (98 mmol litre1),
5. acetate (27mmol litre1),
6. and gluconate (23 mmol litre1).
The NS contained
• sodium (154mmol litre1)
• and chloride (154mmol litre1).
Immediately upon arrival in the operating room, subjects were randomized.
After preoxygenation, general anaesthesia plan was similar for patients
All participants were prescribed a minimum of 2000ml trial fluid during surgery
Electrocardiography, pulse oximetry, capnography, blood pressure, urine output, and core body temperature were monitored.
Use of invasive arterial blood pressure monitoring was at the discretion of the anaesthetist.
Measurement of (CVP) was not used
Other advanced haemodynamic monitoring devices were not used.
Mean arterial pressure was maintained within 20% of the baseline preoperative value and supported with vasoactive therapy where appropriate.
Blood was transfused for haemoglobin <80g litre1,or<90g litre1 when further bleeding was anticipated.
During surgery, the patient’s temperature was kept constant at 36C
and arterial partial pressure of CO2 was maintained at 35–40mm Hg.
Furosemide (125mg i.v.) was administered 5min before reperfusion
. Any additional fluid boluses of trial crystalloid solution could be administered to any patient if volume supplementation was required.
After 48h the study fluid ceased, and the rate and type of any further fluid was at the discretion of the treating clinician.
Immunosuppression was according to the local standard of care, with a regimen of tacrolimus , mycophenolate prednisolone, and basiliximab commenced before surgery and continued throughout.
Perioperative plasma exchange was used for higher immunological risk patients
The primary outcome was the incidence of hyperkalaemia within 48h of surgery.
The highest serum potassium value was also recorded, as was the number of subjects requiring treatment for hyperkalaemia.
Secondary outcomes included hyperkalaemia during hospital admission, treatment for hyperkalaemia, requirement for postoperative dialysis, delayed graft function), postoperative complications, and hospital length of stay.
Treatment for hyperkalaemia :binding resins; insulin, glucose, or both; calcium gluconate i.v.; and dialysis.
Renal perfusion was assessed with (Tc99m MAG3) nuclear medicine scan and Doppler ultrasound performed on postoperative day 1.
Potassium concentrations and all other biochemistry parameters were sampled
• before surgery,
• immediately on arrival at the postoperative anaesthesia recovery unit,
• and at 24 and 48h after surgery.
Renal function (both serum creatinine and estimated GFR ) was also measured at 1week, 1, 3, 6, and 12months post-transplantation.
Statistical analysis Sample size calculations were based on a pilot study from 44 patients receiving renal transplants in our institution
they received ethics approval to recruit 50 subjects.
Statistical analysis was performed using commercial statistical software STATA/IC v.13
Fisher’s exact test was used to investigate differences between groups in categorical outcomes, including the primary outcome of hyperkalaemia (serum potassium >5.5mmol litre1) in the first 48h after surgery. A two tailed P-value of <0.05 was used as a threshold for statistical significance.
The study was reported in accordance with the CONSORTguidelines for reporting randomized trials.
Results
• During the study period, 70 patients underwent deceased donor renal transplantation.
• Thirteen patents were excluded .
• Fifty-seven patients provided informed consent.
• Seven participants did not proceed to transplant because the donor kidney was considered unsuitable.
• Twenty-five subjects were randomized to NS and 25 to PL.
• One subject in the PL group was excluded because of a protocol violation
baseline characteristics were similar with respect to preoperative biochemistry, age, cause of renal failure, donor age, and proportion of kidney donations after circulatory and brain death.
Primary outcome:
hyperkalaemia within 48h ,
there was a higher incidence of hyperkalaemia after NS (80%) than with PC [50%; risk difference: 0.3; 95% confidence interval (CI): 0.05, 0.55; P¼0.04).
Likewise, 64% of subjects were treated for hyperkalaemia after NS vs 21% after PL (risk difference: 0.43; 95% CI: 0.18, 0.68; P¼0.004;).
In the first 48h after surgery, the mean (SD) highest potassium concentrations were 6.1 (0.8)mmol litre1 after NS compared with 5.4 (0.9)mmol litre1 after PL (mean difference: 0.65; 95% CI: 1.12, 0.17; P¼0.009).
Medical management for hyperkalaemia with insulin, dextrose, or both, resonium, or calcium gluconate was instituted in 10 subjects in the NS group vs seven subjects in the PL group (P¼0.55).
Thirteen subjects required dialyses for hyperkalaemia in the NS group vs four in the PL group (P¼0.02).
Intraoperative variables
Fifteen subjects receiving NS and 19 receiving PL had arterial blood gases checked during surgery.
The peak mean (SD) potassium value was 5.4 (1.1)mmol litre1 in the NS group compared with 4.9 (0.8)mmol litre1 in the PL group (mean difference: 0.42; 95% CI: 1.13, 0.28; P¼0.23).
Four subjects were treated for hyperkalaemia with insulin and dextrose in the NS group vs one in the PL group (P¼0.27)
The median (IQR) volume of intraoperative trial fluid administered in NS group was 2500 (2000, 3000)ml compared with 3000 (2000, 3000)ml in the PL group (P¼0.92).
Additional intraoperative fluid, blood, and use of vasoactive medications were similar.
Subjects receiving NS were more acidaemic [mean (SD) pH 7.32 (0.06) vs 7.39 (0.05) (pH normal range: 7.35–7.45); P¼0.002] and hyperchloraemic [median (IQR) 107 (105, 110) vs 101 (99.8, 103.3)mmol litre1; (normal range for chloride: 98–107mmol litre1); (P<0.01)] compared with PL.
Eight subjects (32%) produced urine in the NS group vs 11 (46%) in the PL group (P¼0.39).
The median (IQR) cold ischaemic time in NS group time was 11.8 (6.3; 14.3)h and in the PL group 10.8 (9.8, 13.2)h (WilcoxonMann–Whitney P¼0.74).
Likewise, there were no differences in warm ischaemic time between the NS and PL groups; 34 (27, 41) vs 33 (24, 43)min (Wilcoxon–Mann–Whitney P¼0.56).
Longitudinal analysis, delayed graft function, and complications
For any given time point, subjects receiving PL had lower potassium values by an average of 0.34mmol litre1 (95% CI: 0.63, 0.05; P¼0.02) compared with NS.
Medical management for hyperkalaemia with insulin, dextrose, or both, resonium, or calcium gluconate was instituted in five subjects in the NS group and no subjects in the PL group
There was no requirement for dialysis to manage hyperkalaemia in either group.
No significant difference in the incidence of DGF
The incidence of complications was similar between groups
The median (IQR) length of hospital stay was 6.5 (6, 13.2) days after NS and 7.1 (6, 10.4) days after PL (P¼0.18).
There was no 30day mortality.
Follow-up blood samples obtained at 1week, 1, 3, an 6months and 1yr intervals showed a similar improvement in markers of renal function over time in both groups
Discussion
Relationship to previous findings
Potura and colleagues recently investigated the incidence of hyperkalaemia in the context of deceased donor renal transplantation.
Similar to our findings, they reported no significant difference in the incidence of intraoperative hyperkalaemia in recipients receiving open-label NS or an acetate-buffered solution, and also reported significant intraoperative metabolic acidosis and hyperchloraemia.
In contrast to the present study, however, they continued open-label trial fluid for only 4–5h after surgery, whereas we continued blinded fluids for 48h postsurgery,
Several studies in live donor kidney transplant recipients have also reported an increased incidence of metabolic acidosis in patients receiving NS compared with balanced crystalloid solutions.
Similar to our study, some of these groups also evaluated renal function as a key outcome.
Although iatrogenic hyperchloraemia is associated with renal impairment and reduction of renal cortical perfusion in both animal and human studies,this has not consistently translated into major deleterious renal functional outcomes for renal transplant recipients.
Despite the limited power of the present study, we observed a modest efficacy signal towards better renal outcomes in the PL group than the NS group.
Strengths
• The fluid intervention was blinded and randomized.
• The extended use of blinded fluids for 48 h after surgery was strictly adhered to in all participants, with electronic medical recording allowing a detailed and accurate of fluid use and fluid balances, reinforcing the internal validity of the key out come variables reported.
• Previous studies comparing balanced fluids with NS in kidney transplantation were largely restricted to the intraoperative period and may not have delivered a sufficient volume of trial fluids to determine the full effect of fluid choice.
• This is also the first fluid intervention study in deceased donor renal transplant recipients to report renal outcome at 1week, and 12 months after trial fluid intervention.
Limitations of the study include
inadequate power to compare the effects of NS and PL on short-or long-term graft function and other postoperative complications; addressing this will require a larger, multicenter study.
uncertain whether the immunosuppressive therapy contributed to the incidence of hyperkalaemia in each group; we consider this unlikely because all participants received the same immunosuppressive protocol.
The rate of DGF in the present study was high, possibly reducing the generalize ability of the findings; however, this reinforces the relevance of the results to patients a thigh risk of poor graft function and associated hyperkaliemia.
Level 1
We need more larger studies. However, these solutions are more similar to plasma components and less association with hyperkalemia and acidosis.
If they are available, it will be better to use them
fakhriya Alalawi
2 years ago
Introduction: Hyperkalaemia is a common complication of kidney transplantation, occurring in 25–40% of recipients. Despite the preferential use of NS in renal transplantation, previous studies in live donor and deceased donor renal transplant recipients reported that NS causes hyperchloremic metabolic acidosis, which can increase the risk of hyperkalaemia. Method: this is a a double-blinded randomized trial comparing the effects of intraoperative and early postoperative NS or acetate-buffered crystalloid solution (Plasma-Lyte ). Twenty-five subjects were randomized to NS and 24 to PL.
All participants were prescribed a minimum of 2000 ml trial fluid during surgery, Electrocardiography, pulse oximetry, capnography, blood pressure, urine output, and core body temperature were monitored. After surgery, all subjects received a maintenance infusion of trial fluid, with a starting rate of the previous hour’s urine output plus 30 ml/hr. The primary outcome was the incidence of hyperkalaemia within 48 h of surgery. Hyperkalaemia was defined as potassium >5.5 mmol litre. Secondary outcomes included hyperkalaemia during hospital admission, treatment for hyperkalaemia, requirement for postoperative dialysis, delayed graft function (DGF; hours to first dialysis after surgery, acid–base derangements), postoperative complications, and hospital length of stay. Results: During the first 48 h period after surgery, there was a higher incidence of hyperkalaemia after NS (80%) than with PC [50%; risk difference: 0.3]
Subjects receiving NS were more acidaemic [mean (SD) pH 7.32 (0.06) vs 7.39 (0.05) (pH normal range: 7.35–7.45); P¼0.002] and hyperchloraemic [median (IQR) 107 (105, 110) vs 101 (99.8, 103.3) mmol litre; P<0.01)]
Medical management for hyperkalaemia were given in five subjects in the NS group and no subjects in the PL group. There was no requirement for dialysis to manage hyperkalaemia in either group. Finally, although subjects in the PL group who did not receive dialysis had a greater CRR on day 2, there was no significant difference in the rate of DGF Conclusion: Compared with PL, subjects receiving NS were more acidaemic during surgery, and after surgery had higher serum potassium and a greater incidence of hyperkalaemia. Moreover, there was a higher rate of interventions to correct hyperkalaemia in the first 48 h after surgery. Strengths and limitations The fluid intervention was blinded and randomized, thus minimizing allocation and selection bias.
Limitations of the study include inadequate power to compare the effects of NS and PL on short- or long-term graft function and other postoperative complications; addressing this will require a larger, multicentre study.
level of evidence 1
Rehab Fahmy
2 years ago
Hyperkalaemia is a common and potentially severe complication of cadaveric kidney transplantation.
• Normal saline is commonly used as a potassium-free i.v. fluid therapy, but can cause hyperchloraemic acido- sis and subsequent hyperkalaemia.
Methods:
They compared NS with Plasma-Lyte 148VR (PL) given during surgery and for 48 h after surgery in patients undergoing deceased donor renal transplantation. The primary outcome was hyperkalaemia within 48 h after surgery. Secondary out- comes were need for hyperkalaemia treatment, change in acid–base status, and graft function
Conclusion: hyperkalemia was more in NS group but with no major adverse outcomes
If available PL I will use but I can also manage with NS with close observation
Level of evidence:1
Nasrin Esfandiar
2 years ago
The complication of hyperkalemia after cadaveric kidney transplantation occurs in 25-40% of patients. As normal saline is a potassium free solution, usually is used as the preferred fluid for kidney transplantation, but it causes hyperchloremic metabolic acidosis and is associated with the risk of hyperkalemia. So, in this study a blinded randomized trial was performed and compared the effects of NS with Plasma-Lyte 148 in deceased donor transplantation. Plasma-Lyte contains sodium (140 mmol/L), potassium (5mmol/L), magnesium (3 mmol/L), chloride (98 mmol/L, acetate (27 mmol/ L) and gluconate (23 mmol/L). Whereas NS contains sodium 154 mmol/L and chloride 154 mmol/L. Twenty- five recipients were placed in NS group and 24 in PL group. Twenty patients in NS group vs 12 patients in PL group had hyperkalemia during 48 h after transplantation. Sixteen patients in NS group vs no patient in PL group received hyperkalemia treatment. NS group had more acidosis and higher serum chloride concentration and this difference was significant. But there was no significant difference regarding DGF or other complications. The strength of study was its design as double blinded RCT and the first study in deceased donor transplantation. Limitation of this study was its low power because of small number of participants. So, this study indicates use of balanced crystalloid solutions for deceased donor transplantation.
The level of evidence is 1.
Wael Jebur
2 years ago
Comparing post deceased donors kidney transplantations fluid management with normal saline and balanced solution Plasmalyte, In order to address the prevalence of hyperkalemia post operatively or the need for treatment of hyperkalemia within 48 hours post transplanttion.
Other targets were metabolic acidosis and graft function.
25 recipients were managed with normal saline and 24 with Plasmalyte solution. for 48 hours post transplantation .
surprisingly 80% in the normal saline cohort developed hyperklemia vs 50 % in the other group.
While 65% of hyperkalemic required management for hyperkalemia,21% in Plasmalyte required treatment.
Hyperchloremia was more prevalent as well as acidosis were more prevalent in normal saline group than Plasmalyte, However , clinical outcome didnot adversly affected by the noted changes.
Its a prospective randomized study with level of evidence 1
Mohamad Habli
2 years ago
25–40% of kidney transplant patients develop hyperkalemia. If not treated immediately, hyperkalemia can induce respiratory paralysis and cardiac death. Deceased donor renal transplantation fluids are chosen to preserve kidney transplant perfusion and minimize acid-base and electrolyte abnormalities. The kidney transplantation fluid of choice is potassium-free normal saline (NS).
NS induces hyperchloremic metabolic acidosis and hyperkalemia. This study compared the effects of fluids on hyperkalemia, therapy, acid-base status, and graft function in deceased donor renal transplant patients.
Methodology
Austin Hospital in Melbourne, Australia, hosted the trial from September 2012 to April 2015. It includes adults receiving dead donor kidney transplantation. Preoperative hyperkalemia of more than 6.0 mmol/L that was not treated before surgery, chronic liver illness, known allergic responses to study solutions, and multi-organ transplantation were eliminated.
After consenting, patients were randomly divided into two groups. Participants, anesthetists, surgeons, nephrologists, and nurses were blinded to the trial fluid intervention. Plasma-Lyte 148 (PL) contains sodium, potassium, magnesium, chloride, acetate, and gluconate. NS containes 154 mmol/L sodium and chloride. Surgery patients received at least 2000 mL of trail fluid. Depending on the procedure, the anesthesiologist controlled fluid administration. Electrocardiography, pulse oximetry, capnography, blood pressure, urine output, and core body temperature were measured. Patients got trail fluid maintenance after the operation. protocol required immunosuppression.
Hyperkalemia (>5.5 mmol/L potassium) within 48 hours of surgery was the main outcome.
Secondary results included hospitalization, hyperkalemia treatment, Post-operative dialysis, incidence of DGF
Results
The research included 70 deceased donor kidney transplants. 13 were eliminated. 57 consented. The donor kidney proved unsuitable for 7 people. 25 participants were randomized to NS and 25 to PL.
NS patients had more hyperkalemia in the first 48 hours after surgery than PL patients. NS treated 64% of patients for hyperkalemia, while PL treated 21%. The NS group had 6.1 mmol/L potassium, while the PL group had 5.4. 13 NS patients and 4 PL patients needed dialysis.
NS and PL groups had median intraoperative trial fluid volumes of 2500ml and 3000ml, respectively. NS patients were more acidic than PL patients. 8 NS and 11 PL patients generated urine. The median operation time was 2.8 hours for NS and 3.0 hours for PL. Both groups had comparable difficulties. NS and PL had a median stay of 6.5 and 7.1 days, respectively.
Discussion
NS patients were more acidemic following surgery, had higher potassium levels, and had more hyperkalemia and hyperkalemia treatments than PL patients. DGF was unaffected.
NS also increases metabolic acidosis in living donor renal transplantation patients. Renal function indicators were likewise the same. Hyperchloremic metabolic acidosis does not worsen renal function in renal transplant patients.
NS worsens hyperchloremic metabolic acidosis and hyperkalemia biochemically compared to PL. These data show that balanced solution hyperkalemia problems must be addressed.
Study strengths:
Randomized blinded trial design
Post-surgery blinding increased the study’s validity.
The first fluid intervention trial in deceased donor renal transplantation followed renal functioning for 12 months.
Study limitations:
Hyperkalemia caused by immunosuppression was not considered.
DGF was high.
Small sample
Hyperkalemia’s cause is unclear
Conclusion
Compared to PL, NS had hyperchloremic metabolic acidosis and hyperkalemia that required correction during deceased donor kidney transplantation. They did not affect clinical results. In cadaveric transplants, PL is safer than NS. These conclusions require broader population investigations.
According to last few articles and professor lecture we have changed out protocols as plasmalytes fluid is more physiological and less associated hyperkalemia, and metabolic acidosis. Here the prices are almost the same.
Zahid Nabi
2 years ago
The common myth about use of normal saline in kidney transplant patients is that it does not cause hyperkalemia because it has zero K content.The fact that normal saline does cause hyperchloremic metabolic acidosis and can induce hyperkalemia has been looked in this double blinded randomized trial done in deceased donor transplant patients. Normal saline was compared with plasma -Lyte 148. The PL contained sodium (140 mmol litre), potassium (5 mmol litre), magnesium (3 mmol litre), chloride (98 mmol litre), acetate (27mmol litre), and gluconate (23 mmol litre). The NS contained sodium (154 mmol litre) and chloride (154 mmol litre)
Methods They compared NS with Plasma-Lyte 148VR (PL) given during surgery and for 48 h after surgery in patients undergoing deceased donor renal transplantation. The primary outcome was hyperkalaemia within 48 h after surgery. Secondary outcomes were need for hyperkalaemia treatment, change in acid–base status, and graft function.
RESULTS Twenty-five subjects were randomized to NS and 24 to PL. The incidence of hyperkalaemia in the first 48 h after surgery was higher in the NS group; 20 patients (80%) vs 12 patients (50%) in the PL group (risk difference: 0.3; 95% confidence inter- val: 0.05, 0.55; P1⁄40.037). The mean (SD) peak serum potassium was NS 6.1 (0.8) compared with PL 5.4 (0.9) mmol litre.(P=0.009) Sixteen participants (64%) in the NS group required treatment for hyperkalaemia compared with five (21%) in the PL group (P1⁄40.004). Participants receiving NS were more acidaemic [pH 7.32 (0.06) vs 7.39 (0.05), P1⁄40.001] and had higher serum chloride concentrations (107 vs 101 mmol litre1, P<0.001) at the end of surgery. No differences in the rate of delayed graft function were observed. Subjects receiving PL who did not require dialysis had a greater reduction in creatinine on day 2 (P1⁄40.04).
