Your next patient is a 55-year-old man with chronic kidney disease who is presenting for kidney transplantation from a deceased donor. Your resident asks about the use of intravenous (I.V.) balanced crystalloid solution for perioperative volume resuscitation. According to a recent study, which of the following MOST likely describes the risk of delayed graft function in this patient receiving balanced salt solution compared with a patient receiving I.V. saline?

  • □ (A) Higher
  • □ (B) Lower
  • □ (C) Similar
Delayed graft function may occur in 30%-50% of patients receiving a kidney transplant from a deceased donor. Delayed graft function is caused by ischemia-reperfusion injury and can be associated with inferior outcomes. The choice of I.V. fluid administration may contribute to acute kidney injury or other complications, predisposing the recipient to delayed graft function. Saline contains supraphysiological chloride concentration (154 mmol/L) and causes hyperchloremic metabolic acidosis leading to reduced kidney perfusion. Balanced crystalloid solution contains near physiologic levels of sodium. These solutions also have potassium (4-5 mmol/L), which can potentially exacerbate hyperkalemia, increasing the risk of cardiac arrhythmias and the need for acute dialysis. The authors of a recent trial hypothesized that the risk of delayed graft function in recipients of deceased donor kidney transplants would be lower with I.V. fluid therapy with a balanced crystalloid solution (Plasma-Lyte 148; Baxter International Inc.) compared with saline (0.9% sodium chloride).

Better Evidence for Selecting Transplant Fluids (BEST-Fluids) was a pragmatic, double-blind, randomized, controlled trial conducted at 16 hospitals in New Zealand and Australia. Adult and pediatric patients with kidney failure admitted for a deceased donor kidney transplant were eligible. Exclusion criteria included patients receiving a multi-organ transplant and pediatric patients weighing less than 20 kg. A total of 807 study participants were randomized 1:1 to receive either balanced crystalloid solution (n = 404) or saline (n = 403) for maintenance, replacement, and resuscitation intraoperatively and up to 48 hours postoperatively or until cessation of I.V. fluid administration. Baseline characteristics were similar between the two groups.

Delayed graft function, defined as receiving treatment with any form of dialysis within the first seven days after transplantation, was the primary outcome and occurred in 121 (30%) patients in the balanced crystalloid group versus 160 (40%) in the saline group (adjusted relative risk [RR], 0.74; 95% CI, 0.66-0.84) with an adjusted risk difference of 10.1% (95% CI, 3.5-16.6). The rate of adverse events was not found to be different between the groups, with the exception of fewer patients admitted to an intensive care unit for continuous ventilatory support in the balanced crystalloid group versus the saline group (1 vs. 12). Hyperkalemia within two days after transplant occurred in 56% of patients in the balanced crystalloid group versus 57% of patients in the saline group (RR, 1.00; 95% CI, 0.90-1.11).

In summary, this trial demonstrated lower risk of delayed graft function in patients receiving balanced crystalloid solution versus saline solution for perioperative I.V. fluid maintenance, replacement, and resuscitation when undergoing deceased donor kidney transplantation. No difference was found in the rate of adverse events, including hyperkalemia, between the two groups.

Correct answer: B