Balanced crystalloid solution fluid of choice in deceased donor kidney transplantation: Lancet

Among individuals receiving a deceased donor kidney transplant, intravenous fluid therapy with balanced crystalloid solution should be the standard-of-care as it decreases the delayed graft failure when compared to saline. The study was published in the journal The Lancet. 

A significant unfavourable outcome of kidney transplants using deceased donors is delayed graft function (DGF). Patients undergoing transplants frequently receive intravenous fluids to maintain intravascular volume and enhance graft function. Although saline, which contains 0.9% sodium chloride, is routinely used, its high chloride level raises the possibility of DGF. Hence researchers from Australia and New Zealand conducted a study based on the hypothesis that a balanced low-chloride crystalloid solution (Plasma-Lyte 148) instead of saline would reduce the incidence of DGF between Jan 26, 2018, and Aug 10, 2020. 

BEST-Fluids was a viable, multicenter, double-blind, randomized, controlled trial that included 16 hospitals in Australia and New Zealand and was integrated in a registry. The trial was open to adults and kids of any age getting a kidney transplant from a deceased donor. Multi-organ transplant recipients or individuals weighing less than 20 kg were both disqualified. 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. Identical bags were used to supply trial fluids 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.  

Key findings: 

• Nearly 808 participants were randomly assigned to balanced crystalloid (n=404) or saline (n=404). 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.
• Among the transplant recipients there were 512 [63%] males and 296 [37%] females.
• DGF occurred in 121 (30%) of 404 participants in the balanced crystalloid group versus 160 (40%) of 403 in the saline group.
• 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. 

Thus, When compared to saline, intravenous fluid treatment with balanced crystalloid solution decreased the incidence of DGF in patients following a deceased donor kidney transplant. 

Further reading: Balanced crystalloid solution versus saline in deceased donor kidney transplantation (BEST-Fluids): a pragmatic, double-blind, randomised, controlled trial. https://doi.org/10.1016/S0140-6736(23)00642-6