Conclusions. Compared with PL, participants receiving NS had a greater incidence of hyperkalaemia and hyperchloraemia and were more acidaemic. These biochemical differences were not associated with adverse clinical outcomes. Level of evidence 1 In our practice we r using normal saline but if PL is available we can prefer it over saline
Marius Badal
2 years ago
Summarise this article
What is the evidence provided by this article?
High potassium is one of the complications that are about 25-40 % present post-kidney transplant. Hyperkalaemia can cause neurological adverse effects, cardiovascular effects, respiratory effects, and hemodynamic effects. The fluid that is used during transplant that is cadaveric transplant is to ensure there is good renal perfusion and to prevent complications like disequilibrium of acid-base and electrolytes. NS itself does not contain high K but as such, it can be the right choice in fluid selection it does cause metabolic acidosis and as a result high K.
The aim of this study is to compare the effects of fluids on high K and treatment is high K, the acid-base status, and graft response.
The study included adult patients at age 18 and above.
The study excludes pre-op high K greater than 6.0, not corrected pre-transplant, liver disease, pregnancy, multi-organ transplant, and anyone allergic to any of the solutions.
Methods:
1) The study was conducted at Austin Hospital in Melbourne, Australia from September 2012 to April 2015.
2) Patients were consented and placed in randomized groups.
3) The two solutions used were Plasma-Lyte and NS
4) Fluid used was a minimum of 2000 cc during the surgery.
5) Vitals were monitored
6) Immunosuppression was given as protocol.
Study strength:
1) The two groups were well controlled and matched and biasness was reduced
2) There were proper protocols given and adhere to.
3) The first study addressed intervention and its outcome on the different intervals of FU from 1,2,3,6 and 12 months.
The limitation of the study:
1) The sample size was small
2) The FU was a short period
3) The exact cause of high K was not recognized
The result of the study:
1) The total of patients with NS was 25 and 24 were PL
2) High K in the first 48 hours after surgery was greater in the NS group 80% while only 50% of PL had high K.
3) K mean serum peak was 6.1 with NS and with PL it was 5.4
4) 10 patients on NS were treated with high K while only 7 on PL were treated.
5) Patients receiving NS have more metabolic acidosis and had higher serum of CL at the end of the surgery.
6) There was no delay in graft function
7) Patients who received PL and never received dialysis have their creatinine reduced on day 2
8) The incidence of complications between the two groups was similar.
In conclusion, patients receiving NS had a greater chance of having high K and metabolic acidosis post-op of 48 hours when compared to PL. However, there was no adverse clinical outcome when compared.
The level of evidence of this article is level 1
Amit Sharma
2 years ago
Summarise this article
Hyperkalemia is seen in 25-40% of kidney transplant recipients, which can lead to hemodynamic and neurological complications with respiratory paralysis or cardiac arrest. Normal saline use intraoperatively and post-operatively is associated with hyperchloremic metabolic acidosis, which can cause hyperkalemia.
It was a prospective, randomized, double-blind, single-center study, involving deceased donor kidney transplant recipients between September 2012 and April 2015. The patients were given either normal saline or Plasma-Lyte 148 balanced solution during the surgery (minimum 2000 ml) and for first 48 hours post-surgery as maintenance fluid. Open-label fluids were also used intraoperatively, as per the discretion of the anesthesia team. After 48 hours post-transplant, further fluid was given as per the treating clinician.
The primary outcome was hyperkalemia within 48 hours after surgery, and secondary outcomes involved treatment of hyperkalemia, change in acid-base status, and graft function.
A total of 70 patients underwent transplant during the study period, a total of 49 patients were finally included in the study, 25 received normal saline (NS) while 24 received Plasma-Lyte 148 (PL).
The NS group had higher incidence of hyperkalemia (80% versus 50%), acidosis and higher serum chloride levels at the end of surgery. 64% of NS group patients required treatment for hyperkalemia as compared to 21% in the PL group. 52% of the NS group patients required dialysis for hyperkalemia while only 16% required dialysis in the PL group. The incidence of delayed graft function was similar in both the groups. PL group patients not requiring dialysis had greater fall in serum creatinine on post-operative day 2. The complication rates including ICU care requirement, length of stay, and blood transfusion were similar in the 2 groups.
The strengths of the study include randomization, double-blind use of fluid, continuing blinded fluids for 48 hours post-surgery, providing more detailed evaluation of the impact of the fluid on outcomes, and assessment of renal outcomes upto 1 year post-transplant.
The limitations of the study include small sample size, single-center study, inadequate power to compare the effects, and uncertainty regarding effect of immunosuppressive drugs on the incidence of hyperkalemia.
To conclude, the study demonstrated that buffered crystalloid solution like Plasma-Lyte 148 should be preferred over normal saline in the peri-operative fluid management of deceased kidney transplant recipients.
What is the evidence provided by this article?
Level of evidence: Level 1
Mohammad Alshaikh
2 years ago
Summarise this article
Introduction: Administration of N/S 0.9% is the standard of care fluid used in most centers where kidney transplantations are done, it has been showed that massive infusion of N/S is associated with hyperchloremic acidosis and subsequent hyperkalemia. The use of balanced fluids such as PlasmaLytes have near plasma electrolytes levels, was compared to infusion of N/S in a single transplant center. Study fluids contents: N/S contains 154 mmol/l Na and 154 mmol/l Cl PlasmaLytes 148 contains 140 mmol/l Na, 3 mmol/l Mg, 5 mmol/l K, 98 mmol/l Cl, 27 mmol/l acetate, and 23 mmol/l gluconate.
Methods: Double blinded randomized clinical trial was conducted in a deceased kidney transplantation in Malbourne teaching hospital between September; 2012- April; 2015, comparing the two above mentioned fluids in perioperative period till 48 hours after transplantation. Inclusion criteria: Adult > 18 years of age, cadaveric kidney transplants, informed consent signed. Exclusion criteria: Potassium > 6 mmol/l that is not corrected before transplanation, pregnancy, chronic liver disease(1.5 times normal values of liver function tests), known allergy to study fluids, and whon undergoing multiple organ transplantations. Primary outcome: hyperkalemia > 5,5 mmol/l within 48 hours of surgery. Secondary outcomes: Hyperkalemia requiring treatment, dialysis need post operatively, delayed graft function (DGF), postoperative complications and length of hospital stay. Base line characteristics were comparable between two groups. Results: There was significantly higher potassium level among those received N/S [P= 0.04]. Subjects receiving NS were more academic [P= 0.002], and hyperchloremic [P<0.01]. No significant difference in the incidence of DGF was identified. PlasmaLytes had a more rapid reduction in creatinine on day 2 [P= 0.04]. The post-operative complications, length of hospital stay, and 30 days mortality were comparable in both groups. Study limitations: Single center study with small sample size 24 in N/S group and 25 IN PL group. Done for only cadevaric kidney transplants, no living donor kidney transplant included. No long term outcomes follow up was done by the investigator. Conclusion: The use of PL was associated with better graft function and lower creatinine level 48 hours post transplantation, N/S was associated with more hyperchloremic metabolic acidosis and hyperkalemia (not requiring treatment). Both solutions are safe with comparable results on delayed graft function, surgical complications, and length of hospital stay. What is the evidence provided by this article? Level of evidence I , randomized controlled trial.
Abhijit Patil
2 years ago
Summary:
Introduction
Hyperkalaemia is a common complication of kidney transplantation, occurring in 25–40% of recipients
NS causes hyperchloraemic metabolic acidosis
So, the authors compared the effect of intraoperative and early postoperative NS or Plasma-Lyte 148VR with respect to hyperkalaemia, the need for hyperkalaemia treatment, acid–base status, and graft function in patients receiving a deceased donor renal transplant.
Study duration: September 2012 to April 2015 Study location: Austin Hospital, a university teaching hospital in Melbourne
preoperative hyperkalaemia > 6.0mmol/litre that was not corrected before transplantation
pregnancy
chronic liver disease (liver function tests>1.5 times normal value)
known allergic reaction to study solutions
patients undergoing multi-organ transplantation
Primary outcome
Incidence of hyperkalaemia (potassium >5.5mmol/litre) within 48 h of surgery. Secondary outcomes
hyperkalaemia during hospital admission
treatment for hyperkalaemia
requirement for postoperative dialysis
delayed graft function
postoperative complications
hospital length of stay.
Results
25 subjects were randomized to NS and 24 to PL.
The incidence of hyperkalaemia in the first 48h after surgery was higher in the NS group(P=0.037).
Sixteen participants (64%) in the NS group required treatment for hyperkalaemia compared with five (21%) in the PL group (P=0.004).
Participants receiving NS were more acidaemic (P=0.001] and had higher serum chloride concentrations (P<0.001) at the end of surgery.
No differences in the rate of delayed graft function
Subjects receiving PL who did not require dialysis had a greater reduction in creatinine on day 2 (P=0.04).
Conclusions. Compared with PL, participants receiving NS had a greater incidence of hyperkalaemia and hyperchloraemia and were more acidaemic. These biochemical differences were not associated with adverse clinical outcomes
The prices in India (per 500 ml bottle)
NS: Rs 26/-
RL: Rs 46/-
Plasmalyte: Rs 122/-
Plasmalyte is quite costly. We in our practice regularly use balanced fluids for kidney transplant patient, but we use RL fluid.
Last edited 2 years ago by Abhijit Patil
Manal Malik
2 years ago
Summary of Effects of intraoperative and early postoperative normal saline or Plasma-Lyte – 148 on hyperkalaemia in deceased donor renal transplantation: a double-blind randomized trial Introduction:
Hyperkalaemia is a common complication of kidney transplantation 25-40% of recipients.
Normal saline in renal transplantation reported causes hyperchloremic metabolic acidosis and increase risk of hyperkalaemia.
This randomized double blinded trial comparing the effects of interoperative and early postoperative. Normal saline or acetate-buffered crystalloid solution on hyperkalaemia, the need for hyperkaliaemic treatment, acid-base status and graft function in patients receiving a deceased donor renal transplant. Methods:
Trials register between September 2012 and April 2015.
Inclusion criteria:
Adult patient>or =18 years undergoing deceased donor renal transplantation
Exclusion criteria:
· Hyperkalaemia > 6mmol/L preoperative which was not corrected before transplant.
· Pregnancy.
· Chronic liver disease
· Allergic to study solution
· Multiorgan transplantation
· All participants were given at least of 2000ml trial fluid during surgery
Monitoring include:
ECG, pulse oximetry, capnography, blood pressure, urine output and core body temperature.
Mean arterial pressure was maintained within 20% of the baseline preoperative value .
125 mg IV frusemide given 5 minutes before reperfusion.
Maintenance infusion hours urine output plus 30 ml for the first 48 hours after surgery
After 48 hours fluid ceased and the rate and type of fluid by treating clinician
Immunosuppression was according to the local standard of care. Primary outcome was:
Incidence of hyperkalaemia within 48 hours of surgery>or=5.5mmol/l
Patient whom requiring treatment of hyperkalaemia Secondary outcome:
1. Hyperkalaemia during hospital admission
2. Treatment for hyperkalaemia
3. Requirement for postoperative dialysis after surgery
4. Acid-base derangement
5. Postoperative complication
6. Hospital length of stay Statistical analysis:
Sample size calculations were based on a pilot study.
To analyse potassium values throughout the four pre specific time points we used a random effect generalized linear regression model with individualized subject treated as a random effects Result:
Twenty-five subjects were randomized to normal saline and 25 to PL cout of 70 patients underwent deceased donor renal transplantation
Primary outcome:
Hyperkalaemia within 48 hours
During the first 48 hours period after surgery, higher incidence of hyperkalaemia after NS 80%. 64% were treated for hyperkalaemia vs 21% after PL
13 subjects required dialysis for hyperkalaemia in NS group vs 24 in the PL group.
Longitudinal analysis, delay graft function and complication
No significant difference in the incidence of DGF was identified
PL group a more rapid reduction in creatinine on day 2
The incidence of complication was similar between groups Discussion:
Compared PL receiving patient with NS were more acidaemia during surgery
Had higher serum potassium
Higher incidence of hyperkalaemia
Higher incidence of correction of hyperkalaemia in the first 48 hours
No significance in the rate of BGF
PL group had greater CRR on a day 2 in whom did not receive dialysis
The previous studies showed no different in incidence of hyperkalaemia in both group. Implication:
Comparing PL and NS had inferior biochemical outcomes regarding hyperchloremic metabolic acidosis and hyperkalaemia
In this study there are not certain if the immunosuppression therapy contributes to the incidence of hyperkalaemia in each group Conclusion:
In deceased donor kidney transplantation recipients receiving PL or NS during surgery and for 48 after surgery
Use of NS was associated with:
1. Hyperchloremic acidosis
2. Postoperative hyperkalaemia
3. Use of the treatment for hyperkalaemia
This study favour the use of buffered crystalloid solution for perioperative fluid management in patients undergoing deceased donor renal transplantation.
What is the evidence provided by this article?
leve2
Assafi Mohammed
2 years ago
Summary of the article “Effects of intraoperative and early postoperative normal saline or PlasmaLyte – 148 on hyperkalaemia in deceased donor renal transplantation: a double-blind randomized trial”
This is a prospective randomized double-blind controlled study, comparing the effects of NS andPlasma-Lyte 148(PL) given during surgery and for 48 h after surgery in patients undergoing deceased donor renal transplantation. The primary outcome was hyperkalaemia within 48 h after surgery. Secondary outcomes were need for hyperkalaemia treatment, change in acid-base status, and graft function. Study’s Results and Outcome 1. Normal saline administration, during surgery and after surgery, is associated with more acidemia, and had higher serum potassium and a greater incidence of hyperkalaemia. There was a higher rate of interventions to correct hyper- kalaemia in the first 48h after surgery. 2. No differences in kidney function were observed between groups at 1, 3, 6, and 12months. 3. Compared with PL, NS leads to inferior biochemical outcomes in relationship to hyperchloraemic metabolic acidosis and hyperkalaemia. 4. There was a strong signal in the incidence of hyperkalaemia in participants receiving PL in donation after brain death recipients when compared with donation after cardiac death recipients. 5. The study supports the preferential use of buffered crystalloid solutions for perioperative fluid management in patients undergoing deceased donor renal transplantation.
Strengths of the study 1. A prospective, double-blind controlled study. 2. This is the first fluid intervention study in deceased donor renal transplant recipients to report renal outcomes at 1week, 1, 3, 6, and 12 months after trial fluid intervention. Limitations of the study 1. inadequate power to compare the effects of NS and PL on short- or long-term graft function and other postoperative complications; addressing this will require a larger, multicentre study. 2. The uncertainty, whether the immunosuppressive therapy contributed to the incidence of hyperkalaemia in each group.
What is the evidence provided by this article?
This is a prospective randomized double-blind controlled study.
Level of evidence grade 2.
mai shawky
2 years ago
Club 4; normal saline vs plasma lyte effect on hyperkalemia in KT Summary
· The current study compared risk of hyperkalemia at 48 h post transplantation, and need for anti hyperkalemic measures, acid base disturbance and graft function in 2 groups of cadaveric kidney transplantation, one received saline 0.90 % (25 patients) and the other received plasma-lyte 148 (24 patients).
· The study concluded that higher risk of hyperkalemia and metabolic acidosis (that required treatment or intervention) than in plasma –lyte. However, it was not associated with worse graft outcome (as DGF, ned for RRT).
· This finding made the concept of fear of balanced crystalloid solution (due to its K content) is not justified.
· Points of strength of current study:
o Being randomized and blinded (less bias).
· Limitations of the current study:
o Only applied to the cadaveric (not living kidney transplantation).
o Small number of cases (only 49 cases), and single center study.
Level of evidence: RCT (level I) I think use of plasma lite will be limited by its cost.
Huda Al-Taee
2 years ago
Aim of the study: to demonstrate the effect of normal saline on the risk of hyperkalaemia or postoperative graft function.
Methods: NS was compared with Plasma-Lyte given during surgery and for 48 h after surgery in patients undergoing deceased donor renal transplantation.
The primary outcome: hyperkalaemia within 48 h after surgery.
Secondary outcomes: the need for hyperkalaemia treatment, change in acid-base status, and graft function.
Results: Twenty-five subjects were randomized to NS and 24 to PL.
The incidence of hyperkalaemia in the first 48 h after surgery was higher in the NS group.
The mean peak serum potassium was NS 6.1 compared with PL 5.4 mmol/ litre.
Sixteen NS group participants required hyperkalemia treatment compared with five in the PL group.
Participants receiving NS were more acidic and had higher serum chloride concentrations at the end of surgery.
No differences in the rate of delayed graft function were observed.
Patients receiving PL who did not require dialysis had a more significant reduction in creatinine on day 2.
Conclusion: Compared with PL, participants receiving NS had a greater incidence of hyperkalaemia and hyperchloraemia and were more acidaemic. These biochemical differences were not associated with adverse clinical outcomes.
Limitations:
inadequate power to compare the effects of NS and PL on short- or long-term graft function and other postoperative complications; addressing this will require a larger, multicentre study.
immunosuppressive therapy may contribute to the incidence of hyperkalemia in each group.
The rate of DGF was high, possibly reducing the generalizability of the findings.
Further studies are needed to determine whether our results are applicable to live donor kidney transplant recipients or to other patients at risk of perioperative acute kidney injury.
small sample size.
Level of evidence:
Level 1 ( randomized trial ).
Hussam Juda
2 years ago
· Hyperkalaemia is a common and potentially severe complication of cadaveric kidney transplantation.
· Normal saline used as potassium-free i.v. fluid therapy can cause hyperchloraemic acidosis and subsequent hyperkalaemia.
· In a randomized trial in deceased donor kidney transplant recipients, intraoperative and early postoperative use of normal saline was associated with more hyperkalaemia, hyperchloraeamia, and acidosis compared with a balanced i.v. fluid.
Exclusion criteria: preoperative hyperkalaemia >6.0 mmol /L that was not corrected before transplantation, pregnancy, chronic liver disease, known allergic reaction to study solutions, and patients undergoing multi-organ transplantation
Primary outcome: hyperkalaemia within 48 h
· During the first 48 h period after surgery, there was a higher incidence of hyperkalaemia after NS (80%) than with PL
Discussion
· This is a prospective randomized double-blind controlled study comparing the effects of NS and PL as perioperative i.v. fluid therapy in deceased donor renal transplant recipients
· Patients received NS were more acidaemic during surgery, and after surgery had higher serum potassium and a greater incidence of hyperkalaemia.
· There was a higher rate of interventions to correct hyperkalaemia in the first 48 h after surgery in patients received NS
· PL group who did not receive dialysis had a greater CRR on day 2, but there was no significant difference in the rate of DGF Relationship to previous findings
· Potura and colleagues recently found that no difference in the incidence of intraoperative hyperkalaemia in recipients receiving open-label NS or an acetate-buffered solution, and also reported significant intraoperative metabolic acidosis and hyperchloraemia (deceased donor)
· Several studies in live donor kidney transplant recipients have also reported an increased incidence of metabolic acidosis in patients receiving NS compared with balanced crystalloid solutions.
