Transplant Trial Watch

Effects of intraoperative and early postoperative normal saline or Plasma-Lyte 148 on hyperkalaemia in deceased donor renal transplantation: a double-blind randomized trial.

Weinberg L, Harris L, et al.

British Journal of Anaesthesia 2017; 119(4): 606-615.

To compare the effects of normal saline (NS) versus Plasma-Lyte 148 (PL) given during surgery and for 48h after surgery in patients receiving a deceased donor renal transplant.

Participants were randomised to receive either NS (sodium and chloride) or PL (sodium, potassium, magnesium, chloride, acetate and gluconate), prescribed as a minimum of 2000ml during surgery, then as maintenance infusion after surgery with a starting rate of the previous hour’s urine output plus 30 ml, continued for the first 48h after surgery.

49 adult patients aged ≥ 18 years undergoing deceased donor renal transplantation.

The primary outcome measured was the incidence of hyperkalaemia within 48h of surgery, defined as potassium ≥5.5mmol/litre. Secondary measured outcomes included hyperkalaemia during hospital admission, treatment for hyperkalaemia, requirement for postoperative dialysis, delayed graft function, postoperative complications, and hospital length of stay.

End of hospital stay

CET Conclusions
This is a well conducted and well written study of intra-operative fluids during renal transplantation. The trial was adequately randomised and identical fluid bag designs were provided to keep the staff blinded to the group allocation. There is a good study flow chart presented to show withdrawals and dropouts at each stage, with reasons. In the first 48 hours there was a significant increase in hyperkalaemia and treatment for hyperkalaemia when normal saline was used rather than plasmalyte (80% versus 50%, and 64% versus 21%). The requirement for dialysis management of hyperkalaemia was significantly higher in the normal saline group (52% versus 16%). It should be noted that blinded fluids were continued for 48 hours after surgery. Intra-operatively patients in the saline group were more acidaemic but did not require more intra-operative treatment for hyperkalaemia. Donor and recipient demographics were similar between the groups, with 32% DCD in the saline group and 25% in the plasmalyte group. The study seems small (50 patients), but was adequately powered for the primary outcome. However, it was too small for some secondary outcomes. Overall, this study provides some good evidence that buffered crystalloids carry a lower risk of hyperkalaemia than normal saline following renal transplantation.

Jadad score

Data analysis
Modified intention-to-treat analysis

Allocation concealment

Trial registration
Australian New Zealand Clinical Trials Registry - ACTRN12612000023853

Funding source
Industry & non-industry funded