Balanced fluid therapy and early kidney function in patients undergoing renal transplantation

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Background: Fifty people die every day in Australia with kidney related disease with recent data from December 2009 showing that 1,105 of the 10,341 people receiving dialysis (11%) were on the renal transplant waiting list. Only about 6% receive a transplant each year and when patients present for transplantation, intravenous fluid therapy is critical to ensure optimal graft perfusion and function. Fluid therapy is important to maintain intravascular volume during and after kidney transplantation whilst avoiding metabolic and electrolyte disturbances which may further compromise graft function. Traditionally normal saline (NS) or potassium-free fluids are the IV fluid therapy of choice in the perioperative period for patients undergoing kidney transplantation. The rationale for using NS is the avoidance of the administration of large volumes of potassium which is present in small concentrations in Plasmalyte solution (5mmol/L). The potassium contained in Plasmalyte solution may contribute to hyperkalemia although current evidence suggests that balanced fluid solutions may confer clinical benefits over NS as the administration of large volumes of NS has been strongly associated with the development of hyperchloremic metabolic acidosis which in turn may cause hyperkalemia through an extracellular shift of potassium. Study rationale: There are very few studies comparing the different types of crystalloid fluids that patients receive when undergoing renal transplantation. In order to prevent delayed graft function it is common for patients to receive 4 to 8 litres/day of crystalloid therapy per day to maintain sufficient intravascular volume. The commonest fluid used for patients undergoing renal transplantation at Austin Hospital is 0.9% Normal Saline, however its use is associated with severe metabolic disturbances. There is emerging evidence that for patients undergoing renal transplantation who receive a balanced crystalloid instead of Normal Saline, there may be beneficial effects on the incidence of early allograft dysfunction and electrolyte disturbances. Hypothesis: When used as crystalloid therapy for patients undergoing renal transplantation will the balanced crystalloid fluid Plasmalyte Solution, have more favourable effects on metabolic acidosis and early graft function compared to 0.9% Normal Saline. Study design: Single centre randomised controlled blinded study. Inclusion criteria: Adult patients (age > 18years) undergoing deceased donor renal transplantation (heart-beating or non heart-beating). Primary endpoint: 1. Standard base deficit immediately post surgery in the Post Anaesthesia Care Unit and at 24 hours & 48 hrs postoperatively 2. Serum potassium levels in the Post Anaesthesia Care Unit and at 24 hours & 48 hrs postoperatively 3. Serum Creatinine Secondary endpoints: 4. Strong-ion-difference 5. Serum Albumin 6. Serum Phosphate 7. Renal biomarkers including: serum and urine NGAL and Cystatin C 8. Requirement for Renal Replacement Therapy 9. Duration of Hospital Stay 10. Adverse events including myocardial infarction, pneumonia, cardiac arrythmias, pulmonary embolism, heart failure 11. Death within 30 postoperative days No of participants: 50 Recruiting Hospital: Austin Hospital Clinical significance: A finding that Plasmalyte solution has more favourable effects on renal transplant associated acidosis, strong-ion difference, hyperkaleamia and delayed graft function may influence the fluid chosen for patients undergoing renal transplantation.