· These studies also found no significant difference in markers of renal function between groups
· Compared with previous reports, the auther observed a high rate of both DGF overall and the need for haemodialysis within the first 48 h post-transplant
Strengths of the study
· The fluid intervention was blinded and randomized
· The extended use of blinded fluids for 48 h after surgery to all participants
· This is the first fluid intervention study in deceased donor renal transplant Limitations of the study
· Inadequate power to compare the effects of NS and PL on short- or long-term graft function and other postoperative complications as this require a larger, and multicentre study
· Not sure about immunosuppressive therapy effect on hyperkalemia
This is a double-blinded randomized trial. Evidence 1
Hussein Bagha baghahussein@yahoo.com
2 years ago
Introduction
Hyperkalemia occurs as a complication in 25-40% of kidney transplant recipients. Hyperkalemia causes significant hemodynamic and neurologic adverse effects that cause respiratory paralysis and cardiac death if not corrected urgently. The choice of fluid to administer during a deceased donor renal transplantation is aimed to maintain adequate renal transplant perfusion and to avoid acid-base and electrolyte disturbances. Normal saline (NS) does not contain any potassium and so it is the current fluid of choice for kidney transplantation.
NS, however, causes hyperchloremic metabolic acidosis and resultant increased risk of hyperkalemia. This study was designed to compare the fluids on hyperkalemia, the need for hyperkalemia treatment, acid-base status, and graft function in patients receiving a deceased donor renal transplant.
Methodology
The study was conducted in Austin Hospital in in Melbourne, Australia, between September 2012 and April 2015. It included patients above the age of 18 years, undergoing deceased donor renal transplantation. It excluded patients who has preoperative hyperkalemia of more than 6.0mmol/L that was not corrected before the surgery, chronic liver disease, known allergic reaction to the study solutions and patients who were undergoing multi-organ transplantation.
The patients, after giving consent, were randomized into the two groups. The study participants, anesthetists, surgeons, nephrologists and the nursing staff were blinded to the trial fluid intervention. The Plasma-Lyte 148 (PL) contained sodium (140 mmol/L), potassium (5 mmol/L), magnesium (3 mmol/L), chloride (98 mmol/L), acetate (27 mmol/L), and (gluconate 23 mmol/L). The NS contained sodium (154 mmol/L) and chloride (154 mmol/L). All patients were prescribed a minimum of 2000ml of trail fluid during surgery. The rest of the fluid administration was at the discretion of the anesthetist, depending on the surgery. Electrocardiography, pulse oximetry, capnography, blood pressure, urine output and core body temperature were monitored. After the procedure, the patients received a maintenance infusion of the trail fluid. Immunosuppression was given as per protocol.
The primary outcome was:
The incidence of hyperkalemia (potassium of more than or equal to 5.5 mmol/L) within 48 hours of surgery.
The secondary outcomes include:
Hyperkalemia during hospital admission,
Treatment for hyperkalemia,
Requirement for postoperative dialysis,
Delayed graft function (DGF),
Postoperative complications
Hospital length of stay
Results
During the study period, 70 patients underwent deceased donor renal transplantation. 13 participant were excluded. 57 patients provided an informed consent. 7 participants did not participate as the donor kidney was not suitable. 25 subjects were in the NS group, and 25 were randomized into the PL group.
During the first 48 hours after surgery, there was a higher incidence of hyperkalemia in the NS group compared to the PL group. 64% of the patients were treated for hyperkalemia after the use of NS, compared to the 21% of patients treated for hyperkalemia after the use of PL. The highest level of potassium was 6.1 mmol/L in the NS group, and 5.4 mmol/L in the PL group. 13 patients required dialysis from the NS group, compared to 4 from the PL group.
The median volume of intraoperative trial fluid was 2500ml in the NS group, and 3000ml in the PL group. Subjects receiving NS were more acidotic than the ones receiving PL. 8 subjects produced urine in the NS group, compared to 11 in the PL group. In the NS group, the median duration of surgery was 2.8 hours, and it was 3.0 hours in the PL group. The incidence of complications was similar in both the groups. The median length of stay was 6.5 days after the use of NS, and 7.1 days after the use of PL.
Discussion
Compared with PL, the patients receiving NS were more acidaemic during the surgery, had higher levels of potassium and a greater incidence of hyperkalemia, with a resultant higher rate of interventions to correct the hyperkalemia. There was no significant difference in the rate of DGF.
Many studies in living donor renal transplantation have also reported a higher incidence of metabolic acidosis in patients receiving NS compared with balanced crystalloid solutions. They also noted that there was no difference in renal function markers between the two. Despite the higher incidence of hyperchloremic metabolic acidosis, it has not led to a higher incidence of deleterious renal functional outcomes for the renal transplant recipients.
Compared with PL, NS leads to inferior biochemical outcomes in relationship to hyperchloremic metabolic acidosis and hyperkalemia. These findings help us understand that the concerns for hyperkalemia after the use of balanced solutions need to be rectified.
The strengths of the study include:
The study design was blinded and randomized
The study was blinded for 48 hours post-surgery – further increasing its validity
It is the first fluid intervention study in deceased donor renal transplantation to follow up the renal functions up to 12 months post-transplantation.
The limitations of the study include:
The possibility of the immunosuppression causing the hyperkalemia was not taken into consideration
The rate of DGF was high
A small sample size
The exact mechanism of hyperkalemia is still unknown.
Conclusion
During deceased donor renal transplantation, NS was associated with hyperchloremic metabolic acidosis and more frequent hyperkalemia with more frequent requirement for correction, compared to PL. These differences were not associated with adverse clinical outcomes. Therefore, it is safe to use PL as compared to NS in cadaveric transplants. Further studies, in larger populations are required to confirm these findings.
Level of evidence is I as this is an RCT
Huda Mazloum
2 years ago
● The aims of perioperative fluid administration in deceased donor renal
transplantation include maintenance of adequate kidney transplant perfusion and the avoidance of electrolyte and acid–base
disturbances, including hyperkalaemia.
● The PL contained sodium (140 mmollitre-1), potassium (5 mmol litre-1), magnesium (3 mmol litre-1), chloride (98 mmol litre-1), acetate (27 mmol litre-1), and gluconate (23 mmollitre-1).
● NS contained sodium (154 mmol litre-1) and chloride (154 mmol litre-1)
● similar improvement in markers of renal function over time in both groups
● A prospective randomized double-blind controlled study comparing the effects of NS and PL as perioperative i.v. fluid therapy in deceased donor renal transplant recipients.
● Compared with PL, subjects receiving NS were more acidaemic during surgery, and after surgery had higher serum potassium and a greater incidence of hyperkalaemia.
● there was a higher rate of interventions to correct hyperkalaemia in the first 48 h after surgery
● there was no significant difference in the rate of DGF.
● mechanism for the higher incidence of hyperkalaemia in the NS group relates to its chemical properties (i.e. high chloride, low pH), rather than the fluid volume.
● Strengths
* The fluid intervention was blinded and randomized minimizing bias.
* The extended use of blinded fluid for 48 h after surgery was strictly adhered to in all participants
* This is also the first fluid intervention study in deceased donor renal transplant recipients to report renal outcomes at 1 week, 1, 3, 6, and 12 months
● Limitations include
* inadequate power to compare the effects of NS and PL on short- or long-term graft function and other postoperative complications
* immunosuppressive therapy may contributed to the incidence of hyperkalaemia in each group
* The rate of DGF in the present study was high, possibly reducing the generalizability of the findings
* Study includes only deceased donors
* small sample size
● this study supports the preferential use of buffered crystalloid solutions for perioperative fluid management in patients undergoing deceased donor renal transplantation.
● Level 1
saja Mohammed
2 years ago
This study from BJA published in 2017, an impact factor of 11.719, ranking it 2 out of 34 in anesthesiology and indexed 18 international data base. Introduction
There is growing concern about the use of isotonic saline and the risk of hyperchloremic metabolic acidosis, normal saline is potassium-free IVF makes it the preferred IVF for patients under transplant but the risk of hyperkalemia with the use of isotonic saline in perioperative transplantation is still indeterminate.
This study aims to assess the risk of hyperkalemia after 48 hours, the need for hyperkalemia correction, acid-base status,
and graft function in patients receiving a deceased donor renal transplantation.
Method and Setting
This is a double-blind randomized control trials data from tertiary teaching center data collected between 2012-2015 after getting ethical approval and all patients providing written consent
The inclusion criteria for all adults above 18 years with Deceased donor kidney transplantation randomized the recipients to two group
A Group of 25 DD recipients received isotonic saline intraoperative and post-operative and assess after 48 hours for the risk of hyperkalemia compared with the group of 25 using plasmalyte148 (one case dropped later, a total of 24 ).
Exclusion criteria are those with preoperative hyperkalemia > 6, multiple transplantations, pregnancy, chronic liver disease, and known allergy to study fluids
The minimum intraoperative use was 2000ml, CVP was not used to guide the IVF management, but MAP kept 20% higher than the baseline
Furosemide 125 mg prior to reperfusion as part of the center protocol
Open-label fluids (dextrose 5%, colloids, or blood products) were used at the discretion of the anesthetist. Blood transfusion if hemoglobin <80 g/L
Results
————
A total of 73 underwent DDKTX after the exclusion of many who did not fit the inclusions and did not give written consent
Twenty-five Patients were randomized to NS and 25 to PL. With matched baseline clinical characteristics
One subject in the PL group was excluded because of a protocol
The primary outcome is a hyperkalemia rate 48 hours after surgery
Higher risk of hyperkalemia in the isotonic saline group at 80% with average potassium > 6.1 and treatment of hyperkalemia is also more in isotonic saline 13 patients compared to 5 in PL group
No dialysis was needed in both group and no difference in the incidence of DGF between the two groups
creatinine reduction ratio (CRR) on postoperative day 2, and kinetic estimated glomerular filtration rate (KeGFR ml min 1.73 m-2) at 48 h is higher in PL 148 but did not reach statistical significance
and overall GFR and creatinine level at 12 months was similar between the two groups.
Strength
The methods of blinded Randomization with the control group with well-matched baseline clinical and patients’ characteristics between the two groups and by this they reduce the chances of selection bias
Accurate and adherence to the protocols, with internal validity for reported outcome, was achieved
First study to address intervention (fluid therapy) and its outcome in different intervals of FU from 1.2,3, 6 , 12 months in DD kidney transplants candidates
Limitation
Due to the Small sample size, there is insufficient influence to detect the difference between the two infusion groups for both short and long-term outcomes (type 1 error)
Short FU up to 12 months is not enough to assess such a hard outcome of graft survival
Can’t recognize the exact cause of hyperkalemia in NS group whether due to acidosis or hyperchloremia
Uncertainty regarding the effect of IS like CNI on acidosis and hyperkalemia (cofounders) however both groups have the same IS protocol.
So, we need large prospective studies with longer Follow up and maybe the use of such trials in LD candidates will also good alternative option Conclusion
This Study concludes that saline infusion fluid intra-op and 24, 28 hours after surgery is associated w a h high risk of hyperchloremic acidosis and hyperkalemia that mandate medical therapy compared to plasmalyte148 Fluid in DD kidney transplantation , such conclusion should be taken with caution due to small sample size with type 1 error and we need more studies with large sample size and may be in living donor setting to address such intervention and its short and long term out come.
What is the evidence provided by this article?
Double blinded RCT so its level1 of evidence
Heba Wagdy
2 years ago
Hyperkalemia commonly occur in kidney transplant recipients, it is associated with serious complications.
Fluid management in deceased donor transplantation is crucial to maintain adequate renal perfusion without inducing electrolyte or acid base imbalance.
Normal saline (NS) is the preferred solution in kidney transplantation, however, studies showed that NS is associated with hyperchloremic metabolic acidosis that may result in hyperkalemia.
This study aims to compare the effect of intraoperative and early postoperative NS and plasmaLyte (PL) on hyperkalemia, the need for treatment of hyperkalemia, acid base status and graft function in deceased donor renal transplantation.
It is s randomized double blind controlled trial, included adult patients undergoing DD renal transplants.
Patients with preoperative hyperkalemia were excluded, also those with chronic liver disease, pregnancy, multi organ transplantation and allergy to study solutions.
The primary outcome was incidence of hyperkalemia within 48 hours of surgery, secondary outcomes included hyperkalemia during hospital admission, need for treatment of hyperkalemia, postoperative dialysis, DGF, postoperative complication and duration of hospital stay.
The study showed that NS was associated more metabolic acidosis and more hyperkalemia compared to PL.
There was no significant difference in the rate of DGF between NS and PL.
NS was associated with inferior outcomes regarding hyperchloremic metabolic acidosis and hyperkalemia compared to PL.
The study suggest that concerns about potassium content in PL are not justified clinically and that PL may be more beneficial than NS in patients receiving DD kidney transplantation.
Strengths:
Randomized, blind trial, used electronic medical recording of fluid use, compared NS and PL use within 48 hours postoperative and were not restricted to intraoperative fluids only, also they reported the renal outcome up to 12 months post transplant.
Limitations:
Inadequate power to compare the effect of NS and PL on short and long term graft function, the rate of DGF was high which may limit generalizability of the results and small sample size.
level of evidence: 1 (Randomized controlled trial)
KAMAL ELGORASHI
2 years ago
Summary of the article; Hyperkalemia is a common complication postoperatively, and its Sequelle is dangerous if not treated properly, as it may lead to respiratory and cardiac arrest with increasing mortality. Because the 0.9% saline consider as K free, so is dominating in this setting to avoid such complication.
Recent study found that NS can cause hyperchloremic metabolic acidosis and hyperkalemia, new attention develop on using balanced fluid that are plasma similar and does not affect contents or acid-base balance. Method;
Study done in Australian New Zeland Clinical triala registery, between September 2012 and April 2015, and the study was registered in Austin Hospital.
Exclusion criteria was; Preoperative hyperkalemia >6.0 mmol/L, that was not corrected before transplantation, Pregnancy, Chronic liver disease, Known allergic to study solution, and patient with multiorgan transplantation.
All participants provide written informed consents.
All participants receive 2000 ml trial fluid during surgery, and extra fluid was individualized according to the patient condition.
Measures and vitals (Pulse, BP, UOP, Temperature, ECG, CVP) were monitored.
Postoperative all recipients receive maintenance trial of fluid, based on previous hour UOP, for first 24 hours post-surgery.
Immunosuppressants was according to the local standard of care (TAC/MMF/Pred, and Basiliximab commenced before surgery and continued throughout).
Perioperative PE was used for higher immunological risk recipients.
Results;
The study involve 70 recipients with deceased kidney donor.
Primary outcome was hyperkalemia within 48 hour post operation, which was higher among recipient who receive NS, for which 64% was treated for hyperkalemia.
The mean highest K concentration was 6.1 mmol/l after NS compared to 5.4 mmol/l in after PL.
13 rtecipient required dilaysis for hyperkalemia in NS group compared to 4 recipients in PL group.
Recipient with NS group was more acidemic with pH (7.32 vs 7.39), and more hypercholremic (107 vs 101),compared to PL.
No diiference between 2 group regarding DGF was noticed
PL group noticed to have a rapid reduction in S Cr and a better KeGFR compared to NS group.
No 30 days mortality in both group.
LOS was 6.5 days in NS group, while it was 7.1 days in PL group.
Similar improvement regarding follow up blood sample in week 1,3, and 6, 6 month, and 1 year.
Discussion;
Prospective randomized double blind controlled study, comparing the effects of NS and PL as perioperative IV fluid in deceased donor kidney transplant.
NS group was more acidemic, and more develop hyperkalemia requiring treatment in some.
No difference between 2 group in relation to DGF.
Increased incidence of hyperchloremic metabolic acidosis in NS group.
Strengths;
Fluid intervention was blinded and randomized.
The extended use of blind fluid was strictly adherent to in all participants, with electronic medical recording allowing a detailed and accuracy tally of fluid use and fluid balances.
study follow recipient outcome in regular interval time in all participants .
Limitations;
Inadequate power to compare the effects of NS and PL on short-or long-term graft function and other postoperative complications, which require a large multicenter study.
Uncertainty of whether immunosuppressants medication contribute to hyperkalemia on both group or not .
The rate of DGF was high, may be lead to restriction the outcome of this study, and need to do another study for living donor transplant group.
Small size study.
Conclusion;
Use of NS in deceased donor kidney transplant was associated with hyperchloremic acidosis, and hyperkalemia, with need of correction, compared to PL. This study prefer use of balanced-buffered solution in perioperative period in patient receive deceased kidney donation.
Level of evidence ((I)) Randomizes control trial
Eusha Ansary
2 years ago
Summary:
Infusion of normal saline in renal transplantation is associated with hyperchloraemic metabolic acidosis. Development of hyperkalaemia with infusion of normal saline is demonstrate in this study.
Here comparison done between NS with Plasma-Lyte 148 during surgery and for 48 h after surgery in patients undergoing deceased donor renal transplantation. In this study primary outcome was hyperkalaemia within 48 h after surgery and secondary outcomes were, any need for hyperkalaemia treatment, change in acid–base status, and graft function.
This study showed, twenty-five subjects were randomized to NS and 24 to PL. The incidence of hyperkalaemia in the first 48 h after surgery was higher in the NS group; The mean peak serum potassium was NS 6.1 compared with PL 5.4 mmol/l. Sixteen participants (64%) in the NS group required treatment for hyperkalaemia compared with five (21%) in the PL group. Participants receiving NS were more acidaemic.
Level of evidence: 1
Mohamed Mohamed
2 years ago
IV. Effects of intraoperative and early postoperative normal saline or Plasma-Lyte – 148 on hyperkalaemia in deceased donor renal transplantation: a double-blind randomized trial 1.Summarise this article Introduction Use of saline in KTX is linked to hyperchloraemic metabolic acidosis; however, the effect of NS on the risk of hyperkalaemia or post-op graft function is uncertain. The study NS was compared with Plasma-Lyte 148VR (PL) given during surgery & for 48h after surgery in patients undergoing DKD renal transplantation. Primary outcome: Hyperkalaemia within 48h after surgery. Secondary outcomes: Need for hyperkalaemia treatment Change in acid–base status Graft function. Results.
1.25 patients were randomized to NS & 24 to PL.
2.The incidence of hyperkalaemia in the 1st48h after surgery was higher in the NS group; 20 patients (80%) versus 12 patients (50%) in the PL group (risk difference: 0.3; 95% CI: 0.05, 0.55; P=0.037).
3.The mean peak serum K+ was NS 6.1 compared with PL 5.4 mmol (P=0.009).
4.16 Sixteen patients (64%) in the NS group required treatment for hyperkalaemia compared with 5 (21%) in the PL group (P=0.004).
5.Patients receiving NS were more acidaemic [pH 7.32 versus 7.39, P=0.001] & had higher serum chloride concentrations (107 vs 101mmol, P< 0.001) at the end of surgery.
6.No differences in the rate of DGF were seen.
7.Subjects receiving PL who did not require dialysis had a more reduction in serum creatinine on day 2 (P=0.04). Strengths
1.The fluid intervention was blinded & randomized (minimal allocation & selection bias).
2.Blinding avoided the potential for differences between groups in terms of management of electrolyte & acid–base disturbances attributable to physician awareness of the allocated fluid therapy.
3.It is the 1st fluid intervention study in DKD renal transplantation recipients to report renal outcomes at 1 week, 1, 3, 6, &12 months after trial fluid intervention. Limitations
1.Inadequate power to compare the effects of NS & PL on short- or long-term graft function & other post-op complications; this will require a larger, multicentre study.
