Balanced Crystalloids Versus Normal Saline in Kidney Transplant Patients: An Updated Systematic Review, Meta-analysis, and Trial Sequential Analysis

Lucas Carvalho Pereira; Igor Carvalho Pereira; Thamiris Dias Delfino Cabral; Patricia Viana; Arthur Mendonça Ribeiro; Sara Amaral

doi:10.1213/ANE.0000000000006932

Balanced Crystalloids Versus Normal Saline in Kidney Transplant Patients: An Updated Systematic Review, Meta-analysis, and Trial Sequential Analysis

Anesth Analg. 2024 Apr 5. doi: 10.1213/ANE.0000000000006932. Online ahead of print.

Authors

Lucas Carvalho Pereira¹, Igor Carvalho Pereira¹, Thamiris Dias Delfino Cabral², Patricia Viana³, Arthur Mendonça Ribeiro⁴, Sara Amaral⁵

Affiliations

¹ From the Department of Medicine, Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil.
² Department of Medicine, Faculdade de Medicina Souza Marques, Rio de Janeiro, Brazil.
³ Department of Medicine, University of Extreme South of Santa Catarina, Criciuma, Santa Catarina, Brazil.
⁴ Departament of Anesthesiology, Universidade Federal of Rio Grande do Sul, Rio Grande do Sul, Brazil.
⁵ Department of Anesthesiology, Universidade Nova de Lisboa, Lisboa, Portugal.

PMID: 38578867
DOI: 10.1213/ANE.0000000000006932

Abstract

Background: The use of balanced crystalloids over normal saline for perioperative fluid management during kidney transplantation and its benefits on acid-base and electrolyte balance along with its influence on postoperative clinical outcomes remains a topic of controversy. Therefore, we conducted this review to assess the impact of balanced solutions compared to normal saline on outcomes for kidney transplant patients.

Methods: We searched MEDLINE, EMBASE, and Cochrane databases for randomized controlled trials (RCTs) comparing balanced lower-chloride solutions to normal saline in renal transplant patients. Our main outcome of interest was delayed graft function (DGF). Additionally, we examined acid-base and electrolyte measurements, along with postoperative renal function. We computed relative risk (RR) using the Mantel-Haenszel test for binary outcomes, and mean difference (MD) for continuous data, and applied DerSimonian and Laird random-effects models to address heterogeneity. Furthermore, we performed a trial sequential analysis (TSA) for all outcomes.

Results: Twelve RCTs comprising a total of 1668 patients were included; 832 (49.9%) were assigned to receive balanced solutions. Balanced crystalloids reduced the occurrence of DGF compared to normal saline, with RR of 0.82 (95% confidence interval [CI], 0.71-0.94), P = .005; I² = 0%. The occurrence was 25% (194 of 787) in the balanced crystalloids group and 34% (240 of 701) in the normal saline group. Moreover, our TSA supported the primary outcome result and suggests that the sample size was sufficient for our conclusion. End-of-surgery chloride (MD, -8.80 mEq·L-1; 95% CI, -13.98 to -3.63 mEq.L-1; P < .001), bicarbonate (MD, 2.12 mEq·L-1; 95% CI, 1.02-3.21 mEq·L-1; P < .001), pH (MD, 0.06; 95% CI, 0.04-0.07; P < .001), and base excess (BE) (MD, 2.41 mEq·L-1; 95% CI, 0.88-3.95 mEq·L-1; P = .002) significantly favored the balanced crystalloids groups and the end of surgery potassium (MD, -0.17 mEq·L-1; 95% CI, -0.36 to 0.02 mEq·L-1; P = .07) did not differ between groups. However, creatinine did not differ in the first (MD, -0.06 mg·dL-1; 95% CI, -0.38 to 0.26 mg·dL-1; P = .71) and seventh (MD, -0.06 mg·dL-1; 95% CI, -0.18 to 0.06 mg·dL-1; P = .30) postoperative days nor urine output in the first (MD, -1.12 L; 95% CI, -3.67 to 1.43 L; P = .39) and seventh (MD, -0.01 L; 95% CI, -0.45 to 0.42 L; P = .95) postoperative days.

Conclusions: Balanced lower-chloride solutions significantly reduce the occurrence of DGF and provide an improved acid-base and electrolyte control in patients undergoing kidney transplantation.