Perioperative Normal Saline Administration and Delayed Graft Function in Patients Undergoing Kidney Transplantation: A Retrospective Cohort Study
“Background: Perioperative normal saline administration remains common practice during kidney transplantation. The authors hypothesized that the proportion of balanced crystalloids versus normal saline administered during the perioperative period would be associated with the likelihood of delayed graft function.
Methods: The authors linked outcome data from a national transplant registry with institutional anesthesia records from 2005 to 2015. The cohort included adult living and deceased donor transplants, and recipients with or without need for dialysis before transplant. The primary exposure was the percent normal saline of the total amount of crystalloids administered perioperatively, categorized into a low (less than or equal to 30%), intermediate (greater than 30% but less than 80%), and high normal saline group (greater than or equal to 80%). The primary outcome was the incidence of delayed graft function, defined as the need for dialysis within 1 week of transplant. The authors adjusted for the following potential confounders and covariates: transplant year, total crystalloid volume, surgical duration, vasopressor infusions, and erythrocyte transfusions; recipient sex, age, body mass index, race, number of human leukocyte antigen mismatches, and dialysis vintage; and donor type, age, and sex.
Results: The authors analyzed 2,515 records. The incidence of delayed graft function in the low, intermediate, and high normal saline group was 15.8% (61/385), 17.5% (113/646), and 21% (311/1,484), respectively. The adjusted odds ratio (95% CI) for delayed graft function was 1.24 (0.85 to 1.81) for the intermediate and 1.55 (1.09 to 2.19) for the high normal saline group compared with the low normal saline group. For deceased donor transplants, delayed graft function in the low, intermediate, and high normal saline group was 24% (54/225 [reference]), 28.6% (99/346; adjusted odds ratio, 1.28 [0.85 to 1.93]), and 30.8% (277/901; adjusted odds ratio, 1.52 [1.05 to 2.21]); and for living donor transplants, 4.4% (7/160 [reference]), 4.7% (14/300; adjusted odds ratio, 1.15 [0.42 to 3.10]), and 5.8% (34/583; adjusted odds ratio, 1.66 [0.65 to 4.25]), respectively.
Conclusions: High percent normal saline administration is associated with delayed graft function in kidney transplant recipients.”
Comments by Scott Byram M.D.
This article1 from Anesthesiology was chosen because of the extremely common and often contentious debate on choice of crystalloid during renal transplantation. Many anesthesiologists prefer to avoid lactated ringers or PlasmaLyte (Baxter International Inc., USA) in favor of normal saline, because of the perceived risk of perioperative hyperkalemia after high volume resuscitation with potassium-containing crystalloids. Conversely, several studies have actually shown MORE hyperkalemia with normal saline administration due to hyperchloremic acidosis and subsequent extracellular potassium shift.
This study was a retrospective database review of 2515 patients who received a renal transplant from 2005-2015 at a single institution. The authors grouped patients into 3 groups based on percent of fluid resuscitation consisting of normal saline (low ≤30%, intermediate 30-80%, and high ≥80%). The primary outcome variable was delayed graft function as defined by need for hemodialysis within 1 week of transplantation. The results of this study showed the incidence of delayed graft function was 15.8%, 17.5%, and 21% respectively in the low, intermediate, and high saline groups. This association was still seen regardless of donor type (deceased vs. living); however, the magnitude was much greater in deceased donors. The authors speculated that the delayed graft function in the high saline group was due to a high chloride load causing decreased renal perfusion and glomerular filtration rate, which has been previously demonstrated in animal and volunteer studies. In this retrospective cohort study, a high percentage of normal saline administration was associated with delayed graft function in renal transplant recipients.
Kolodzie K, Cakmakkaya OS, Boparai ES, Tavakol M, Feiner JR, Kim MO, Newman TB, Niemann CU. Perioperative Normal Saline Administration and Delayed Graft Function in Patients Undergoing Kidney Transplantation: A Retrospective Cohort Study. Anesthesiology. 2021 Oct 1;135(4):621-632. doi: 10.1097/ALN.0000000000003887. Erratum in: Anesthesiology. 2022 Jan 1;136(1):251. PMID: 34265037.