신이식 전후 수액의 선택

신이식 수혜자에서 IV 수액은 수술 전후 체액 유지와 graft function을 최적화 하기 위해 일상적으로 투여됩니다. 비록 0.9% normal saline이 널리 사용되지만 이것은 hyperchloremia, metabolic acidosis, renal vasoconstriction, 감소된 GFR, kidney injury와 관련이 있습니다. 800명 이상의 deceased-donor kidney transplant recipients를 포함한 무작위 시험에서 balanced low-chloride crystalloid solution은 normal saline과 비교하여 delayed graft function (need for dialysis within seven days after transplantation)의 발생률을 줄였습니다 (30% 대 40%).

We select a balanced electrolyte solution (eg, Plasmalyte, Normosol, or Lactated Ringer [also termed Hartmann's solution]), although centers vary in their selection of solutions. Some administer normal saline and a balanced electrolyte solution in a 50-50 combination. We avoid administering >2 to 3 L of normal saline, as this may result in hyperchloremia, hyperchloremic metabolic acidosis, renal vasoconstriction, decreased glomerular filtration rate, and kidney injury. In one randomized trial in 807 recipients of a deceased donor kidney transplant, the incidence of delayed graft function (defined as receiving dialysis in the first seven days after transplantation) was lower among recipients receiving a balanced crystalloid solution compared with those receiving normal saline (30 versus 40 percent, respectively). In another randomized trial in 150 transplant recipients, those receiving normal saline had significantly more hyperchloremia and metabolic acidosis than those receiving an acetate-buffered, chloride-reduced solution, although hyperkalemia was more common in patients receiving the chloride-reduced solution. UpToDate 2023.07.22

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Summary

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Background

Delayed graft function (DGF) is a major adverse complication of deceased donor kidney transplantation. Intravenous fluids are routinely given to patients receiving a transplant to maintain intravascular volume and optimise graft function. Saline (0·9% sodium chloride) is widely used but might increase the risk of DGF due to its high chloride content. We aimed to test our hypothesis that using a balanced low-chloride crystalloid solution (Plasma-Lyte 148) instead of saline would reduce the incidence of DGF.

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Methods

BEST-Fluids was a pragmatic, registry-embedded, multicentre, double-blind, randomised, controlled trial at 16 hospitals in Australia and New Zealand. Adults and children of any age receiving a deceased donor kidney transplant were eligible; those receiving a multi-organ transplant or weighing less than 20 kg were excluded. Participants were randomly assigned (1:1) using an adaptive minimisation algorithm to intravenous balanced crystalloid solution (Plasma-Lyte 148) or saline during surgery and up until 48 h after transplantation. Trial fluids were supplied in identical bags and clinicians determined the fluid volume, rate, and time of discontinuation. The primary outcome was DGF, defined as receiving dialysis within 7 days after transplantation. All participants who consented and received a transplant were included in the intention-to-treat analysis of the primary outcome. Safety was analysed in all randomly assigned eligible participants who commenced surgery and received trial fluids, whether or not they received a transplant. This study is registered with Australian New Zealand Clinical Trials Registry, (ACTRN12617000358347), and ClinicalTrials.gov (NCT03829488).

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Findings

Between Jan 26, 2018, and Aug 10, 2020, 808 participants were randomly assigned to balanced crystalloid (n=404) or saline (n=404) and received a transplant (512 [63%] were male and 296 [37%] were female). One participant in the saline group withdrew before 7 days and was excluded, leaving 404 participants in the balanced crystalloid group and 403 in the saline group that were included in the primary analysis. DGF occurred in 121 (30%) of 404 participants in the balanced crystalloid group versus 160 (40%) of 403 in the saline group (adjusted relative risk 0·74 [95% CI 0·66 to 0·84; p<0·0001]; adjusted risk difference 10·1% [95% CI 3·5 to 16·6]). In the safety analysis, numbers of investigator-reported serious adverse events were similar in both groups, being reported in three (<1%) of 406 participants in the balanced crystalloid group versus five (1%) of 409 participants in the saline group (adjusted risk difference –0·5%, 95% CI –1·8 to 0·9; p=0·48).

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Interpretation

Among patients receiving a deceased donor kidney transplant, intravenous fluid therapy with balanced crystalloid solution reduced the incidence of DGF compared with saline. Balanced crystalloid solution should be the standard-of-care intravenous fluid used in deceased donor kidney transplantation.