BEST-Fluids Supports Balanced Crystalloids for Deceased Donor Transplant

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Compared with saline solution, intravenous fluid therapy with a balanced crystalloid solution reduces the incidence of delayed graft function (DGF) after deceased donor kidney transplantation, reports a pragmatic randomized trial in The Lancet.

The double-blind Better Evidence for Selecting Transplant Fluids (BEST-Fluids) trial enrolled 808 patients undergoing deceased donor kidney transplantation at 16 hospitals in Australia and New Zealand between 2018 and 2020. The patients were 512 males and 296 females; mean age, 55 years; and four patients younger than 16 years old. Patients were randomly assigned to receive intravenous balanced crystalloid solution (Plasma-Lyte 148) or saline solution during surgery and up to 48 hours afterward. DGF, defined as need for dialysis within 7 days, was the main outcome of interest.

Incidence of DGF was 30% in the group assigned to balanced crystalloid solution compared with 40% in the saline group: adjusted relative risk, 0.74. The advantage of balance crystalloid solution persisted in sensitivity and subgroup analyses. The benefit appeared larger in patients receiving kidneys from donors after circulatory death compared with donors after brain death.

Secondary outcomes were similar between groups, including a ranked composite outcome of duration of DGF and creatinine reduction ratio on day 2. Serious adverse events occurred in three patients in the balanced crystalloid group and five in the saline group.

The choice of intravenous fluid therapy might affect the risk of DGF after deceased donor kidney transplant. Saline solution is the most common type of fluid therapy but may increase DGF risk due to its high sodium content. Previous data comparing balanced crystalloids with saline have shown low certainty of evidence.

The BEST-Fluids results show a reduced risk of DGF in deceased donor kidney recipients assigned to balanced crystalloid solution. Balanced crystalloids prevent approximately one case of DGF for every 10 patients treated, with no increase in serious adverse events or hyperkalemia. The investigators conclude: “Balanced crystalloid solution should be the standard-of-care intravenous fluid used in deceased donor kidney transplantation” [Collins MG, et al. Balanced crystalloid solution versus saline in deceased donor kidney transplantation (BEST-Fluids): A pragmatic, double-blind, randomised, controlled trial. Lancet 2023; 402:105–117. doi: 10.1016/S0140-6736(23)00642-6].