2.It is uncertain whether the IS therapy contributed to the incidence of hyperkalaemia in each group. Conclusions Compared with PL, participants receiving NS had a greater incidence of hyperkalaemia & hyper-chloraemia& were more acidaemic. These biochemical differences were not associated with adverse clinical outcomes. ////////////////////////////////////////// 2.What is the evidence provided by this article? Level I (RCT)
Hadeel Badawi
2 years ago
NaCl 0.9% is potassium free and, and partly for this reason has been used as the current standard of care for IV fluid therapy for kidney transplantation. Administration of NS in KT is associated with hyperchloraemic metabolic acidosis, but the effect of (NS) on the risk of hyperkalaemia or postoperative graft function is uncertain.
Methods:
– Prospective, double-blinded randomized trial
-Compared NS with Plasma-Lyte 148VR (PL) given during surgery and for 48h after surgery in patients undergoing
deceased donor renal transplantation.
– Inclusion criteria: adult patients (age 18 yr) undergoing DD KT. – Exclusion criteria: preoperative hyperkalaemia >6.0mmol/L that was not corrected before transplantation,
pregnancy, chronic liver disease (liver function tests >1.5 times normal value), known allergic reaction to study solutions, and patients undergoing multi-organ transplantation. The primary outcome was hyperkalaemia within 48h after surgery, defined as K>=5.5mmol/l Secondary outcomes
were need for hyperkalaemia treatment, change in acid–base status, and graft function, and postoperative complications, and hospital length of stay.
Results:
25 subjects were randomized to NS and 24 to PL.
The incidence of hyperkalemia in the first 48h after surgery was higher in the NS group 80% vs 50% in the PL group.
The mean (SD) peak serum potassium was NS 6.1 compared with PL 5.4.
Medical management for hyperkalemia was instituted in 10 subjects in the NS group vs 7 subjects in the PL group
16 participants (64%) in the NS group required treatment for hyperkalemia compared with 5 (21%) in the PL group
Participants receiving NS were more academic and had higher serum chloride at the end of surgery.
No differences in the rate of delayed graft function were observed.
Subjects receiving PL who did not require dialysis had a greater reduction in creatinine on day 2.
The incidence of complications was similar between groups
Limitations:
-Single center.
– Small sample size
– Uncertain about the influence of the immunosuppressive therapy to hyperkalemia.
– Applicability on LKD need to be determine.
Strengths:
– RCT, therefore, minimal allocation and selection bias.
– Study extend to 48 hours post-operative period in contrast to other studies.
Conclusions:
Compared with PL, participants receiving NS during the surgery and for 48 hours postoperatively had a greater incidence of hyperkalemia and hyperchloremic acidosis.
These biochemical differences were not associated with adverse clinical outcomes.
Level of evidence: level 1
The study in favor the use of buffered crystalloid solutions for perioperative fluid management in patients undergoing DDKT, given the adverse metabolic profile associated with NS.
Keeping in mind, the availability of the solution and it price may influence the practice, if both are available use of PL is highly recommended.
That is a superb summary and analysis mentioning the strengths and limitations of this article. Ajay
Mohamed Saad
2 years ago
Effects of intraoperative and early postoperative normal saline or Plasma-Lyte 148VR on hyperkalemia in deceased donor renal transplantation: a double-blind randomized trial.
Hyperkalemia is considered on of the most common electrolyte disturbance post KTX and so 0.9 NaCl is the most common IV fluid used pre, in and postoperative as potassium free solution but now many clinical studies shown the deleterious effect of normal saline in acid-base and kidney function mainly due to Hyperchloremic acidosis that finally lead to hyperkalemia. Aim of this study:
Comparing the effects of intraoperative and early postoperative NS or acetate-buffered crystalloid solution (Plasma-Lyte 148) on hyperkalaemia, the need for
hyperkalaemia treatment, acid–base status, and graft function in patients receiving a deceased donor renal
transplant. Methods.
A double-blinded randomized trial, done Between September 2012 and April 2015, on 50 patients classified to 25 subjects were randomized to NS and 24 to PL.
compared NS with Plasma-Lyte 148VR (PL) given during surgery (which is minimally 2 L)and for 48h after surgery in patients undergoing deceased donor renal transplantation. The primary outcome was hyperkalaemia(ABOVE >5.5) within 48h after surgery. Secondary outcomes were need for hyperkalaemia treatment, change in acid–base status, and graft function. Results.
The first 48h period after surgery, there was a higher
Incidence of hyperkalaemia after NS (80%) than with PC (50%).
Thirteen subjects required dialyses for hyperkalaemia in the NS group vs four in the PL group.
Patients received intraoperative NS were more acideimc and hyperkalemic than those who received PL .
Effects on graft function shown no significant difference in the incidence of DGF was identified.
The incidence of complications was similar between groups and no 30 days mortality, 6 months and 1 yr intervals. Strengths.
-Blinded and randomized.
-Extended use of blinded fluids for 48 h after surgery was strictly adhered to in all participants.
-First fluid intervention study in deceased donor renal transplant with long term follow up. Limitation.
-Small sample size.
-Compare the effects of NS and PL on short- or long-term graft function and other postoperative complications not conclusive. Conclusion.
NS in deceased donor kidney transplantation recipients has deleterious effect during surgery and for 48h after surgery as Hyperchloremic acidosis and hyperkalemia comparing to PL but without adverse clinical outcomes. Level of evidence I.(Randomized controlled trial).
That is a superb summary and analysis mentioning the strengths and limitations of this article. Will you change your practice based on this article? Ajay
Thanks , prof
We do not have deceased kidney transplant program but our view regarding balanced solution is much changed specially post kidney transplant with living KTX
ISAAC BUSAYO ABIOLA
2 years ago
SUMMARY
Introduction
The incidence of hyperkalemia in kidney transplantation is about 25%-40% making it one of the most common complications with attendant side effect if urgent treatment is not deplored. To this end, many transplant centres resolved to use of potassium free fluid of which normal saline is the most used. However, 0.9% normal saline has been known to cause hyperchloremic metabolic acidosis which can eventually cause hyperkalemia in patient following kidney transplantation. This study was set out to see which of the fluid between the traditional normal saline and acetate buffered crystalloid solution (Plasma -Lyte 148)
Method
a prospective single randomized control trial
approval obtained and also informed consent from participant
all management team member were blinded to the use of the fluid during the surgery
about 2000ml of fluid were administered during the surgery
patients received maintenance fluid after the surgery according to urine output
primary outcome was the incidence of hyperkalemia within 48hours
secondary outcome is, treatment of hyperkalemia, DGF, requirement for post operative dialysis.
Results
50 patients were finally recruited for the diseased kidney transplantation out of the total of 70 done under the study year
25 participants on each half received normal saline and PL, although one participant from PL group was removed due to breach of protocol
there was a significant high incidence of hyperkalemia (80%) in the NS group compared to the PL (50%) withing 48 hours
64% of people in the NS group were treated for hyperkalemia compared to the PL group (21%)
the mean highest incidence of hyperkalemia was reported among the NS group
13 subjects in the NS group required dialysis for hyperkalemia compared to 4 in PL group
more fluids were administered during the intra-operation in the NS group
subject receiving NS has more acidosis and hyperchloremia during the intra op
the median hospital stay was found to be longer in the NS group
Limitations
small sample size
single center study
the uncertainty of the influence of immunosuppressives on hyperkalemia
Strengths of the study
is an RCT study
extending of use of the fluids beyond the intraoperative time
Conclusion
This study has substantiated the advantage of use of buffered Crystaloid solution over the traditional NS that is frost with a lot of complication like hyperkalemia, metabolic acidosis, and adverse clinical outcomes both intraoperatively and even till 48 hours after kidney transplantation in diseased donors
Thank you, Will you change your practice based on this article?
Mahmoud Wadi
2 years ago
IV. Effects of intraoperative and early postoperative normal saline or Plasma-Lyte – 148 on hyperkalaemia in deceased donor renal transplantation: a double-blind randomized trial
Administration of saline in renal transplantation is associated with hyperchloraemic metabolic acidosis, but can be risk of hyperkalaemia or postoperative graft function is uncertain.
Hyperkalaemia is a common complication of kidney transplantation, occurring in 25–40% of recipients.
The aims of perioperative fluid administration in deceased donor renal transplantation include maintenance of adequate kidney transplant perfusion and the avoidance of electrolyte and acid–base disturbances, including hyperkalaemia.
Methods
The trial was prospectively registered with the Australian New Zealand Clinical Trials between 2012 – 2015
Inclusion criteria included:
Adult patients (age more than 18 yr) undergoing deceased donor renal transplantation.
Exclusion criteria included :
Preoperative hyperkalaemia >6.0 mmol/l not corrected before transplantation.
Pregnancy.
Chronic liver disease (liver function tests >1.5 times normal value).
known allergic reaction to study solutions,
Patients undergoing multiorgan transplantation.
–Electrocardiography, pulse oximetry, capnography, blood pressure, urine output, and core body temperature were monitored.
Measurement of central venous pressure (CVP) was not used for the assessment of volume responsiveness .
The primary outcome was the incidence of hyperkalaemia within 48 h of surgery.
Secondary outcomes included hyperkalaemia during hospital admission, treatment for hyperkalaemia, requirement for postoperative dialysis, delayed graft function (DGF; hours to first dialysis after surgery, acid–base derangements), postoperative complications, and hospital length of stay.
Results
Twenty-five subjects were randomized to NS and 24 to PL. The incidence of hyperkalaemia in the first 48 h after surgery was higher in the NS group:-
20 patients (80%).
12 patients (50%) in the PL group.
The mean (SD) peak serum potassium was NS 6.1 (0.8) compared with PL 5.4 (0.9) mmol litre1 (P¼0.009).
Sixteen participants (64%) in the NS group required treatment for hyperkalaemia compared with five (21%) in the PL group.
Participants receiving NS were more MA and hyperchloremic
No differences in the rate of delayed graft function in all group.
Strengths and limitations
Blinded and randomized, and extended 48 hours postoperatively(strengths).
The study not compared the effects of NS and PL on short- or long-term graft function and other postoperative complications(limitation ).
Conclusions
Compared with PL, participants receiving NS had a greater incidence of hyperkalaemia and hyperchloraemia and were more acidaemic.
These biochemical differences were not associated with adverse clinical outcomes.
What is the evidence provided by this article?
The evidence level is 1
Thanks alot our Prof. Halawa
Certainly, after this article, I will be reconsidered, patients will be monitored and the required examinations will be performed for them.
Mohammed Abdallah
2 years ago
Summarise this article
Introduction
NS is associated with hypercholeremic metabolic acidosis and is the preferred solution in kidney transplantation
Effect of NS on hyperkalemia is not well studied
The aim of the study
A prospective double-blinded randomized trial in a deceased donor renal transplant comparing the effects of NS to PL intraoperatively and in the early posttransplant period
Materials and Methods
The study was conducted at one Hospital (2012-2015)
Exclusion criteria:
1. Preoperative hyperkalaemia >6.0mmol/L that was not corrected before transplantation
2. Pregnancy
3. Chronic liver disease (liver function tests >1.5 times normal value)
4. Known allergic reaction to study solutions
5. Patients undergoing multi-organ transplantation
Measurement of CVP was not used for the assessment of volume responsiveness
The primary outcome: hyperkalaemia within 48h of surgery
Secondary outcomes: hyperkalaemia during hospital admission, treatment for hyperkalaemia, requirement for postoperative dialysis, DGF (hours to first dialysis after surgery), acid–base derangements), postoperative complications, and hospital length of stay
Results
Forty nine deceased donors were randomized (25 allocated to NS and 24 to PL)
During the first 48h period after surgery, the incidence of hyperkalaemia was higher after NS (80%) than with Pl (50%)
64% of subjects were treated for hyperkalaemia after NS vs 21% after PL
The mean K concentrations were 6.1 after NS compared with 5.4 after PL
Medical management for hyperkalaemia was instituted in 10 subjects in the NS group vs 7 subjects in the PL group
Thirteen subjects required dialyses for hyperkalaemia in the NS group vs four in the PL group
Subjects receiving NS were more acidaemic (pH 7.32 vs 7.39) and had higher serum chloride concentrations (107vs 101mmol/L) at the end of surgery
No differences in the rate of DGF
Strength and limitations Strengths: blinded and randomized, and extended 48 hours postoperatively
Limitations: the study not compared the effects of NS and PL on short- or long-term graft func- tion and other postoperative complications
Conclusion
In deceased donor kidney transplant, use of NS was associated with hyperchloremic metabolic acidosis, more postoperative hyperkalemia and more needs of treatment of hyperkalemia when compared with PL
Owing to the serious consequences of these adverse effects, the study preferred use of mor physiologic solution in the perioperative period
What is the evidence provided by this article?
Level 1 (randomized trial)
– Summary Introduction
To maintain adequate kidney transplant perfusion and avoid hyperkalaemia , perioperative fluid is administrated in deceased donor renal transplantation.
0.9% sodium chloride being K free is used for kidney transplantation IV fluid therapy but it can cause hyperchloremic acidosis which can lead to hyperkalaemia. Methods
This a double blinded randomized trial assessing the effects of intraoperative and early postoperative NS versus Plasma-Lyte intake on hyperkalaemia as the primary outcome , and secondary outcomes including the need for hyperkalaemia treatment, acid–base status,and graft function ,postoperative complications ,and duration of the hospital stay in recipients of deceased donor renal transplant. Results The primary outcome :Hyperkalaemia within 48 h had higher incidence in NS group compared to Plasma Lyte group.
Also higher number of hyperkalaemia cases and higher number of cases requiring treatment was detected with NS group more than PL group. Intraoperative variables
The intraoperative K level and the number of cases requiring hyperkalaemia treatment were higher in NS group as well .
Acidosis and hyperchloremia was higher in NS group.
Intraoperative fluid ,blood and vasoactive medications used was similar between the 2 groups.
Number of cases of PL group producing urine was more than NS group.
The median cold ischemia time in NS group time was
11.8 h and in the PL group 10.8 h.
Warm ischemia time was similar between both groups. Delayed graft function and complications
PL had lower potassium values than NS group,5 cases treated with NS needed hyperkalaemia treatment while in PL group not a single case needed hyperkalaemia therapy.
No cases in both group required dialysis for management of hyperkalaemia.
DGF was similar in both groups, PL group cases who did not require dialysis had a more rapid decrease in creatinine on day 2 , with better eGFR at 48 h.
Complications incidence was similar in the 2 groups.
Renal function markers taken at specific intervals revealed improvement in both groups. Discussion
NS group were more acidaemic during surgery, and after surgery and had higher serum K and a greater incidence of hyperkalaemia and more interventions to treat hyperkalemia 48 h post surgery than PL group.
DGF was similar in both groups.
Potura et al findings were in concordance with this study regarding lack of significance between the 2 groups in the intraoperative incidence of hyperkalaemia.
Hyperkalemia in NS group can be explained by high Cl content and low PH in NS.
Other studies conducted on living donors reached the same conclusion which is in spite that NS is associated with hyperchloremia that leads to renal impairment ,it doesnot lead to major hazardous renal outcomes in transplant recipients.
Modest advantage of PL over NS was declared by this study concerning the renal outcomes.
A statistically significant increase in CRR was noticed in the PL group and better KeGFR at 48 h.
Dialysis within 7 days post-transplant failed to account due to the severity and duration of DGF; dialysis for hyperkalaemia and fluid overload with good graft function; and poor graft function where dialysis is not needed.
DGF leads to poor renal outcomes apart from dialysis need or not.
The higher DGF rate can be due to donor
time to death, cold perfusion pharmacological treatment, or ECD, or variable decisions for initiation of dialysis .
PL can be better than NS in recipients of deceased donor kidney transplants because NS can cause hyperchloremic metabolic acidosis that in turn increases hyperkalaemia incidence more than PL with lower Cl concentration. Strengths
Being a blinded randomized trial therefore avoiding any possible bias.
All previous studies involved intraoperative periods but this study included follow up of postoperative period.
This is the first study conducted on deceased donor renal transplant recipients accessing the effect of fluid therapy on report renal outcomes.
This study detected significantly higher hyperkalaemia in PL group in donation after brain death recipients when compared with donation after cardiac death recipients followed by reduction of the hyperkalaemia after surgery ,24h and 48 h afterwards. Limitations
Insufficient comparison of the 2 fluids effect on short and long term outcome regarding graft function as this will need a bigger multicentric trial.
The DGF rate in this study was high, therefore reducing the generalizability of the findings.
Sample size was small indicating type 1 error. Conclusion
NS use lead to hyperchloraemic acidosis and postoperative hyperkalaemia, with greater use of medical interventions to treat serum potassium but it did not cause hazardous clinical outcomes.
The current study favours the use of buffered crystalloid solutions for perioperative fluid replacement in deceased donor renal transplantation recipients .
Thank you, Will you change your practice based on this article?
Weam Elnazer
2 years ago
Introduction;
In renal transplantation, the administration of salt is linked to a condition known as hyperchloraemic metabolic acidosis; however, the impact of normal saline (NS) on the risk of hyperkalemia or on postoperative graft function is unknown.
Methods:
In patients having kidney transplantation from dead donors, we compared Plasma-Lyte 148VR (PL) and Normal Saline (NS), both of which were administered during surgery and for 48 hours following surgery. The hyperkalemia that occurred within 48 hours after surgery was the main outcome. The requirement for therapy of hyperkalemia, changes in acid-base status, and graft function were secondary outcomes.
Results:
Random assignment of 25 patients to the NS group and 24 individuals to the PL group was performed. In the first 48 hours following surgery, the incidence of hyperkalemia was greater in the NS group: (at 80%) vs. (50%) in the PL group. Peak serum potassium was found to be NS 6.1 (0.8) mmol litre1 on average, which is significantly higher than PL 5.4 (0.9) mmol litre1.
In the NS group, 64%, needed therapy for hyperkalemia. In the PL group, only 21%, needed treatment.
At the conclusion of surgery, participants who were given NS had a pH that was more acidic and a higher serum chloride content (107 vs 101 mmol litre1] than those who were given the placebo.
It was shown that there was no discernible difference in the rate of delayed graft function. On day 2, the subjects who received PL and did not need to undergo dialysis showed a larger drop in their creatinine levels.
Strength:
-Blinding and randomization reduced allocation and selection bias.
-Blinding minimized disparities in electrolyte and acid-base disturbance treatment across groups due to physician knowledge of fluid therapy.
-This is the first research to evaluate renal outcomes 1 week, 1, 3, 6, and 12 months following fluid intervention in dead donor renal transplant patients.
Limitation :
-We don’t know whether immunosuppression caused hyperkalemia in either group.
– inadequate power to compare the effects of NS and PL on short- or long-term graft function.
-Small number and Single-center trial.
-High DGF rates in this research may reduce generalizability.
Conclusion:
-In kidney transplant patients receiving PL or NS during surgery and for 48 h after surgery, NS was linked with hyperchloraemic acidosis and more frequent postoperative hyperkalemia, requiring more medical interventions to manage blood potassium. Biochemical variations didn’t affect clinical results.
Thank you, Will you change your practice based on this article?
