Perioperative fluid management in kidney transplantation: What’s new and future directives?

Table 1 Different types of perioperative fluids in kidney transplantation

Type of fluid	Pros	Cons
Normal saline	Less expensive, easily available, potassium free	Potentially hypertonic, Risk of hyperchloremic metabolic acidosis, hyperkalemia, decreased GFR and urine output, AKI, and DGF large volume infusion should be avoided
Low chloride solutions (e.g., Kabilyte, Plasm-Lyte A)	Physiologically like plasma, no risk of hyperkalemia, metabolic acidosis, and DGF. Fluid of choice during kidney transplant	More expensive than other crystalloids
Ringer lactate	Balanced crystalloid, isotonic, has buffering capacity, is cost-effective, and safe	Theoretical risk of lactic acidosis and hyperkalemia
Hydroxyethyl starch	Volume expander, easily available	Risk of AKI, renal replacement therapy, and coagulopathy
Albumin	Increases plasma oncotic pressure, antioxidant properties, immunomodulation, protection from ischemia-reperfusion injury, less requirement of crystalloids, and vasopressors	Increased cost, risk of allergic reactions, and disease transmission. No benefit or increased risk of volume-related complications in recipients with cardio-pulmonary compromise. Routine use is not recommended

GFR: Glomerular filtration rate; AKI: Acute kidney injury; DGF: Delayed graft function.

Table 2 Intraoperative hemodynamic monitoring to assess fluid responsiveness

Hemodynamic indices	Advantages and targets	Limitations
Central venous pressure	Relatively cheap, measures right atrial pressure to predict volume status 1-2 kPa, upper and lower limits vary among institutions	Static parameter, complications associated with central venous cannulation (injury to major vessels, haematoma, and infection, etc.), erroneous results in PAH, valvular heart disease, and pulmonary disease, etc., poorly predict volume status. No benefit in post-transplant renal function recovery
Pulse pressure variation/stroke volume variation	Dynamic indices, minimally invasive, easy to interpret, and high accuracy. Decreased incidence of DGF in postoperative periods. 6%-15% varies among institutions	Confounding factors: Low tidal volume (< 8 mL/kg), spontaneous ventilation, high PEEP, and arrhythmias
Stroke volume	Dynamic index, minimally invasive, easy to interpret, and more accurate. Reduced incidence of DGF in postoperative periods% change in stroke volume (</> 10%)	Confounding factors: Low tidal volume (< 8 mL/kg), spontaneous ventilation, high PEEP, and arrhythmias
Transoesophageal Doppler	Dynamic index, non-invasive, continuous, real-time, and more accurate reduces requirements of intraoperative fluids along with fluid-related complications (tissue edema, dyspnoea)	Equipment cost, operator dependent, requires training, risk of oesophageal injury
Invasive blood pressure	Beat-to-beat monitoring of arterial pressure, post reperfusion MAP ≥ 11 kPa, varies among institutions	Difficult arterial line placement due to AV fistula or objected by treating physicians, risk of infection, hematoma, etc. No specified targets, depends on donor and recipient’s characteristics (age, co-morbidities, and type of donation)

PAH: Pulmonary artery hypertension; PEEP: Positive end expiratory pressure; DGF: Delayed graft function; AV: Arterio-venous; MAP: Mean arterial pressure.