Effects Of The Type Of Intraoperative Fluid in Living Donor Kidney Transplantation: A Single-Center Retrospective Cohort Study
Jan 19, 2024
DISCUSSION
In this retrospective study, we demonstrated that Plasma-lyte administration during surgery reduces the occurrence of metabolic acidosis during the intraoperative and early postoperative periods, compared with the administration of 0.45% half saline. Postoperative kidney graft function measured using eGFR showed favorable results in the Plasma-lyte group.
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Various factors may affect acid-base and electrolyte balance in patients undergoing kidney transplantation, such as the type of intravascular solution used during surgery.8,9,19,22,23 Crystalloid fluids comprise different components based on their composition of electrolytes and the presence of buffers. Comparisons of clinical outcomes associated with different types of intravenous crystalloids used in kidney transplantation have been reported,4,8,9,17,19,24-26 with each fluid demonstrating its own pros and cons. Recently, a balanced crystalloid solution has shown a better metabolic profile and is preferred in kidney transplantation.27
Metabolic acidosis after using a large volume of NS is a risk factor for subsequent hyperkalemia that is mediated by an extracellular shift of potassium ions.19 Solutions with lower chloride content, such as balanced crystalloids, have been administered to minimize the risk of hyperchloremic metabolic acidosis.4,28 Compared with NS, Hartman's solution contains potassium (4 mEq/L) and has a lower chloride concentration (109 mEq/L). O'Malley reported that the use of Hartman's solution reduced hyperkalemia and acidosis during kidney transplantation when compared with the use of NS.29
Unlike Hartman's solution, half saline does not contain potassium ions. Based on the same reasons outlined for NS, the lack of potassium ions may reduce the risk of hyperkalemia. Patients with end-stage renal disease may also have co-morbid salt-sensitive hypertension and coronary artery disease.30 These
conditions may adversely affect left ventricular function.31 Consequently, the administration of a large volume of a salt solution may cause sodium retention and volume overload, which can worsen cardiac and renal function in these patients.32-34 The lower sodium concentration in half saline may reduce the risk of such events. The risk of hyperchloremic metabolic acidosis may also be reduced with the administration of half saline compared with NS administration. This rationale supported the use of half saline during preoperative and intraoperative periods in kidney transplant patients treated at our hospital. However, the administration of a large volume of hypotonic fluid, such as half saline, may cause dilutional hyponatremia due to its lower sodium concentration. Hyponatremia may contribute to serious brain injury, and efforts to correct hyponatremia may even cause osmotic demyelinating syndrome in patients.35 However, no experience of brain injury has been recorded over several decades in our institute
Several studies have reported that the use of plasma-Lyte in kidney transplantation is associated with a lower prevalence of hyperchloremic metabolic acidosis8,17,19,25 and hyperkalemia events than NS.9 In our study, no significant differences were observed in the incidence of hyperkalemia events between both groups during surgery. This is consistent with previous reports that have compared the use of NS-based crystalloids and balanced crystalloids containing potassium during kidney transplantation.18,29 Metabolic acidosis was more severe in the half-saline group than in the Plasma-lyte group. The buffer components in the Plasma-lyte solution may have contributed to a more favorable acid-base balance.
Early diuresis is a good marker of successful transplantation because it reflects the recovery status of kidney graft function. In this study, administration of Plasma-lyte in the intraoperative period was associated with more urine output on PODs 1 and 2 (p<0.001, both). Similarly, serum creatinine reduction over time was more rapid in the Plasma-lyte group than in the half-saline group (p<0.001). Plasma-lyte use was also associated with better postoperative kidney graft function as measured by eGFR in a multivariable linear analysis at both 1 month and 1 year after transplantation (p<0.001 and p=0.043, respectively). The influence of the type of crystalloid solution used only during the intraoperative period on long-term kidney graft recovery may be limited, as reported previously.8,19 Kidney graft function may be affected by several factors in addition to intraoperative fluid type.36 As metabolic acidosis may negatively affect kidney function, intraoperative fluid management employing improved acid-base balance may be associated with postoperative kidney graft function.37,38 As mentioned above, we administered half saline to prevent hyperchloremic metabolic acidosis. However, acidosis may occur without hyperchloremia. According to the Stewart method to analyze acid-base balance, the strong ion difference (SID) of half saline is zero, which is exactly the same as NS.39 At physiologic pH, the SID is positive. Therefore, continuous administration of half saline can reduce SID and result in metabolic acidosis. In contrast, the SID of Plasma-lyte in vivo is 50, which can increase the SID of the patients and increase the tendency to develop alkalosis.
To maintain adequate intravascular volume, a larger volume of half saline is needed than that of Plasma-Lyte due to the lower tonicity of half saline. This may lead to more distribution of free water to the interstitial space in the half-saline group. Renal interstitial edema might impair renal function because the kidney is an encapsulated organ and could be affected by fluid congestion and elevated tubular pressure.40,41 Identifying a direct association between the type of intraoperative fluid used and graft outcomes at 1-year post-transplantation is challenging. Furthermore, the choice of intraoperative fluid used may affect the early recovery of kidney grafts, and better early graft function may be associated with the long-term outcomes of kidney transplantations.
Our study has a few key limitations. First, as a single-center investigation, the generalizability of this study is limited. In addition, we included only patients who underwent living donor kidney transplantation and excluded deceased donor kidney transplantation. However, this made it possible to maintain homogeneity in surgical technique, intraoperative anesthetic management, and postoperative management including fluid therapy, immunosuppressive regimen, and follow-up protocol. Second, although we tried to reduce indication bias and adjusted baseline demographic differences between groups due to the retrospective design of the study, the design is still unlikely to be perfect. Third, it is uncertain whether the impact of Plasma-lyte on postoperative graft function is due to its favorable intraoperative acid-base balance or chloride concentration. Further study comparing Plasma-Lyte with another type of fluid that is more balanced than half saline and with lower chloride content than Plasma-lyte, such as half saline mixed with 50–75 mEq of sodium bicarbonate, could help determine the intraoperative fluid choice
In conclusion, intraoperative Plasma-lyte use was associated with more favorable results in terms of acid-base balance during kidney transplantation. Compared to the administration of half saline, Plasma-lyte administration did not lead to an increase in the occurrence of hyperkalemia. Patients receiving Plasma-lyte showed superior postoperative graft function at 1 month and 1 year after transplantation. Further studies are needed to evaluate the superiority of intraoperative plasma-Lyte over other types of crystalloids about graft outcomes.
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