Sherif Yusuf
2 years ago
Hyperkalemia is a common and serious complication occurring in transplantation
There is a concern of hyperkalemia that can occur with large infusion of potassium containing IV fluid (PL); 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 controlled (level of evidence II) study evaluating 49 deceased renal transplant recipients regarding the effect of intra and post -operative normal saline (25 patients) versus Plasmalyte (24 patients) on serum the incidence of DGF, potassium, acid base balance and the need for treatment of hyperkalemia 48 hours after transplantation
The results
No increase in the incidence of DGF in both groups, but PL goup ha significant lower creatinine level than normal saline group
Hyperkalemia was more frequent in normal saline group (80% versus 50% in PL group) with higher mean of serum potassium in normal, saline group (6.1 compared to 5.4 mmol/ L in PL group)
Hyperkalemia was more frequently treated in normal, saline group compared to PL group 64% versus 21% respectively
Metabolic acidosis were more common in normal saline group with pH 7.32 versus 7.39 in PL group
Conclusions.
PL was more safe and associated with lower incidence of hyperkalemia and metabolic acidosis compared to normal saline but both had no effect on graft function
Thank you, Will you change your practice based on this article?
Ban Mezher
2 years ago
Hyperkalemia can occurs in 25-40% of kidney transplant recipients.
Fluid infusion used widely peri-operatively to maintain perfusion to transplanted kidneys and to avoid electrolytes & acid base disturbance.
NS found to be associated with hyperchloremic acidosis leading to increase risk of hyperkalemia.
Method:
Study include 50 DDT( 25 receive NS & 25 receive PL) between Sep.2012-Apr.2015.
Exclusion criteria: preoperative serum potassium > or equal 6 meq/l, pregnancy, CLD, known allergy to used solution & patients with multiple transplantation.
All patients receive trial of 2L of fluid during surgery.
ECG, pulse oximetry, capengraphy, blood pressure, UOP & core body temperature were monitored.
CVP not used due to poor relationship between CVP & blood volume.
After surgery all patients receive trial of fluid at rate of UOP+30ml.
Maintenance immunosuppression include tacrolimus, MMF & steroid, induction with basiliximab.
All patients CDC result was negative for both B & T cells.
Patients with high DSA receive PE during surgery.
Primary outcome of study was incidence of hyperkalemia(>5.5meq/L) 48 hours of surgery.
Secondary outcome include: hyperkalemia during hospital admission, treatment of hyperkalemia, post operative dialysis, DGF, post operative complication, & hospital length stay.
Post transplant graft function assessed with CRR on post operative day 2 & KeGFR.
Renal perfusion assessed by Tc99MAG3 & doppler US at day 1 post operative.
Result & discussion:
Patients receive NS were more acidemic during surgery & higher serum potassium after surgery with greater risk of hyperkalemia compared to PL solution.
Higher rate of hyperkalemia treatment in first 48 hours in patients receive NS.
No significant difference in DGF rate between 2 groups.
Lower UOP in patients use NS & this may result from using of lower volume of NS in total during study time.
PL group have higher CRR & better KeGFR at 48 hours post operation.
PL found to be superior than NS in recipient of DDT on both physiological & biochemical ground.
Strength of the study:
Low bias due to use blind & randomization.
Avoidance of difference between group regarding management of electrolytes & acid base disturbance.
Extend blind randomization to 48 hours post operation.
Fluid intervention in DDT that report renal outcome at 1week, 1,3,6 & 12 months .
Limitations:
Inadequate power for NS & PL effect on short & long term graft function & other post operative complications.
High DGF rate which can limit the generalizability of finding.
Hi Dr Ben, That is a superb summary and analysis mentioning the strengths and limitations of this article. Will you change your practice based on this article? Ajay
Ben Lomatayo
2 years ago
Introduction;
Hyperkalemia is potential complication following deceased kidney transplantation
IV saline is well known to be associated with hyperchloremic metabolic acidosis but it is not known whether it can cause hyperkalemia nor postoperative graft dysfunction
Methodology;
This was RCT which compared saline with plasma-Lyte 148 (PL) administered during and 48 hours postoperatively in deceased donor transplantation
Twenty-five patients were randomized to saline and 24 to PL
The primary outcome was hyperkaelmia within 48 hours after surgery
Results;
Twenty patents in saline group developed hyperkaemia (80%)
Twelve patients in PL had hyperkaemia(50%)
The mean peak K was 6.1(0.8)in saline group compared with 5.4(0.9) in PL group
Sixteen patients(64%) in saline group were treated for their hyperkalemia compared to five (21%) in PL group
Saline group had more of hyperchloremic metabolic acidosis
There were no differences in DGF between the two group
In summary; the saline group had more hyperkalemia and hyperchoremic metabolic acidosis versus PL group. How ever, these difference had no effect on the allograft outcome.
Thank you, All
Will you change your practice based on this article?
No one mentioned the price difference between the 2 solutions?
plasmalytes fluid is more physiological compared to isotonic saline, with less chloride and less sodium but potassium 5mmol/l, magnesium 3mmol/l, calcium 1.5mmol, and more cost, $12 /1liter of osmolytes compared to$2 /liter for isotonic saline and $4 / l for RL
so it is a more costly fluid but more physiologically balanced IVF
I may not use NS, if PL is available I may use it.
PL is more expensive but there may be cost effectiveness in some patients.
in our practise we use normal saline and is more cheaper than PL
I think the availability and the cost can limit using plasma Lyte; of course, if it is available, I’ll prefer using it.
The protocol in our transplant unit involves using Plasma-Lyte.
Plasma-Lyte is costlier than normal saline, but the overall benefits with a balanced solution like Plasma-Lyte tilt the balance towards its use over normal saline.
I may use PL instead of NS if it is available. I am not too sure about the exact cost but PL may be more expensive.
PL is more expensive than NS. But it is more physiologic than NS.
INTRODUCTION:
Hyperkalemia is a common complication of kidney transplantation, occurring in 25–40% of recipients. Although the outcomes of severe postoperative hyperkalemia in kidney transplantation are not well studied, adverse consequences of hyperkalemia in this setting include significant hemodynamic and neurological effects that result in respiratory paralysis or cardiac arrest if not treated urgently.
Administration of saline in renal transplantation is associated with hyperchloremic metabolic acidosis, but the effect of normal saline (NS) on the risk of hyperkalemia or postoperative graft function is uncertain.
Methods.
A double-blinded randomized trial comparing the effects of intraoperative and early postoperative NS or acetate-buffered crystalloid solution (Plasma-Lyte 148 on hyperkalemia, the need for hyperkalemia treatment, acid–base status, and graft function in patients
Compared NS with Plasma-Lyte 148VR (PL) given during surgery and for 48 h after surgery in patients undergoing deceased donor renal transplantation.
Outcome:
The primary outcome was hyperkalemia within 48 h after surgery. Secondary outcomes were need for hyperkalemia treatment, change in acid–base status, and graft function.
Results.
Between September 2012 and April 2015, the trial was conducted at Austin Hospital, a university teaching hospital in Melbourne with expertise in renal transplantation.
Twenty-five subjects were randomized to NS and 24 to PL. The incidence of hyperkalemia in the first 48 h after surgery was higher in the NS group; 20 patients (80%) vs 12 patients (50%) in the PL group (risk difference: 0.3; 95% confidence interval: 0.05, 0.55; P¼0.037).
The mean (SD) peak serum potassium was NS 6.1 (0.8) compared with PL 5.4 (0.9) mmol litre1 (P¼0.009). Sixteen participants (64%) in the NS group required treatment for hyperkalemia compared with five (21%) in the PL group (P¼0.004). Participants receiving NS were more acidemia [pH 7.32 (0.06) vs 7.39 (0.05), P¼0.001] and had higher serum chloride concentrations (107 vs 101 mmol litre1.
Conclusions.
Compared with PL, participants receiving NS had a greater incidence of hyperkalemia and hyperchloremia and were more acidemia. These biochemical differences were not associated with adverse clinical outcome.
level of evidence 1
Methods
The trial was prospectively registered with the Australian New Zealand Clinical Trials Registry.
Between September 2012 and April 2015,
the trial was conducted at Austin Hospital, in Melbourne
Inclusion criteria included
adult patients (age 18yr)
undergoing deceased donor RT.
1. Exclusion criteria included preoperative hyperkalaemia >6.0mmol litre
2. that was not corrected before transplantation,
3. pregnancy,
4. chronic liver disease (liver function tests >1.5 times normal value),
5. known allergic reaction to study solutions,
6. and patients undergoing multi-organ transplantation.
A statistician generated a computerised randomization sequence of 50 allocation codes, 25 for each group.
Independent research staff sealed the allocation codes into sequentially numbered opaque envelopes.
The sequence was decoded after data analysis.
The study was completely blinded to the trial fluid intervention.
Baxter Healthcare provided either NS or PL as 1000ml identical blinded carrier solution containers.
The PL contained
1. sodium (140mmol litre1),
2. potassium (5mmol litre1),
3. magnesium (3mmol litre1),
4. chloride (98 mmol litre1),
5. acetate (27mmol litre1),
6. and gluconate (23 mmol litre1).
The NS contained
• sodium (154mmol litre1)
• and chloride (154mmol litre1).
Immediately upon arrival in the operating room, subjects were randomized.
After preoxygenation, general anaesthesia plan was similar for patients
All participants were prescribed a minimum of 2000ml trial fluid during surgery
Electrocardiography, pulse oximetry, capnography, blood pressure, urine output, and core body temperature were monitored.
Use of invasive arterial blood pressure monitoring was at the discretion of the anaesthetist.
Measurement of (CVP) was not used
Other advanced haemodynamic monitoring devices were not used.
Mean arterial pressure was maintained within 20% of the baseline preoperative value and supported with vasoactive therapy where appropriate.
Blood was transfused for haemoglobin <80g litre1,or<90g litre1 when further bleeding was anticipated.
During surgery, the patient’s temperature was kept constant at 36C
and arterial partial pressure of CO2 was maintained at 35–40mm Hg.
Furosemide (125mg i.v.) was administered 5min before reperfusion
. Any additional fluid boluses of trial crystalloid solution could be administered to any patient if volume supplementation was required.
After 48h the study fluid ceased, and the rate and type of any further fluid was at the discretion of the treating clinician.
Immunosuppression was according to the local standard of care, with a regimen of tacrolimus , mycophenolate prednisolone, and basiliximab commenced before surgery and continued throughout.
Perioperative plasma exchange was used for higher immunological risk patients
The primary outcome was the incidence of hyperkalaemia within 48h of surgery.
The highest serum potassium value was also recorded, as was the number of subjects requiring treatment for hyperkalaemia.
Secondary outcomes included hyperkalaemia during hospital admission, treatment for hyperkalaemia, requirement for postoperative dialysis, delayed graft function), postoperative complications, and hospital length of stay.
Treatment for hyperkalaemia :binding resins; insulin, glucose, or both; calcium gluconate i.v.; and dialysis.
Renal perfusion was assessed with (Tc99m MAG3) nuclear medicine scan and Doppler ultrasound performed on postoperative day 1.
Potassium concentrations and all other biochemistry parameters were sampled
• before surgery,
• immediately on arrival at the postoperative anaesthesia recovery unit,
• and at 24 and 48h after surgery.
Renal function (both serum creatinine and estimated GFR ) was also measured at 1week, 1, 3, 6, and 12months post-transplantation.
Statistical analysis Sample size calculations were based on a pilot study from 44 patients receiving renal transplants in our institution
they received ethics approval to recruit 50 subjects.
Statistical analysis was performed using commercial statistical software STATA/IC v.13
Fisher’s exact test was used to investigate differences between groups in categorical outcomes, including the primary outcome of hyperkalaemia (serum potassium >5.5mmol litre1) in the first 48h after surgery. A two tailed P-value of <0.05 was used as a threshold for statistical significance.
The study was reported in accordance with the CONSORTguidelines for reporting randomized trials.
Results
• During the study period, 70 patients underwent deceased donor renal transplantation.
• Thirteen patents were excluded .
• Fifty-seven patients provided informed consent.
• Seven participants did not proceed to transplant because the donor kidney was considered unsuitable.
• Twenty-five subjects were randomized to NS and 25 to PL.
• One subject in the PL group was excluded because of a protocol violation
baseline characteristics were similar with respect to preoperative biochemistry, age, cause of renal failure, donor age, and proportion of kidney donations after circulatory and brain death.
Primary outcome:
hyperkalaemia within 48h ,
there was a higher incidence of hyperkalaemia after NS (80%) than with PC [50%; risk difference: 0.3; 95% confidence interval (CI): 0.05, 0.55; P¼0.04).
Likewise, 64% of subjects were treated for hyperkalaemia after NS vs 21% after PL (risk difference: 0.43; 95% CI: 0.18, 0.68; P¼0.004;).
In the first 48h after surgery, the mean (SD) highest potassium concentrations were 6.1 (0.8)mmol litre1 after NS compared with 5.4 (0.9)mmol litre1 after PL (mean difference: 0.65; 95% CI: 1.12, 0.17; P¼0.009).
Medical management for hyperkalaemia with insulin, dextrose, or both, resonium, or calcium gluconate was instituted in 10 subjects in the NS group vs seven subjects in the PL group (P¼0.55).
Thirteen subjects required dialyses for hyperkalaemia in the NS group vs four in the PL group (P¼0.02).
Intraoperative variables
Fifteen subjects receiving NS and 19 receiving PL had arterial blood gases checked during surgery.
The peak mean (SD) potassium value was 5.4 (1.1)mmol litre1 in the NS group compared with 4.9 (0.8)mmol litre1 in the PL group (mean difference: 0.42; 95% CI: 1.13, 0.28; P¼0.23).
Four subjects were treated for hyperkalaemia with insulin and dextrose in the NS group vs one in the PL group (P¼0.27)
The median (IQR) volume of intraoperative trial fluid administered in NS group was 2500 (2000, 3000)ml compared with 3000 (2000, 3000)ml in the PL group (P¼0.92).
Additional intraoperative fluid, blood, and use of vasoactive medications were similar.
Subjects receiving NS were more acidaemic [mean (SD) pH 7.32 (0.06) vs 7.39 (0.05) (pH normal range: 7.35–7.45); P¼0.002] and hyperchloraemic [median (IQR) 107 (105, 110) vs 101 (99.8, 103.3)mmol litre1; (normal range for chloride: 98–107mmol litre1); (P<0.01)] compared with PL.
Eight subjects (32%) produced urine in the NS group vs 11 (46%) in the PL group (P¼0.39).
The median (IQR) cold ischaemic time in NS group time was 11.8 (6.3; 14.3)h and in the PL group 10.8 (9.8, 13.2)h (WilcoxonMann–Whitney P¼0.74).
Likewise, there were no differences in warm ischaemic time between the NS and PL groups; 34 (27, 41) vs 33 (24, 43)min (Wilcoxon–Mann–Whitney P¼0.56).
Longitudinal analysis, delayed graft function, and complications
For any given time point, subjects receiving PL had lower potassium values by an average of 0.34mmol litre1 (95% CI: 0.63, 0.05; P¼0.02) compared with NS.
Medical management for hyperkalaemia with insulin, dextrose, or both, resonium, or calcium gluconate was instituted in five subjects in the NS group and no subjects in the PL group
There was no requirement for dialysis to manage hyperkalaemia in either group.
No significant difference in the incidence of DGF
The incidence of complications was similar between groups
The median (IQR) length of hospital stay was 6.5 (6, 13.2) days after NS and 7.1 (6, 10.4) days after PL (P¼0.18).
There was no 30day mortality.
Follow-up blood samples obtained at 1week, 1, 3, an 6months and 1yr intervals showed a similar improvement in markers of renal function over time in both groups
Discussion
Relationship to previous findings
Potura and colleagues recently investigated the incidence of hyperkalaemia in the context of deceased donor renal transplantation.
Similar to our findings, they reported no significant difference in the incidence of intraoperative hyperkalaemia in recipients receiving open-label NS or an acetate-buffered solution, and also reported significant intraoperative metabolic acidosis and hyperchloraemia.
In contrast to the present study, however, they continued open-label trial fluid for only 4–5h after surgery, whereas we continued blinded fluids for 48h postsurgery,
Several studies in live donor kidney transplant recipients have also reported an increased incidence of metabolic acidosis in patients receiving NS compared with balanced crystalloid solutions.
Similar to our study, some of these groups also evaluated renal function as a key outcome.
Although iatrogenic hyperchloraemia is associated with renal impairment and reduction of renal cortical perfusion in both animal and human studies,this has not consistently translated into major deleterious renal functional outcomes for renal transplant recipients.
Despite the limited power of the present study, we observed a modest efficacy signal towards better renal outcomes in the PL group than the NS group.
Strengths
• The fluid intervention was blinded and randomized.
• The extended use of blinded fluids for 48 h after surgery was strictly adhered to in all participants, with electronic medical recording allowing a detailed and accurate of fluid use and fluid balances, reinforcing the internal validity of the key out come variables reported.
• Previous studies comparing balanced fluids with NS in kidney transplantation were largely restricted to the intraoperative period and may not have delivered a sufficient volume of trial fluids to determine the full effect of fluid choice.
• This is also the first fluid intervention study in deceased donor renal transplant recipients to report renal outcome at 1week, and 12 months after trial fluid intervention.
Limitations of the study include
inadequate power to compare the effects of NS and PL on short-or long-term graft function and other postoperative complications; addressing this will require a larger, multicenter study.
uncertain whether the immunosuppressive therapy contributed to the incidence of hyperkalaemia in each group; we consider this unlikely because all participants received the same immunosuppressive protocol.
The rate of DGF in the present study was high, possibly reducing the generalize ability of the findings; however, this reinforces the relevance of the results to patients a thigh risk of poor graft function and associated hyperkaliemia.
Level 1
We need more larger studies. However, these solutions are more similar to plasma components and less association with hyperkalemia and acidosis.
If they are available, it will be better to use them
Introduction: Hyperkalaemia is a common complication of kidney transplantation, occurring in 25–40% of recipients. Despite the preferential use of NS in renal transplantation, previous studies in live donor and deceased donor renal transplant recipients reported that NS causes hyperchloremic metabolic acidosis, which can increase the risk of hyperkalaemia.
Method: this is a a double-blinded randomized trial comparing the effects of intraoperative and early postoperative NS or acetate-buffered crystalloid solution (Plasma-Lyte ). Twenty-five subjects were randomized to NS and 24 to PL.
All participants were prescribed a minimum of 2000 ml trial fluid during surgery, Electrocardiography, pulse oximetry, capnography, blood pressure, urine output, and core body temperature were monitored. After surgery, all subjects received a maintenance infusion of trial fluid, with a starting rate of the previous hour’s urine output plus 30 ml/hr.
The primary outcome was the incidence of hyperkalaemia within 48 h of surgery. Hyperkalaemia was defined as potassium >5.5 mmol litre.
Secondary outcomes included hyperkalaemia during hospital admission, treatment for hyperkalaemia, requirement for postoperative dialysis, delayed graft function (DGF; hours to first dialysis after surgery, acid–base derangements), postoperative complications, and hospital length of stay.
Results: During the first 48 h period after surgery, there was a higher incidence of hyperkalaemia after NS (80%) than with PC [50%; risk difference: 0.3]
Subjects receiving NS were more acidaemic [mean (SD) pH 7.32 (0.06) vs 7.39 (0.05) (pH normal range: 7.35–7.45); P¼0.002] and hyperchloraemic [median (IQR) 107 (105, 110) vs 101 (99.8, 103.3) mmol litre; P<0.01)]
Medical management for hyperkalaemia were given in five subjects in the NS group and no subjects in the PL group. There was no requirement for dialysis to manage hyperkalaemia in either group. Finally, although subjects in the PL group who did not receive dialysis had a greater CRR on day 2, there was no significant difference in the rate of DGF
Conclusion: Compared with PL, subjects receiving NS were more acidaemic during surgery, and after surgery had higher serum potassium and a greater incidence of hyperkalaemia. Moreover, there was a higher rate of interventions to correct hyperkalaemia in the first 48 h after surgery.
