CARI Guideline: Evidence-Based Recommendations for Balanced Electrolyte Solutions to Improve Kidney Transplant Outcomes

Kidney transplantation is an optimal treatment for kidney failure; however, delayed graft function is a common complication with a prevalence of up to 40% in deceased donor transplantation. The use of i.v. fluids during kidney transplantation is required for hemodynamic stability; however, there are concerns that normal saline may contribute to increased delayed graft function and hyperchloremic metabolic acidosis. Balanced electrolyte solutions have been suggested as an alternative i.v. fluid that may decrease delayed graft function. However, there have been concerns that this may increase hyperkalemia in transplant recipients. This guideline seeks to synthesize the available evidence and make recommendations for the Australian and New Zealand care by a multidisciplinary working group, including consumers with lived experience of kidney transplantation. A recently published systematic review and meta-analysis of randomized controlled trials (RCTs), including data from the BEST Fluids trial, evaluating balanced electrolyte solutions versus normal saline in kidney transplants was identified and absolute effects were determined using baseline risks of SONG Transplant Core outcomes from either national registries or event rates in the control arms of the included trials. All outcomes were assessed using the GRADE certainty of evidence. The GRADE Evidence-to-Decision framework was used to develop recommendations for care and clinical practice points. Balanced electrolyte solution compared with normal saline resulted in an 18% reduction in delayed graft function (7 studies, 1306 participants, risk ratio: 0.82; 95% confidence interval [CI]: 0.71-0.94) and no differences across living and deceased donation were evident. In deceased donation, balanced electrolyte solution compared with normal saline has a clinically important decrease in delayed graft function (69 fewer per 1000 patients; 95% CI: 111 to 23 fewer]). The use of balanced electrolyte solution compared with normal saline has an unclear effect on hyperkalemia but it may be no different (66 fewer per 1000 patients; 95% CI: 207 fewer to 136 more). In living donation, the use of balanced electrolyte solutions had very small benefits on the risk of delayed graft function (7 few per 1000 patients; 95% CI: 12 fewer to 2 fewer). In those receiving a living donor kidney transplant, the effects of balanced electrolyte solutions compared with normal saline on hyperkalemia were unclear but are likely to be no different (25 fewer per 1000 patients; 95% CI: 79 fewer to 52 more). Balanced electrolyte solutions are recommended for deceased donor transplants, with a moderate certainty of evidence. However, in living donation transplants balanced electrolyte solutions are only suggested with a low degree of certainty of evidence. Further research is needed on patient-centered outcomes and the use of balanced solutions in pediatric populations to optimize kidney transplant care.