Preoperative Fluid Management for Kidney Transplant Patients
Use buffered crystalloid solutions (such as Lactated Ringer's or Plasmalyte) exclusively for preoperative fluid resuscitation in kidney transplant recipients, avoiding 0.9% saline. 1
Recommended Fluid Type
Buffered crystalloid solutions are strongly recommended over 0.9% saline in kidney transplantation (strong recommendation, high-quality evidence from the British Journal of Anaesthesia 2024 guidelines). 1
The American Society of Anesthesiologists Committee on Transplant Anesthesia consensus statement confirms that balanced crystalloid solutions such as Lactated Ringer's are associated with less acidosis and may lead to less hyperkalemia than 0.9% saline solutions. 2
Large volumes of 0.9% saline cause hyperchloremic metabolic acidosis, renal vasoconstriction, and acute kidney injury—particularly problematic in patients about to receive a transplanted kidney. 1
Why This Matters for Transplant Outcomes
Delayed graft function (DGF)—defined as requiring dialysis within the first week post-transplant—is associated with worse outcomes including increased risk of acute rejection, graft failure, and death. 1
A multicentre trial of 808 deceased donor kidney transplant recipients showed that buffered crystalloid solutions reduced the incidence of DGF compared with 0.9% saline. 1
Meta-analyses demonstrate that buffered crystalloids reduce the risk of hyperchloremic metabolic acidosis and hyperkalaemia compared with 0.9% saline in kidney transplant recipients. 1
Fluids to Avoid
Starch solutions should be avoided entirely in kidney transplant recipients as they are associated with increased risk of renal injury in randomized trials. 2
There is no evidence supporting the routine use of albumin solutions in kidney transplants. 2
Synthetic colloids are not recommended due to potential kidney dysfunction risks. 3
Volume Strategy
Aim for adequate volume resuscitation to ensure euvolemia prior to surgery, targeting a mildly positive fluid balance of 1-2 liters by the end of the surgical procedure to protect kidney function while avoiding fluid overload. 3
Both intravascular hypovolemia and fluid overload are harmful and associated with organ dysfunction—this is particularly critical in ESRD patients with comorbidities like hypertension and diabetes who have altered fluid tolerance. 3
A large multicenter RCT of 3,000 patients demonstrated that stringently restrictive fluid regimens resulted in higher acute kidney injury rates compared to modestly liberal regimens. 3
Monitoring Considerations
Central venous pressure (CVP) is only weakly supported as a tool to assess fluid status in kidney transplant recipients. 2
In high-risk patients with significant comorbidities (heart failure, chronic kidney disease), consider hemodynamic monitoring with stroke volume variation (SVV) to guide goal-directed fluid therapy, targeting SVV <10%. 3
Critical Pitfalls to Avoid
Do not use 0.9% saline as your primary resuscitation fluid—the dose-response relationship between volume of 0.9% saline and adverse outcomes means that even moderate volumes can cause harm in this population. 1
Avoid synthetic colloids and routine albumin use, as these provide no benefit and may cause harm. 2
Patients with congestive heart failure, chronic kidney disease, and lung disease have lower fluid tolerance and require more conservative fluid strategies even while maintaining adequate preload. 3
Hyperchloremia from saline administration is present in approximately 20% of surgical patients and is associated with increased 30-day mortality. 1