Strengths and limitations The fluid intervention was blinded and randomized, thus minimizing allocation and selection bias.
Limitations of the study include inadequate power to compare the effects of NS and PL on short- or long-term graft function and other postoperative complications; addressing this will require a larger, multicentre study.
level of evidence 1
Hyperkalaemia is a common and potentially severe complication of cadaveric kidney transplantation.
• Normal saline is commonly used as a potassium-free i.v. fluid therapy, but can cause hyperchloraemic acido- sis and subsequent hyperkalaemia.
Methods:
They compared NS with Plasma-Lyte 148VR (PL) given during surgery and for 48 h after surgery in patients undergoing deceased donor renal transplantation. The primary outcome was hyperkalaemia within 48 h after surgery. Secondary out- comes were need for hyperkalaemia treatment, change in acid–base status, and graft function
Conclusion: hyperkalemia was more in NS group but with no major adverse outcomes
If available PL I will use but I can also manage with NS with close observation
Level of evidence:1
The complication of hyperkalemia after cadaveric kidney transplantation occurs in 25-40% of patients. As normal saline is a potassium free solution, usually is used as the preferred fluid for kidney transplantation, but it causes hyperchloremic metabolic acidosis and is associated with the risk of hyperkalemia. So, in this study a blinded randomized trial was performed and compared the effects of NS with Plasma-Lyte 148 in deceased donor transplantation. Plasma-Lyte contains sodium (140 mmol/L), potassium (5mmol/L), magnesium (3 mmol/L), chloride (98 mmol/L, acetate (27 mmol/ L) and gluconate (23 mmol/L). Whereas NS contains sodium 154 mmol/L and chloride 154 mmol/L. Twenty- five recipients were placed in NS group and 24 in PL group. Twenty patients in NS group vs 12 patients in PL group had hyperkalemia during 48 h after transplantation. Sixteen patients in NS group vs no patient in PL group received hyperkalemia treatment. NS group had more acidosis and higher serum chloride concentration and this difference was significant. But there was no significant difference regarding DGF or other complications. The strength of study was its design as double blinded RCT and the first study in deceased donor transplantation. Limitation of this study was its low power because of small number of participants. So, this study indicates use of balanced crystalloid solutions for deceased donor transplantation.
The level of evidence is 1.
Comparing post deceased donors kidney transplantations fluid management with normal saline and balanced solution Plasmalyte, In order to address the prevalence of hyperkalemia post operatively or the need for treatment of hyperkalemia within 48 hours post transplanttion.
Other targets were metabolic acidosis and graft function.
25 recipients were managed with normal saline and 24 with Plasmalyte solution. for 48 hours post transplantation .
surprisingly 80% in the normal saline cohort developed hyperklemia vs 50 % in the other group.
While 65% of hyperkalemic required management for hyperkalemia,21% in Plasmalyte required treatment.
Hyperchloremia was more prevalent as well as acidosis were more prevalent in normal saline group than Plasmalyte, However , clinical outcome didnot adversly affected by the noted changes.
Its a prospective randomized study with level of evidence 1
25–40% of kidney transplant patients develop hyperkalemia. If not treated immediately, hyperkalemia can induce respiratory paralysis and cardiac death. Deceased donor renal transplantation fluids are chosen to preserve kidney transplant perfusion and minimize acid-base and electrolyte abnormalities. The kidney transplantation fluid of choice is potassium-free normal saline (NS).
NS induces hyperchloremic metabolic acidosis and hyperkalemia. This study compared the effects of fluids on hyperkalemia, therapy, acid-base status, and graft function in deceased donor renal transplant patients.
Methodology
Austin Hospital in Melbourne, Australia, hosted the trial from September 2012 to April 2015. It includes adults receiving dead donor kidney transplantation. Preoperative hyperkalemia of more than 6.0 mmol/L that was not treated before surgery, chronic liver illness, known allergic responses to study solutions, and multi-organ transplantation were eliminated.
After consenting, patients were randomly divided into two groups. Participants, anesthetists, surgeons, nephrologists, and nurses were blinded to the trial fluid intervention. Plasma-Lyte 148 (PL) contains sodium, potassium, magnesium, chloride, acetate, and gluconate. NS containes 154 mmol/L sodium and chloride. Surgery patients received at least 2000 mL of trail fluid. Depending on the procedure, the anesthesiologist controlled fluid administration. Electrocardiography, pulse oximetry, capnography, blood pressure, urine output, and core body temperature were measured. Patients got trail fluid maintenance after the operation. protocol required immunosuppression.
Hyperkalemia (>5.5 mmol/L potassium) within 48 hours of surgery was the main outcome.
Secondary results included hospitalization, hyperkalemia treatment, Post-operative dialysis, incidence of DGF
Results
The research included 70 deceased donor kidney transplants. 13 were eliminated. 57 consented. The donor kidney proved unsuitable for 7 people. 25 participants were randomized to NS and 25 to PL.
NS patients had more hyperkalemia in the first 48 hours after surgery than PL patients. NS treated 64% of patients for hyperkalemia, while PL treated 21%. The NS group had 6.1 mmol/L potassium, while the PL group had 5.4. 13 NS patients and 4 PL patients needed dialysis.
NS and PL groups had median intraoperative trial fluid volumes of 2500ml and 3000ml, respectively. NS patients were more acidic than PL patients. 8 NS and 11 PL patients generated urine. The median operation time was 2.8 hours for NS and 3.0 hours for PL. Both groups had comparable difficulties. NS and PL had a median stay of 6.5 and 7.1 days, respectively.
Discussion
NS patients were more acidemic following surgery, had higher potassium levels, and had more hyperkalemia and hyperkalemia treatments than PL patients. DGF was unaffected.
NS also increases metabolic acidosis in living donor renal transplantation patients. Renal function indicators were likewise the same. Hyperchloremic metabolic acidosis does not worsen renal function in renal transplant patients.
NS worsens hyperchloremic metabolic acidosis and hyperkalemia biochemically compared to PL. These data show that balanced solution hyperkalemia problems must be addressed.
Study strengths:
Randomized blinded trial design
Post-surgery blinding increased the study’s validity.
The first fluid intervention trial in deceased donor renal transplantation followed renal functioning for 12 months.
Study limitations:
Hyperkalemia caused by immunosuppression was not considered.
DGF was high.
Small sample
Hyperkalemia’s cause is unclear
Conclusion
Compared to PL, NS had hyperchloremic metabolic acidosis and hyperkalemia that required correction during deceased donor kidney transplantation. They did not affect clinical results. In cadaveric transplants, PL is safer than NS. These conclusions require broader population investigations.
According to last few articles and professor lecture we have changed out protocols as plasmalytes fluid is more physiological and less associated hyperkalemia, and metabolic acidosis. Here the prices are almost the same.
The common myth about use of normal saline in kidney transplant patients is that it does not cause hyperkalemia because it has zero K content.The fact that normal saline does cause hyperchloremic metabolic acidosis and can induce hyperkalemia has been looked in this double blinded randomized trial done in deceased donor transplant patients.
Normal saline was compared with plasma -Lyte 148.
The PL contained sodium (140 mmol litre), potassium (5 mmol litre), magnesium (3 mmol litre), chloride (98 mmol litre), acetate (27mmol litre), and gluconate (23 mmol litre). The NS contained sodium (154 mmol litre) and chloride (154 mmol litre)
Methods
They compared NS with Plasma-Lyte 148VR (PL) given during surgery and for 48 h after surgery in patients undergoing deceased donor renal transplantation.
The primary outcome was hyperkalaemia within 48 h after surgery. Secondary outcomes were need for hyperkalaemia treatment, change in acid–base status, and graft function.
RESULTS
Twenty-five subjects were randomized to NS and 24 to PL.
The incidence of hyperkalaemia in the first 48 h after surgery was higher in the NS group; 20 patients (80%) vs 12 patients (50%) in the PL group (risk difference: 0.3; 95% confidence inter- val: 0.05, 0.55; P1⁄40.037).
The mean (SD) peak serum potassium was NS 6.1 (0.8) compared with PL 5.4 (0.9) mmol litre.(P=0.009)
Sixteen participants (64%) in the NS group required treatment for hyperkalaemia compared with five (21%) in the PL group (P1⁄40.004).
Participants receiving NS were more acidaemic [pH 7.32 (0.06) vs 7.39 (0.05), P1⁄40.001] and had higher serum chloride concentrations (107 vs 101 mmol litre1, P<0.001) at the end of surgery.
No differences in the rate of delayed graft function were observed. Subjects receiving PL who did not require dialysis had a greater reduction in creatinine on day 2 (P1⁄40.04).
Conclusions. Compared with PL, participants receiving NS had a greater incidence of hyperkalaemia and hyperchloraemia and were more acidaemic. These biochemical differences were not associated with adverse clinical outcomes.
Level of evidence 1
In our practice we r using normal saline but if PL is available we can prefer it over saline
High potassium is one of the complications that are about 25-40 % present post-kidney transplant. Hyperkalaemia can cause neurological adverse effects, cardiovascular effects, respiratory effects, and hemodynamic effects. The fluid that is used during transplant that is cadaveric transplant is to ensure there is good renal perfusion and to prevent complications like disequilibrium of acid-base and electrolytes. NS itself does not contain high K but as such, it can be the right choice in fluid selection it does cause metabolic acidosis and as a result high K.
The aim of this study is to compare the effects of fluids on high K and treatment is high K, the acid-base status, and graft response.
The study included adult patients at age 18 and above.
The study excludes pre-op high K greater than 6.0, not corrected pre-transplant, liver disease, pregnancy, multi-organ transplant, and anyone allergic to any of the solutions.
Methods:
1) The study was conducted at Austin Hospital in Melbourne, Australia from September 2012 to April 2015.
2) Patients were consented and placed in randomized groups.
3) The two solutions used were Plasma-Lyte and NS
4) Fluid used was a minimum of 2000 cc during the surgery.
5) Vitals were monitored
6) Immunosuppression was given as protocol.
Study strength:
1) The two groups were well controlled and matched and biasness was reduced
2) There were proper protocols given and adhere to.
3) The first study addressed intervention and its outcome on the different intervals of FU from 1,2,3,6 and 12 months.
The limitation of the study:
1) The sample size was small
2) The FU was a short period
3) The exact cause of high K was not recognized
The result of the study:
1) The total of patients with NS was 25 and 24 were PL
2) High K in the first 48 hours after surgery was greater in the NS group 80% while only 50% of PL had high K.
3) K mean serum peak was 6.1 with NS and with PL it was 5.4
4) 10 patients on NS were treated with high K while only 7 on PL were treated.
5) Patients receiving NS have more metabolic acidosis and had higher serum of CL at the end of the surgery.
6) There was no delay in graft function
7) Patients who received PL and never received dialysis have their creatinine reduced on day 2
8) The incidence of complications between the two groups was similar.
In conclusion, patients receiving NS had a greater chance of having high K and metabolic acidosis post-op of 48 hours when compared to PL. However, there was no adverse clinical outcome when compared.
The level of evidence of this article is level 1
Hyperkalemia is seen in 25-40% of kidney transplant recipients, which can lead to hemodynamic and neurological complications with respiratory paralysis or cardiac arrest. Normal saline use intraoperatively and post-operatively is associated with hyperchloremic metabolic acidosis, which can cause hyperkalemia.
It was a prospective, randomized, double-blind, single-center study, involving deceased donor kidney transplant recipients between September 2012 and April 2015. The patients were given either normal saline or Plasma-Lyte 148 balanced solution during the surgery (minimum 2000 ml) and for first 48 hours post-surgery as maintenance fluid. Open-label fluids were also used intraoperatively, as per the discretion of the anesthesia team. After 48 hours post-transplant, further fluid was given as per the treating clinician.
The primary outcome was hyperkalemia within 48 hours after surgery, and secondary outcomes involved treatment of hyperkalemia, change in acid-base status, and graft function.
A total of 70 patients underwent transplant during the study period, a total of 49 patients were finally included in the study, 25 received normal saline (NS) while 24 received Plasma-Lyte 148 (PL).
The NS group had higher incidence of hyperkalemia (80% versus 50%), acidosis and higher serum chloride levels at the end of surgery. 64% of NS group patients required treatment for hyperkalemia as compared to 21% in the PL group. 52% of the NS group patients required dialysis for hyperkalemia while only 16% required dialysis in the PL group. The incidence of delayed graft function was similar in both the groups. PL group patients not requiring dialysis had greater fall in serum creatinine on post-operative day 2. The complication rates including ICU care requirement, length of stay, and blood transfusion were similar in the 2 groups.
The strengths of the study include randomization, double-blind use of fluid, continuing blinded fluids for 48 hours post-surgery, providing more detailed evaluation of the impact of the fluid on outcomes, and assessment of renal outcomes upto 1 year post-transplant.
The limitations of the study include small sample size, single-center study, inadequate power to compare the effects, and uncertainty regarding effect of immunosuppressive drugs on the incidence of hyperkalemia.
To conclude, the study demonstrated that buffered crystalloid solution like Plasma-Lyte 148 should be preferred over normal saline in the peri-operative fluid management of deceased kidney transplant recipients.
Level of evidence: Level 1
Summarise this article
Introduction:
Administration of N/S 0.9% is the standard of care fluid used in most centers where kidney transplantations are done, it has been showed that massive infusion of N/S is associated with hyperchloremic acidosis and subsequent hyperkalemia.
The use of balanced fluids such as PlasmaLytes have near plasma electrolytes levels, was compared to infusion of N/S in a single transplant center.
Study fluids contents:
N/S contains 154 mmol/l Na and 154 mmol/l Cl
PlasmaLytes 148 contains 140 mmol/l Na, 3 mmol/l Mg, 5 mmol/l K, 98 mmol/l Cl, 27 mmol/l acetate, and 23 mmol/l gluconate.
Methods:
Double blinded randomized clinical trial was conducted in a deceased kidney transplantation in Malbourne teaching hospital between September; 2012- April; 2015, comparing the two above mentioned fluids in perioperative period till 48 hours after transplantation.
Inclusion criteria:
Adult > 18 years of age, cadaveric kidney transplants, informed consent signed.
Exclusion criteria:
Potassium > 6 mmol/l that is not corrected before transplanation, pregnancy, chronic liver disease(1.5 times normal values of liver function tests), known allergy to study fluids, and whon undergoing multiple organ transplantations.
Primary outcome: hyperkalemia > 5,5 mmol/l within 48 hours of surgery.
Secondary outcomes:
Hyperkalemia requiring treatment, dialysis need post operatively, delayed graft function (DGF), postoperative complications and length of hospital stay.
Base line characteristics were comparable between two groups.
Results:
There was significantly higher potassium level among those received N/S [P= 0.04].
Subjects receiving NS were more academic [P= 0.002], and hyperchloremic [P<0.01].
No significant difference in the incidence of DGF was identified.
PlasmaLytes had a more rapid reduction in creatinine on day 2 [P= 0.04].
The post-operative complications, length of hospital stay, and 30 days mortality were comparable in both groups.
Study limitations:
Single center study with small sample size 24 in N/S group and 25 IN PL group.
Done for only cadevaric kidney transplants, no living donor kidney transplant included.
No long term outcomes follow up was done by the investigator.
Conclusion:
The use of PL was associated with better graft function and lower creatinine level 48 hours post transplantation, N/S was associated with more hyperchloremic metabolic acidosis and hyperkalemia (not requiring treatment).
Both solutions are safe with comparable results on delayed graft function, surgical complications, and length of hospital stay.
What is the evidence provided by this article?
Level of evidence I , randomized controlled trial.
Summary:
Introduction
Study duration: September 2012 to April 2015
Study location: Austin Hospital, a university teaching hospital in Melbourne
Inclusion criteria:
adult patients (age 18 yr) undergoing deceased donor renal transplantation.
Exclusion criteria
Primary outcome
Incidence of hyperkalaemia (potassium >5.5mmol/litre) within 48 h of surgery.
Secondary outcomes
Results
Conclusions. Compared with PL, participants receiving NS had a greater incidence of hyperkalaemia and hyperchloraemia and were more acidaemic. These biochemical differences were not associated with adverse clinical outcomes
The prices in India (per 500 ml bottle)
NS: Rs 26/-
RL: Rs 46/-
Plasmalyte: Rs 122/-
Plasmalyte is quite costly. We in our practice regularly use balanced fluids for kidney transplant patient, but we use RL fluid.
Summary of Effects of intraoperative and early postoperative normal saline or Plasma-Lyte – 148 on hyperkalaemia in deceased donor renal transplantation: a double-blind randomized trial
Introduction:
Hyperkalaemia is a common complication of kidney transplantation 25-40% of recipients.
Normal saline in renal transplantation reported causes hyperchloremic metabolic acidosis and increase risk of hyperkalaemia.
This randomized double blinded trial comparing the effects of interoperative and early postoperative. Normal saline or acetate-buffered crystalloid solution on hyperkalaemia, the need for hyperkaliaemic treatment, acid-base status and graft function in patients receiving a deceased donor renal transplant.
Methods:
Trials register between September 2012 and April 2015.
Inclusion criteria:
Adult patient>or =18 years undergoing deceased donor renal transplantation
Exclusion criteria:
· Hyperkalaemia > 6mmol/L preoperative which was not corrected before transplant.
· Pregnancy.
· Chronic liver disease
· Allergic to study solution
· Multiorgan transplantation
· All participants were given at least of 2000ml trial fluid during surgery
Monitoring include:
ECG, pulse oximetry, capnography, blood pressure, urine output and core body temperature.
Mean arterial pressure was maintained within 20% of the baseline preoperative value .
125 mg IV frusemide given 5 minutes before reperfusion.
Maintenance infusion hours urine output plus 30 ml for the first 48 hours after surgery
After 48 hours fluid ceased and the rate and type of fluid by treating clinician
Immunosuppression was according to the local standard of care.
Primary outcome was:
Incidence of hyperkalaemia within 48 hours of surgery>or=5.5mmol/l
Patient whom requiring treatment of hyperkalaemia
Secondary outcome:
1. Hyperkalaemia during hospital admission
2. Treatment for hyperkalaemia
3. Requirement for postoperative dialysis after surgery
4. Acid-base derangement
5. Postoperative complication
6. Hospital length of stay
Statistical analysis:
Sample size calculations were based on a pilot study.
To analyse potassium values throughout the four pre specific time points we used a random effect generalized linear regression model with individualized subject treated as a random effects
Result:
Twenty-five subjects were randomized to normal saline and 25 to PL cout of 70 patients underwent deceased donor renal transplantation
Primary outcome:
Hyperkalaemia within 48 hours
During the first 48 hours period after surgery, higher incidence of hyperkalaemia after NS 80%. 64% were treated for hyperkalaemia vs 21% after PL
13 subjects required dialysis for hyperkalaemia in NS group vs 24 in the PL group.
Longitudinal analysis, delay graft function and complication
No significant difference in the incidence of DGF was identified
PL group a more rapid reduction in creatinine on day 2
The incidence of complication was similar between groups
Discussion:
Compared PL receiving patient with NS were more acidaemia during surgery
Had higher serum potassium
Higher incidence of hyperkalaemia
Higher incidence of correction of hyperkalaemia in the first 48 hours
No significance in the rate of BGF
PL group had greater CRR on a day 2 in whom did not receive dialysis
The previous studies showed no different in incidence of hyperkalaemia in both group.
