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.


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.


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.


High percent normal saline administration is associated with delayed graft function in kidney transplant recipients.

Editor’s Perspective
What We Already Know about This Topic
  • Randomized controlled trials of balanced crystalloids versus normal saline have not demonstrated superiority of either strategy in the generalized surgical population
  • Patients undergoing kidney transplantation and receiving normal saline experience the metabolic complications of hyperchloremia
  • The association of normal saline administration with delayed graft function, defined as renal replacement therapy within 1 week of transplant, is unclear
What This Article Tells Us That Is New
  • In a single-center analysis of 2,515 patients undergoing kidney transplantation between 2004 and 2015, delayed graft function occurred in 21% of patients receiving greater than or equal to 80% normal saline, in 17.5% of patients receiving between 30 and 80% normal saline, and in 15.8% of patients receiving less than or equal to 30% normal saline
  • For patients receiving greater than or equal to 80% normal saline compared with patients receiving less than or equal to 30% normal saline, the adjusted odds ratios for delayed graft function were 1.52 (95% CI, 1.05 to 2.21; P = 0.028) for deceased donor transplants (n = 1,472) and 1.66 (95% CI, 0.65 to 4.25; P = 0.287) for living donor transplants (n = 1,043)