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Half Saline-Bicarbonate Solution as Intraoperative Fluid Replacement Therapy Leads to Less Acidosis and Better Early Renal Function During Deceased-Donor Transplant

Exp Clin Transplant. 2020 Feb;18(1):34-38 doi: 10.6002/ect.2018.0328.

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Abstract

OBJECTIVES:

Normal saline is the most common crystalloid solution that is used in renal transplant surgery. In this study, our aim was to determine the effects of a combination of half saline and bicarbonate versus normal saline as a routine solution.

MATERIALS AND METHODS:

For this double-blind random-ized clinical trial, we enrolled 100 adult patients undergoing kidney transplant. Patients were divided into 2 groups: those who received normal saline and those who received half saline and bicarbonate infusion as fluid replacement therapy during renal transplant. All patients received about 40 mL/kg of crystalloids during surgery. Serial creatinine con-centrations (primary outcomes) were compared between groups at 1, 2, 3, and 7 days after surgery. Urine output (secondary outcome) was compared between groups at recovery and at 6 and 24 hours after surgery. In addition, base excess, chloride, and sodium levels were measured before and 6 hours after surgery. Each liter of half saline-bircarbonate, which is relatively isoosmotic to human plasma, was composed of 70 mEq bicarbonate, 77 mEq chloride, and 147 mEq sodium.

RESULTS:

Patients who received half saline-bicarbonate had significantly lower postoperative creatinine levels at all time points than patients who received normal saline (P = .019). Serum chloride and sodium levels (P = .001) were significantly higher and base excess (P = .007) was significantly lower in the normal saline group at 6 hours after transplant. At all time points, urine output levels were significantly higher in the half saline-bicarbonate group (P = .001).

CONCLUSIONS:

The use of half saline-bicarbonate was associated with better early graft function compared with normal saline in the first 7 days after transplant.

CET Conclusion

Reviewer:	Mr John O'Callaghan, Centre for Evidence in Transplantation, The Royal College of Surgeons of England.
Conclusion:	This is a well-written and well-conducted RCT in renal transplantation. It was computer randomised and attempt was made at double-blinding, although this may not have been completely effective; the two solutions were made up by the hospital pharmacy in “the same-shape containers and with similar labels”. Sealed envelopes were used, which is not a fully satisfactory method to ensure allocation concealment. In this study the intra-operative administration of half saline-bicarbonate was associated with less hyperchloremic metabolic acidosis, improved urine output, and quicker fall in creatinine post-operatively. A previous Cochrane review concluded that low-chloride fluids were beneficial in renal transplantation for the prevention of metabolic acidosis, although with no proven effect on transplant outcomes (Wan et al 2016). This study finds a significant early benefit, but longer-term outcomes were not reported here. Rather than mandating the fluid used, perhaps a tight control of intra-operative acid-base balance is the important factor, as has previously been shown; this can then be applied to the population of patients that were excluded from this study (high potassium, intra-operative transfusion and low perioperative base excess or bicarbonate levels).

Reviewer:

Mr John O'Callaghan, Centre for Evidence in Transplantation, The Royal College of Surgeons of England.

Conclusion:

This is a well-written and well-conducted RCT in renal transplantation. It was computer randomised and attempt was made at double-blinding, although this may not have been completely effective; the two solutions were made up by the hospital pharmacy in “the same-shape containers and with similar labels”. Sealed envelopes were used, which is not a fully satisfactory method to ensure allocation concealment. In this study the intra-operative administration of half saline-bicarbonate was associated with less hyperchloremic metabolic acidosis, improved urine output, and quicker fall in creatinine post-operatively. A previous Cochrane review concluded that low-chloride fluids were beneficial in renal transplantation for the prevention of metabolic acidosis, although with no proven effect on transplant outcomes (Wan et al 2016). This study finds a significant early benefit, but longer-term outcomes were not reported here. Rather than mandating the fluid used, perhaps a tight control of intra-operative acid-base balance is the important factor, as has previously been shown; this can then be applied to the population of patients that were excluded from this study (high potassium, intra-operative transfusion and low perioperative base excess or bicarbonate levels).

Methodological quality

Jadad score	4
Allocation concealment	YES
Data analysis	STRICT INTENTION TO TREAT

Study Details

Aims:	The aim of this study was to determine the effects of a combination of half saline and bicarbonate versus normal saline as a routine solution.
Interventions:	Patients were divided into either those who received normal saline, or those who received half saline and bicarbonate infusion as fluid replacement therapy during renal transplant.
Participants:	100 adult patients undergoing kidney transplantation.
Outcomes:	Primary outcome was measured as serial creatinine concentration at days 1, 2, 3, and 7 after transplantation. Secondary outcome were measured as urine output at recovery, 6 hours and 24 hours after transplant. Additonally, chloride, and sodium levels were analyzed before operation and at 6 hours posttransplant.
Follow Up:	N/A

Metadata

Publication type:	Randomized Controlled Trial, Randomised Controlled Trial
Organ:	Kidney
Language:	English
MeSH terms:	Acid-Base Equilibrium; Acidosis; Adult; Bicarbonates; Biomarkers; Creatinine; Double-Blind Method; Female; Fluid Therapy; Humans; Intraoperative Care; Iran; Kidney Transplantation; Male; Middle Aged; Saline Solution; Time Factors; Treatment Outcome; Young Adult; 0 (Bicarbonates); 0 (Biomarkers); 0 (Saline Solution); AYI8EX34EU (Creatinine)