Implication:
Comparing PL and NS had inferior biochemical outcomes regarding hyperchloremic metabolic acidosis and hyperkalaemia
In this study there are not certain if the immunosuppression therapy contributes to the incidence of hyperkalaemia in each group
Conclusion:
In deceased donor kidney transplantation recipients receiving PL or NS during surgery and for 48 after surgery
Use of NS was associated with:
1. Hyperchloremic acidosis
2. Postoperative hyperkalaemia
3. Use of the treatment for hyperkalaemia
This study favour the use of buffered crystalloid solution for perioperative fluid management in patients undergoing deceased donor renal transplantation.
leve2
Summary of the article
“Effects of intraoperative and early postoperative normal saline or PlasmaLyte – 148 on hyperkalaemia in deceased donor renal transplantation: a double-blind randomized trial”
This is a prospective randomized double-blind controlled study, comparing the effects of NS andPlasma-Lyte 148(PL) given during surgery and for 48 h after surgery in patients undergoing deceased donor renal transplantation. The primary outcome was hyperkalaemia within 48 h after surgery. Secondary outcomes were need for hyperkalaemia treatment, change in acid-base status, and graft function.
Study’s Results and Outcome
1. Normal saline administration, during surgery and after surgery, is associated with more acidemia, and had higher serum potassium and a greater incidence of hyperkalaemia. There was a higher rate of interventions to correct hyper- kalaemia in the first 48h after surgery.
2. No differences in kidney function were observed between groups at 1, 3, 6, and 12months.
3. Compared with PL, NS leads to inferior biochemical outcomes in relationship to hyperchloraemic metabolic acidosis and hyperkalaemia.
4. There was a strong signal in the incidence of hyperkalaemia in participants receiving PL in donation after brain death recipients when compared with donation after cardiac death recipients.
5. The study supports the preferential use of buffered crystalloid solutions for perioperative fluid management in patients undergoing deceased donor renal transplantation.
Strengths of the study
1. A prospective, double-blind controlled study.
2. This is the first fluid intervention study in deceased donor renal transplant recipients to report renal outcomes at 1week, 1, 3, 6, and 12 months after trial fluid intervention.
Limitations of the study
1. inadequate power to compare the effects of NS and PL on short- or long-term graft function and other postoperative complications; addressing this will require a larger, multicentre study.
2. The uncertainty, whether the immunosuppressive therapy contributed to the incidence of hyperkalaemia in each group.
What is the evidence provided by this article?
This is a prospective randomized double-blind controlled study.
Level of evidence grade 2.
Club 4; normal saline vs plasma lyte effect on hyperkalemia in KT
Summary
· The current study compared risk of hyperkalemia at 48 h post transplantation, and need for anti hyperkalemic measures, acid base disturbance and graft function in 2 groups of cadaveric kidney transplantation, one received saline 0.90 % (25 patients) and the other received plasma-lyte 148 (24 patients).
· The study concluded that higher risk of hyperkalemia and metabolic acidosis (that required treatment or intervention) than in plasma –lyte. However, it was not associated with worse graft outcome (as DGF, ned for RRT).
· This finding made the concept of fear of balanced crystalloid solution (due to its K content) is not justified.
· Points of strength of current study:
o Being randomized and blinded (less bias).
· Limitations of the current study:
o Only applied to the cadaveric (not living kidney transplantation).
o Small number of cases (only 49 cases), and single center study.
Level of evidence: RCT (level I)
I think use of plasma lite will be limited by its cost.
Aim of the study: to demonstrate the effect of normal saline on the risk of hyperkalaemia or postoperative graft function.
Methods: NS was compared with Plasma-Lyte given during surgery and for 48 h after surgery in patients undergoing deceased donor renal transplantation.
The primary outcome: hyperkalaemia within 48 h after surgery.
Secondary outcomes: the need for hyperkalaemia treatment, change in acid-base status, and graft function.
Results: Twenty-five subjects were randomized to NS and 24 to PL.
The incidence of hyperkalaemia in the first 48 h after surgery was higher in the NS group.
The mean peak serum potassium was NS 6.1 compared with PL 5.4 mmol/ litre.
Sixteen NS group participants required hyperkalemia treatment compared with five in the PL group.
Participants receiving NS were more acidic and had higher serum chloride concentrations at the end of surgery.
No differences in the rate of delayed graft function were observed.
Patients receiving PL who did not require dialysis had a more significant reduction in creatinine on day 2.
Conclusion: Compared with PL, participants receiving NS had a greater incidence of hyperkalaemia and hyperchloraemia and were more acidaemic. These biochemical differences were not associated with adverse clinical outcomes.
Limitations:
Level of evidence:
Level 1 ( randomized trial ).
· Hyperkalaemia is a common and potentially severe complication of cadaveric kidney transplantation.
· Normal saline used as potassium-free i.v. fluid therapy can cause hyperchloraemic acidosis and subsequent hyperkalaemia.
· In a randomized trial in deceased donor kidney transplant recipients, intraoperative and early postoperative use of normal saline was associated with more hyperkalaemia, hyperchloraeamia, and acidosis compared with a balanced i.v. fluid.
Inclusion criteria: adult patients (age 18 yr) undergoing deceased donor renal transplantation.
Exclusion criteria: preoperative hyperkalaemia >6.0 mmol /L that was not corrected before transplantation, pregnancy, chronic liver disease, known allergic reaction to study solutions, and patients undergoing multi-organ transplantation
Primary outcome: hyperkalaemia within 48 h
· During the first 48 h period after surgery, there was a higher incidence of hyperkalaemia after NS (80%) than with PL
Discussion
· This is a prospective randomized double-blind controlled study comparing the effects of NS and PL as perioperative i.v. fluid therapy in deceased donor renal transplant recipients
· Patients received NS were more acidaemic during surgery, and after surgery had higher serum potassium and a greater incidence of hyperkalaemia.
· There was a higher rate of interventions to correct hyperkalaemia in the first 48 h after surgery in patients received NS
· PL group who did not receive dialysis had a greater CRR on day 2, but there was no significant difference in the rate of DGF
Relationship to previous findings
· Potura and colleagues recently found that no difference in the incidence of intraoperative hyperkalaemia in recipients receiving open-label NS or an acetate-buffered solution, and also reported significant intraoperative metabolic acidosis and hyperchloraemia (deceased donor)
· Several studies in live donor kidney transplant recipients have also reported an increased incidence of metabolic acidosis in patients receiving NS compared with balanced crystalloid solutions.
· These studies also found no significant difference in markers of renal function between groups
· Compared with previous reports, the auther observed a high rate of both DGF overall and the need for haemodialysis within the first 48 h post-transplant
Strengths of the study
· The fluid intervention was blinded and randomized
· The extended use of blinded fluids for 48 h after surgery to all participants
· This is the first fluid intervention study in deceased donor renal transplant
Limitations of the study
· Inadequate power to compare the effects of NS and PL on short- or long-term graft function and other postoperative complications as this require a larger, and multicentre study
· Not sure about immunosuppressive therapy effect on hyperkalemia
This is a double-blinded randomized trial. Evidence 1
Introduction
Hyperkalemia occurs as a complication in 25-40% of kidney transplant recipients. Hyperkalemia causes significant hemodynamic and neurologic adverse effects that cause respiratory paralysis and cardiac death if not corrected urgently. The choice of fluid to administer during a deceased donor renal transplantation is aimed to maintain adequate renal transplant perfusion and to avoid acid-base and electrolyte disturbances. Normal saline (NS) does not contain any potassium and so it is the current fluid of choice for kidney transplantation.
NS, however, causes hyperchloremic metabolic acidosis and resultant increased risk of hyperkalemia. This study was designed to compare the fluids on hyperkalemia, the need for hyperkalemia treatment, acid-base status, and graft function in patients receiving a deceased donor renal transplant.
Methodology
The study was conducted in Austin Hospital in in Melbourne, Australia, between September 2012 and April 2015. It included patients above the age of 18 years, undergoing deceased donor renal transplantation. It excluded patients who has preoperative hyperkalemia of more than 6.0mmol/L that was not corrected before the surgery, chronic liver disease, known allergic reaction to the study solutions and patients who were undergoing multi-organ transplantation.
The patients, after giving consent, were randomized into the two groups. The study participants, anesthetists, surgeons, nephrologists and the nursing staff were blinded to the trial fluid intervention. The Plasma-Lyte 148 (PL) contained sodium (140 mmol/L), potassium (5 mmol/L), magnesium (3 mmol/L), chloride (98 mmol/L), acetate (27 mmol/L), and (gluconate 23 mmol/L). The NS contained sodium (154 mmol/L) and chloride (154 mmol/L). All patients were prescribed a minimum of 2000ml of trail fluid during surgery. The rest of the fluid administration was at the discretion of the anesthetist, depending on the surgery. Electrocardiography, pulse oximetry, capnography, blood pressure, urine output and core body temperature were monitored. After the procedure, the patients received a maintenance infusion of the trail fluid. Immunosuppression was given as per protocol.
The primary outcome was:
The incidence of hyperkalemia (potassium of more than or equal to 5.5 mmol/L) within 48 hours of surgery.
The secondary outcomes include:
Results
During the study period, 70 patients underwent deceased donor renal transplantation. 13 participant were excluded. 57 patients provided an informed consent. 7 participants did not participate as the donor kidney was not suitable. 25 subjects were in the NS group, and 25 were randomized into the PL group.
During the first 48 hours after surgery, there was a higher incidence of hyperkalemia in the NS group compared to the PL group. 64% of the patients were treated for hyperkalemia after the use of NS, compared to the 21% of patients treated for hyperkalemia after the use of PL. The highest level of potassium was 6.1 mmol/L in the NS group, and 5.4 mmol/L in the PL group. 13 patients required dialysis from the NS group, compared to 4 from the PL group.
The median volume of intraoperative trial fluid was 2500ml in the NS group, and 3000ml in the PL group. Subjects receiving NS were more acidotic than the ones receiving PL. 8 subjects produced urine in the NS group, compared to 11 in the PL group. In the NS group, the median duration of surgery was 2.8 hours, and it was 3.0 hours in the PL group. The incidence of complications was similar in both the groups. The median length of stay was 6.5 days after the use of NS, and 7.1 days after the use of PL.
Discussion
Compared with PL, the patients receiving NS were more acidaemic during the surgery, had higher levels of potassium and a greater incidence of hyperkalemia, with a resultant higher rate of interventions to correct the hyperkalemia. There was no significant difference in the rate of DGF.
Many studies in living donor renal transplantation have also reported a higher incidence of metabolic acidosis in patients receiving NS compared with balanced crystalloid solutions. They also noted that there was no difference in renal function markers between the two. Despite the higher incidence of hyperchloremic metabolic acidosis, it has not led to a higher incidence of deleterious renal functional outcomes for the renal transplant recipients.
Compared with PL, NS leads to inferior biochemical outcomes in relationship to hyperchloremic metabolic acidosis and hyperkalemia. These findings help us understand that the concerns for hyperkalemia after the use of balanced solutions need to be rectified.
The strengths of the study include:
The limitations of the study include:
Conclusion
During deceased donor renal transplantation, NS was associated with hyperchloremic metabolic acidosis and more frequent hyperkalemia with more frequent requirement for correction, compared to PL. These differences were not associated with adverse clinical outcomes. Therefore, it is safe to use PL as compared to NS in cadaveric transplants. Further studies, in larger populations are required to confirm these findings.
Level of evidence is I as this is an RCT
● The aims of perioperative fluid administration in deceased donor renal
transplantation include maintenance of adequate kidney transplant perfusion and the avoidance of electrolyte and acid–base
disturbances, including hyperkalaemia.
● The PL contained sodium (140 mmollitre-1), potassium (5 mmol litre-1), magnesium (3 mmol litre-1), chloride (98 mmol litre-1), acetate (27 mmol litre-1), and gluconate (23 mmollitre-1).
● NS contained sodium (154 mmol litre-1) and chloride (154 mmol litre-1)
● similar improvement in markers of renal function over time in both groups
● A prospective randomized double-blind controlled study comparing the effects of NS and PL as perioperative i.v. fluid therapy in deceased donor renal transplant recipients.
● Compared with PL, subjects receiving NS were more acidaemic during surgery, and after surgery had higher serum potassium and a greater incidence of hyperkalaemia.
● there was a higher rate of interventions to correct hyperkalaemia in the first 48 h after surgery
● there was no significant difference in the rate of DGF.
● mechanism for the higher incidence of hyperkalaemia in the NS group relates to its chemical properties (i.e. high chloride, low pH), rather than the fluid volume.
● Strengths
* The fluid intervention was blinded and randomized minimizing bias.
* The extended use of blinded fluid for 48 h after surgery was strictly adhered to in all participants
* This is also the first fluid intervention study in deceased donor renal transplant recipients to report renal outcomes at 1 week, 1, 3, 6, and 12 months
● Limitations include
* inadequate power to compare the effects of NS and PL on short- or long-term graft function and other postoperative complications
* immunosuppressive therapy may contributed to the incidence of hyperkalaemia in each group
* The rate of DGF in the present study was high, possibly reducing the generalizability of the findings
* Study includes only deceased donors
* small sample size
● this study supports the preferential use of buffered crystalloid solutions for perioperative fluid management in patients undergoing deceased donor renal transplantation.
● Level 1
This study from BJA published in 2017, an impact factor of 11.719, ranking it 2 out of 34 in anesthesiology and indexed 18 international data base.
Introduction
There is growing concern about the use of isotonic saline and the risk of hyperchloremic metabolic acidosis, normal saline is potassium-free IVF makes it the preferred IVF for patients under transplant but the risk of hyperkalemia with the use of isotonic saline in perioperative transplantation is still indeterminate.
This study aims to assess the risk of hyperkalemia after 48 hours, the need for hyperkalemia correction, acid-base status,
and graft function in patients receiving a deceased donor renal transplantation.
Method and Setting
This is a double-blind randomized control trials data from tertiary teaching center data collected between 2012-2015 after getting ethical approval and all patients providing written consent
The inclusion criteria for all adults above 18 years with Deceased donor kidney transplantation randomized the recipients to two group
A Group of 25 DD recipients received isotonic saline intraoperative and post-operative and assess after 48 hours for the risk of hyperkalemia compared with the group of 25 using plasmalyte148 (one case dropped later, a total of 24 ).
Exclusion criteria are those with preoperative hyperkalemia > 6, multiple transplantations, pregnancy, chronic liver disease, and known allergy to study fluids
The minimum intraoperative use was 2000ml, CVP was not used to guide the IVF management, but MAP kept 20% higher than the baseline
Furosemide 125 mg prior to reperfusion as part of the center protocol
Open-label fluids (dextrose 5%, colloids, or blood products) were used at the discretion of the anesthetist. Blood transfusion if hemoglobin <80 g/L
Results
————
A total of 73 underwent DDKTX after the exclusion of many who did not fit the inclusions and did not give written consent
Twenty-five Patients were randomized to NS and 25 to PL. With matched baseline clinical characteristics
One subject in the PL group was excluded because of a protocol
The primary outcome is a hyperkalemia rate 48 hours after surgery
Higher risk of hyperkalemia in the isotonic saline group at 80% with average potassium > 6.1 and treatment of hyperkalemia is also more in isotonic saline 13 patients compared to 5 in PL group
No dialysis was needed in both group and no difference in the incidence of DGF between the two groups
creatinine reduction ratio (CRR) on postoperative day 2, and kinetic estimated glomerular filtration rate (KeGFR ml min 1.73 m-2) at 48 h is higher in PL 148 but did not reach statistical significance
and overall GFR and creatinine level at 12 months was similar between the two groups.
Strength
The methods of blinded Randomization with the control group with well-matched baseline clinical and patients’ characteristics between the two groups and by this they reduce the chances of selection bias
Accurate and adherence to the protocols, with internal validity for reported outcome, was achieved
First study to address intervention (fluid therapy) and its outcome in different intervals of FU from 1.2,3, 6 , 12 months in DD kidney transplants candidates
Limitation
Due to the Small sample size, there is insufficient influence to detect the difference between the two infusion groups for both short and long-term outcomes (type 1 error)
Short FU up to 12 months is not enough to assess such a hard outcome of graft survival
Can’t recognize the exact cause of hyperkalemia in NS group whether due to acidosis or hyperchloremia
Uncertainty regarding the effect of IS like CNI on acidosis and hyperkalemia (cofounders) however both groups have the same IS protocol.
So, we need large prospective studies with longer Follow up and maybe the use of such trials in LD candidates will also good alternative option
Conclusion
This Study concludes that saline infusion fluid intra-op and 24, 28 hours after surgery is associated w a h high risk of hyperchloremic acidosis and hyperkalemia that mandate medical therapy compared to plasmalyte148 Fluid in DD kidney transplantation , such conclusion should be taken with caution due to small sample size with type 1 error and we need more studies with large sample size and may be in living donor setting to address such intervention and its short and long term out come.
Double blinded RCT so its level1 of evidence
Hyperkalemia commonly occur in kidney transplant recipients, it is associated with serious complications.
Fluid management in deceased donor transplantation is crucial to maintain adequate renal perfusion without inducing electrolyte or acid base imbalance.
Normal saline (NS) is the preferred solution in kidney transplantation, however, studies showed that NS is associated with hyperchloremic metabolic acidosis that may result in hyperkalemia.
This study aims to compare the effect of intraoperative and early postoperative NS and plasmaLyte (PL) on hyperkalemia, the need for treatment of hyperkalemia, acid base status and graft function in deceased donor renal transplantation.
It is s randomized double blind controlled trial, included adult patients undergoing DD renal transplants.
Patients with preoperative hyperkalemia were excluded, also those with chronic liver disease, pregnancy, multi organ transplantation and allergy to study solutions.
The primary outcome was incidence of hyperkalemia within 48 hours of surgery, secondary outcomes included hyperkalemia during hospital admission, need for treatment of hyperkalemia, postoperative dialysis, DGF, postoperative complication and duration of hospital stay.
The study showed that NS was associated more metabolic acidosis and more hyperkalemia compared to PL.
There was no significant difference in the rate of DGF between NS and PL.
NS was associated with inferior outcomes regarding hyperchloremic metabolic acidosis and hyperkalemia compared to PL.
The study suggest that concerns about potassium content in PL are not justified clinically and that PL may be more beneficial than NS in patients receiving DD kidney transplantation.
Strengths:
Randomized, blind trial, used electronic medical recording of fluid use, compared NS and PL use within 48 hours postoperative and were not restricted to intraoperative fluids only, also they reported the renal outcome up to 12 months post transplant.
Limitations:
Inadequate power to compare the effect of NS and PL on short and long term graft function, the rate of DGF was high which may limit generalizability of the results and small sample size.
level of evidence: 1 (Randomized controlled trial)
Summary of the article;
Hyperkalemia is a common complication postoperatively, and its Sequelle is dangerous if not treated properly, as it may lead to respiratory and cardiac arrest with increasing mortality.
Because the 0.9% saline consider as K free, so is dominating in this setting to avoid such complication.
Recent study found that NS can cause hyperchloremic metabolic acidosis and hyperkalemia, new attention develop on using balanced fluid that are plasma similar and does not affect contents or acid-base balance.
Method;
Results;
Discussion;
Strengths;
Limitations;
Conclusion;
Use of NS in deceased donor kidney transplant was associated with hyperchloremic acidosis, and hyperkalemia, with need of correction, compared to PL.
This study prefer use of balanced-buffered solution in perioperative period in patient receive deceased kidney donation.
