Choosing fluids to reduce the risk of delayed graft function after deceased donor kidney transplantation

Abstract

Delayed graft function (DGF) after deceased donor kidney transplantation, defined clinically as the need for at least one dialysis session within the first week after transplantation, is a common occurrence. 1 Swanson KJ Bhattarai M Parajuli S Delayed graft function: current status and future directions. Curr Opin Organ Transplant. 2023; 28: 1-7 Crossref PubMed Scopus (0) Google Scholar Use of organs that are predisposed to DGF is increasing, 2 NHS Blood and TransplantOrgan and tissue donation and transplantation. Activity Report 2021/22. nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/27108/activity-report-2021-2022.pdfDate accessed: March 23, 2023 Google Scholar meaning it is important to consider the clinical sequelae of DGF. In a systematic review and meta-analysis of 38 studies, 3 Li MT Ramakrishnan A Yu M et al. Effects of delayed graft function on transplant outcomes: a meta-analysis. Transplant Direct. 2023; 9: e1433 Crossref PubMed Scopus (1) Google Scholar DGF was associated with adverse short-term and long-term outcomes, including risk for rejection, graft failure, and (in single-centre studies only) all-cause mortality. Some studies suggest the duration of DGF is more important than its occurrence. 4 Schrezenmeier E Müller M Friedersdorff F et al. Evaluation of severity of delayed graft function in kidney transplant recipients. Nephrol Dial Transplant. 2022; 37: 973-981 Crossref PubMed Scopus (2) Google Scholar However, any DGF has a real-world impact on patients and can influence decision making for clinicians. For example, a third of North American transplant professionals indicated in a survey that the risk of DGF had a role in their willingness to accept organs, 5 Jadlowiec CC Hippen B Gill J et al. Current opinions on DGF management practices: a survey of the United States and Canada. Clin Transplant. 2023; 37: e14949 Crossref PubMed Scopus (0) Google Scholar and strategies to reduce DGF are a clinical priority. A simple intervention to reduce DGF might relate to optimising intravenous fluid replacement. Isotonic sodium chloride (0·9% saline) is the standard of care in many transplantation units. However, 0·9% saline might be harmful due to its high chloride content, which causes metabolic acidosis and can promote acute kidney injury, thus DGF. 6 Yunos NM Bellomo R Hegarty C Story D Ho L Bailey M Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA. 2012; 308: 1566-1572 Crossref PubMed Scopus (844) Google Scholar Balanced crystalloid solution versus saline in deceased donor kidney transplantation (BEST-Fluids): a pragmatic, double-blind, randomised, controlled trialAmong 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. Full-Text PDF