Preoperative Fluid Management for Kidney Transplant Patients

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, 2, 3
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 2, 3

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, 2, 3
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, 2, 3
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, 2, 3

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 4
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 4
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 4

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, 2, 3
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 4
Hyperchloremia from saline administration is present in approximately 20% of surgical patients and is associated with increased 30-day mortality 2, 3