Level of evidence ((I)) Randomizes control trial
Summary:
Infusion of normal saline in renal transplantation is associated with hyperchloraemic metabolic acidosis. Development of hyperkalaemia with infusion of normal saline is demonstrate in this study.
Here comparison done between NS with Plasma-Lyte 148 during surgery and for 48 h after surgery in patients undergoing deceased donor renal transplantation. In this study primary outcome was hyperkalaemia within 48 h after surgery and secondary outcomes were, any need for hyperkalaemia treatment, change in acid–base status, and graft function.
This study showed, twenty-five subjects were randomized to NS and 24 to PL. The incidence of hyperkalaemia in the first 48 h after surgery was higher in the NS group; The mean peak serum potassium was NS 6.1 compared with PL 5.4 mmol/l. Sixteen participants (64%) in the NS group required treatment for hyperkalaemia compared with five (21%) in the PL group. Participants receiving NS were more acidaemic.
Level of evidence: 1
IV. Effects of intraoperative and early postoperative normal saline or Plasma-Lyte – 148 on hyperkalaemia in deceased donor renal transplantation: a double-blind randomized trial
1.Summarise this article
Introduction
Use of saline in KTX is linked to hyperchloraemic metabolic acidosis; however, the effect of NS on the risk of hyperkalaemia or post-op graft function is uncertain.
The study
NS was compared with Plasma-Lyte 148VR (PL) given during surgery & for 48h after surgery in patients undergoing DKD renal transplantation.
Primary outcome:
Hyperkalaemia within 48h after surgery.
Secondary outcomes:
Need for hyperkalaemia treatment
Change in acid–base status
Graft function.
Results.
1.25 patients were randomized to NS & 24 to PL.
2.The incidence of hyperkalaemia in the 1st48h after surgery was higher in the NS group; 20 patients (80%) versus 12 patients (50%) in the PL group (risk difference: 0.3; 95% CI: 0.05, 0.55; P=0.037).
3.The mean peak serum K+ was NS 6.1 compared with PL 5.4 mmol (P=0.009).
4.16 Sixteen patients (64%) in the NS group required treatment for hyperkalaemia compared with 5 (21%) in the PL group (P=0.004).
5.Patients receiving NS were more acidaemic [pH 7.32 versus 7.39, P=0.001] & had higher serum chloride concentrations (107 vs 101mmol, P< 0.001) at the end of surgery.
6.No differences in the rate of DGF were seen.
7.Subjects receiving PL who did not require dialysis had a more reduction in serum creatinine on day 2 (P=0.04).
Strengths
1.The fluid intervention was blinded & randomized (minimal allocation & selection bias).
2.Blinding avoided the potential for differences between groups in terms of management of electrolyte & acid–base disturbances attributable to physician awareness of the allocated fluid therapy.
3.It is the 1st fluid intervention study in DKD renal transplantation recipients to report renal outcomes at 1 week, 1, 3, 6, &12 months after trial fluid intervention.
Limitations
1.Inadequate power to compare the effects of NS & PL on short- or long-term graft function & other post-op complications; this will require a larger, multicentre study.
2.It is uncertain whether the IS therapy contributed to the incidence of hyperkalaemia in each group.
Conclusions
Compared with PL, participants receiving NS had a greater incidence of hyperkalaemia & hyper-chloraemia & were more acidaemic.
These biochemical differences were not associated with adverse clinical outcomes.
//////////////////////////////////////////
2.What is the evidence provided by this article?
Level I (RCT)
NaCl 0.9% is potassium free and, and partly for this reason has been used as the current standard of care for IV fluid therapy for kidney transplantation. Administration of NS in KT is associated with hyperchloraemic metabolic acidosis, but the effect of (NS) on the risk of hyperkalaemia or postoperative graft function is uncertain.
Methods:
– Prospective, double-blinded randomized trial
-Compared NS with Plasma-Lyte 148VR (PL) given during surgery and for 48h after surgery in patients undergoing
deceased donor renal transplantation.
– Inclusion criteria: adult patients (age 18 yr) undergoing DD KT.
– Exclusion criteria: preoperative hyperkalaemia >6.0mmol/L that was not corrected before transplantation,
pregnancy, chronic liver disease (liver function tests >1.5 times normal value), known allergic reaction to study solutions, and patients undergoing multi-organ transplantation.
The primary outcome was hyperkalaemia within 48h after surgery, defined as K>=5.5mmol/l
Secondary outcomes
were need for hyperkalaemia treatment, change in acid–base status, and graft function, and postoperative complications, and hospital length of stay.
Results:
25 subjects were randomized to NS and 24 to PL.
The incidence of hyperkalemia in the first 48h after surgery was higher in the NS group 80% vs 50% in the PL group.
The mean (SD) peak serum potassium was NS 6.1 compared with PL 5.4.
Medical management for hyperkalemia was instituted in 10 subjects in the NS group vs 7 subjects in the PL group
16 participants (64%) in the NS group required treatment for hyperkalemia compared with 5 (21%) in the PL group
Participants receiving NS were more academic and had higher serum chloride at the end of surgery.
No differences in the rate of delayed graft function were observed.
Subjects receiving PL who did not require dialysis had a greater reduction in creatinine on day 2.
The incidence of complications was similar between groups
Limitations:
-Single center.
– Small sample size
– Uncertain about the influence of the immunosuppressive therapy to hyperkalemia.
– Applicability on LKD need to be determine.
Strengths:
– RCT, therefore, minimal allocation and selection bias.
– Study extend to 48 hours post-operative period in contrast to other studies.
Conclusions:
Compared with PL, participants receiving NS during the surgery and for 48 hours postoperatively had a greater incidence of hyperkalemia and hyperchloremic acidosis.
These biochemical differences were not associated with adverse clinical outcomes.
Level of evidence: level 1
The study in favor the use of buffered crystalloid solutions for perioperative fluid management in patients undergoing DDKT, given the adverse metabolic profile associated with NS.
Keeping in mind, the availability of the solution and it price may influence the practice, if both are available use of PL is highly recommended.
That is a superb summary and analysis mentioning the strengths and limitations of this article.
Ajay
Effects of intraoperative and early postoperative
normal saline or Plasma-Lyte 148VR on hyperkalemia
in deceased donor renal transplantation:
a double-blind randomized trial.
Hyperkalemia is considered on of the most common electrolyte disturbance post KTX and so 0.9 NaCl is the most common IV fluid used pre, in and postoperative as potassium free solution but now many clinical studies shown the deleterious effect of normal saline in acid-base and kidney function mainly due to Hyperchloremic acidosis that finally lead to hyperkalemia.
Aim of this study:
Comparing the effects of intraoperative and early postoperative NS or acetate-buffered crystalloid solution (Plasma-Lyte 148) on hyperkalaemia, the need for
hyperkalaemia treatment, acid–base status, and graft function in patients receiving a deceased donor renal
transplant.
Methods.
A double-blinded randomized trial, done Between September 2012 and April 2015, on 50 patients classified to 25 subjects were randomized to NS and 24 to PL.
compared NS with Plasma-Lyte 148VR (PL) given during surgery (which is minimally 2 L)and for 48h after surgery in patients undergoing deceased donor renal transplantation. The primary outcome was hyperkalaemia(ABOVE >5.5) within 48h after surgery. Secondary outcomes were need for hyperkalaemia treatment, change in acid–base status, and graft function.
Results.
The first 48h period after surgery, there was a higher
Incidence of hyperkalaemia after NS (80%) than with PC (50%).
Thirteen subjects required dialyses for hyperkalaemia in the NS group vs four in the PL group.
Patients received intraoperative NS were more acideimc and hyperkalemic than those who received PL .
Effects on graft function shown no significant difference in the incidence of DGF was identified.
The incidence of complications was similar between groups and no 30 days mortality, 6 months and 1 yr intervals.
Strengths.
-Blinded and randomized.
-Extended use of blinded fluids for 48 h after surgery was strictly adhered to in all participants.
-First fluid intervention study in deceased donor renal transplant with long term follow up.
Limitation.
-Small sample size.
-Compare the effects of NS and PL on short- or long-term graft function and other postoperative complications not conclusive.
Conclusion.
NS in deceased donor kidney transplantation recipients has deleterious effect during surgery and for 48h after surgery as Hyperchloremic acidosis and hyperkalemia comparing to PL but without adverse clinical outcomes.
Level of evidence I.(Randomized controlled trial).
That is a superb summary and analysis mentioning the strengths and limitations of this article. Will you change your practice based on this article?
Ajay
Thanks , prof
We do not have deceased kidney transplant program but our view regarding balanced solution is much changed specially post kidney transplant with living KTX
SUMMARY
Introduction
The incidence of hyperkalemia in kidney transplantation is about 25%-40% making it one of the most common complications with attendant side effect if urgent treatment is not deplored. To this end, many transplant centres resolved to use of potassium free fluid of which normal saline is the most used. However, 0.9% normal saline has been known to cause hyperchloremic metabolic acidosis which can eventually cause hyperkalemia in patient following kidney transplantation. This study was set out to see which of the fluid between the traditional normal saline and acetate buffered crystalloid solution (Plasma -Lyte 148)
Method
Results
Limitations
Strengths of the study
Conclusion
This study has substantiated the advantage of use of buffered Crystaloid solution over the traditional NS that is frost with a lot of complication like hyperkalemia, metabolic acidosis, and adverse clinical outcomes both intraoperatively and even till 48 hours after kidney transplantation in diseased donors
This is a level 1 type of study
Thank you,
Will you change your practice based on this article?
IV. Effects of intraoperative and early postoperative normal saline or Plasma-Lyte – 148 on hyperkalaemia in deceased donor renal transplantation: a double-blind randomized trial
====================================================================
Methods
Inclusion criteria included:
Exclusion criteria included :
–Electrocardiography, pulse oximetry, capnography, blood pressure, urine output, and core body temperature were monitored.
Results
Strengths and limitations
Conclusions
What is the evidence provided by this article?
The evidence level is 1
Thank you,
Will you change your practice based on this article?
Thanks alot our Prof. Halawa
Certainly, after this article, I will be reconsidered, patients will be monitored and the required examinations will be performed for them.
Summarise this article
Introduction
NS is associated with hypercholeremic metabolic acidosis and is the preferred solution in kidney transplantation
Effect of NS on hyperkalemia is not well studied
The aim of the study
A prospective double-blinded randomized trial in a deceased donor renal transplant comparing the effects of NS to PL intraoperatively and in the early posttransplant period
Materials and Methods
The study was conducted at one Hospital (2012-2015)
Inclusion criteria: adult patients (age 18yr or more) undergoing deceased donor renal transplantation
Exclusion criteria:
1. Preoperative hyperkalaemia >6.0mmol/L that was not corrected before transplantation
2. Pregnancy
3. Chronic liver disease (liver function tests >1.5 times normal value)
4. Known allergic reaction to study solutions
5. Patients undergoing multi-organ transplantation
Measurement of CVP was not used for the assessment of volume responsiveness
The primary outcome: hyperkalaemia within 48h of surgery
Secondary outcomes: hyperkalaemia during hospital admission, treatment for hyperkalaemia, requirement for postoperative dialysis, DGF (hours to first dialysis after surgery), acid–base derangements), postoperative complications, and hospital length of stay
Results
Forty nine deceased donors were randomized (25 allocated to NS and 24 to PL)
During the first 48h period after surgery, the incidence of hyperkalaemia was higher after NS (80%) than with Pl (50%)
64% of subjects were treated for hyperkalaemia after NS vs 21% after PL
The mean K concentrations were 6.1 after NS compared with 5.4 after PL
Medical management for hyperkalaemia was instituted in 10 subjects in the NS group vs 7 subjects in the PL group
Thirteen subjects required dialyses for hyperkalaemia in the NS group vs four in the PL group
Subjects receiving NS were more acidaemic (pH 7.32 vs 7.39) and had higher serum chloride concentrations (107vs 101mmol/L) at the end of surgery
No differences in the rate of DGF
Strength and limitations
Strengths: blinded and randomized, and extended 48 hours postoperatively
Limitations: the study not compared the effects of NS and PL on short- or long-term graft func- tion and other postoperative complications
Conclusion
In deceased donor kidney transplant, use of NS was associated with hyperchloremic metabolic acidosis, more postoperative hyperkalemia and more needs of treatment of hyperkalemia when compared with PL
Owing to the serious consequences of these adverse effects, the study preferred use of mor physiologic solution in the perioperative period
What is the evidence provided by this article?
Level 1 (randomized trial)
Thank you,
Will you change your practice based on this article?
Yes, of course
– Summary
Introduction
To maintain adequate kidney transplant perfusion and avoid hyperkalaemia , perioperative fluid is administrated in deceased donor renal transplantation.
0.9% sodium chloride being K free is used for kidney transplantation IV fluid therapy but it can cause hyperchloremic acidosis which can lead to hyperkalaemia.
Methods
This a double blinded randomized trial assessing the effects of intraoperative and early postoperative NS versus Plasma-Lyte intake on hyperkalaemia as the primary outcome , and secondary outcomes including the need for hyperkalaemia treatment, acid–base status,and graft function ,postoperative complications ,and duration of the hospital stay in recipients of deceased donor renal transplant.
Results
The primary outcome :Hyperkalaemia within 48 h had higher incidence in NS group compared to Plasma Lyte group.
Also higher number of hyperkalaemia cases and higher number of cases requiring treatment was detected with NS group more than PL group.
Intraoperative variables
The intraoperative K level and the number of cases requiring hyperkalaemia treatment were higher in NS group as well .
Acidosis and hyperchloremia was higher in NS group.
Intraoperative fluid ,blood and vasoactive medications used was similar between the 2 groups.
Number of cases of PL group producing urine was more than NS group.
The median cold ischemia time in NS group time was
11.8 h and in the PL group 10.8 h.
Warm ischemia time was similar between both groups.
Delayed graft function and complications
PL had lower potassium values than NS group,5 cases treated with NS needed hyperkalaemia treatment while in PL group not a single case needed hyperkalaemia therapy.
No cases in both group required dialysis for management of hyperkalaemia.
DGF was similar in both groups, PL group cases who did not require dialysis had a more rapid decrease in creatinine on day 2 , with better eGFR at 48 h.
Complications incidence was similar in the 2 groups.
Renal function markers taken at specific intervals revealed improvement in both groups.
Discussion
NS group were more acidaemic during surgery, and after surgery and had higher serum K and a greater incidence of hyperkalaemia and more interventions to treat hyperkalemia 48 h post surgery than PL group.
DGF was similar in both groups.
Potura et al findings were in concordance with this study regarding lack of significance between the 2 groups in the intraoperative incidence of hyperkalaemia.
Hyperkalemia in NS group can be explained by high Cl content and low PH in NS.
Other studies conducted on living donors reached the same conclusion which is in spite that NS is associated with hyperchloremia that leads to renal impairment ,it doesnot lead to major hazardous renal outcomes in transplant recipients.
Modest advantage of PL over NS was declared by this study concerning the renal outcomes.
A statistically significant increase in CRR was noticed in the PL group and better KeGFR at 48 h.
Dialysis within 7 days post-transplant failed to account due to the severity and duration of DGF; dialysis for hyperkalaemia and fluid overload with good graft function; and poor graft function where dialysis is not needed.
DGF leads to poor renal outcomes apart from dialysis need or not.
The higher DGF rate can be due to donor
time to death, cold perfusion pharmacological treatment, or ECD, or variable decisions for initiation of dialysis .
PL can be better than NS in recipients of deceased donor kidney transplants because NS can cause hyperchloremic metabolic acidosis that in turn increases hyperkalaemia incidence more than PL with lower Cl concentration.
Strengths
Being a blinded randomized trial therefore avoiding any possible bias.
All previous studies involved intraoperative periods but this study included follow up of postoperative period.
This is the first study conducted on deceased donor renal transplant recipients accessing the effect of fluid therapy on report renal outcomes.
This study detected significantly higher hyperkalaemia in PL group in donation after brain death recipients when compared with donation after cardiac death recipients followed by reduction of the hyperkalaemia after surgery ,24h and 48 h afterwards.
Limitations
Insufficient comparison of the 2 fluids effect on short and long term outcome regarding graft function as this will need a bigger multicentric trial.
The DGF rate in this study was high, therefore reducing the generalizability of the findings.
Sample size was small indicating type 1 error.
Conclusion
NS use lead to hyperchloraemic acidosis and postoperative hyperkalaemia, with greater use of medical interventions to treat serum potassium but it did not cause hazardous clinical outcomes.
The current study favours the use of buffered crystalloid solutions for perioperative fluid replacement in deceased donor renal transplantation recipients .
-level of evidence is 1
Thank you,
Will you change your practice based on this article?
Introduction;
In renal transplantation, the administration of salt is linked to a condition known as hyperchloraemic metabolic acidosis; however, the impact of normal saline (NS) on the risk of hyperkalemia or on postoperative graft function is unknown.
Methods:
In patients having kidney transplantation from dead donors, we compared Plasma-Lyte 148VR (PL) and Normal Saline (NS), both of which were administered during surgery and for 48 hours following surgery. The hyperkalemia that occurred within 48 hours after surgery was the main outcome. The requirement for therapy of hyperkalemia, changes in acid-base status, and graft function were secondary outcomes.
Results:
Random assignment of 25 patients to the NS group and 24 individuals to the PL group was performed. In the first 48 hours following surgery, the incidence of hyperkalemia was greater in the NS group: (at 80%) vs. (50%) in the PL group. Peak serum potassium was found to be NS 6.1 (0.8) mmol litre1 on average, which is significantly higher than PL 5.4 (0.9) mmol litre1.
In the NS group, 64%, needed therapy for hyperkalemia. In the PL group, only 21%, needed treatment.
At the conclusion of surgery, participants who were given NS had a pH that was more acidic and a higher serum chloride content (107 vs 101 mmol litre1] than those who were given the placebo.
It was shown that there was no discernible difference in the rate of delayed graft function. On day 2, the subjects who received PL and did not need to undergo dialysis showed a larger drop in their creatinine levels.
Strength:
-Blinding and randomization reduced allocation and selection bias.
-Blinding minimized disparities in electrolyte and acid-base disturbance treatment across groups due to physician knowledge of fluid therapy.
-This is the first research to evaluate renal outcomes 1 week, 1, 3, 6, and 12 months following fluid intervention in dead donor renal transplant patients.
Limitation :
-We don’t know whether immunosuppression caused hyperkalemia in either group.
– inadequate power to compare the effects of NS and PL on short- or long-term graft function.
-Small number and Single-center trial.
-High DGF rates in this research may reduce generalizability.
Conclusion:
-In kidney transplant patients receiving PL or NS during surgery and for 48 h after surgery, NS was linked with hyperchloraemic acidosis and more frequent postoperative hyperkalemia, requiring more medical interventions to manage blood potassium. Biochemical variations didn’t affect clinical results.
Level of evidence 1
Thank you,
Will you change your practice based on this article?
Hyperkalemia is a common and serious complication occurring in transplantation
There is a concern of hyperkalemia that can occur with large infusion of potassium containing IV fluid (PL); 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 controlled (level of evidence II) study evaluating 49 deceased renal transplant recipients regarding the effect of intra and post -operative normal saline (25 patients) versus Plasmalyte (24 patients) on serum the incidence of DGF, potassium, acid base balance and the need for treatment of hyperkalemia 48 hours after transplantation
The results
Conclusions.
Thank you,
Will you change your practice based on this article?
Method:
Result & discussion:
Strength of the study:
Limitations:
Level of evidence is 1.
Hi Dr Ben,
That is a superb summary and analysis mentioning the strengths and limitations of this article. 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