Intraoperative Fluid Restriction is Associated with Functional Delayed Graft Function in Living Donor Kidney Transplantation: A Retrospective Cohort Analysis

Abstract

Background: In 2016 we observed a marked increase in functional delayed graft function (fDGF) in our living donor kidney transplantation (LDKT) recipients from 8.5% in 2014 and 8.8% in 2015 to 23.0% in 2016. This increase coincided with the introduction of a goal-directed fluid therapy (GDFT) protocol in our kidney transplant recipients. Hereupon, we changed our intraoperative fluid regimen to a fixed amount of 50 mL/kg body weight (BW) and questioned whether the intraoperative fluid regimen was related to this increase in fDGF. Methods: a retrospective cohort analysis of all donors and recipients in our LDKT program between January 2014–February 2017 (n = 275 pairs). Results: Univariate analysis detected various risk factors for fDGF. Dialysis dependent recipients were more likely to develop fDGF compared to pre-emptively transplanted patients (p < 0.001). Recipients developing fDGF received less intraoperative fluid (36 (25.9–50.0) mL/kg BW vs. 47 (37.3–55.6) mL/kg BW (p = 0.007)). The GDFT protocol resulted in a reduction of intraoperative fluid administration on average by 850 mL in total volume and 21% in mL/kg BW compared to our old protocol (p < 0.001). In the unadjusted analysis, a higher intraoperative fluid volume in mL/kg BW was associated with a lower risk for the developing fDGF (OR 0.967, CI (0.941–0.993)). After adjustment for the confounders, prior dialysis and the use of intraoperative noradrenaline, the relationship of fDGF with fluid volume was still apparent (OR 0.970, CI (0.943–0.998)). Conclusion: Implementation of a GDFT protocol led to reduced intraoperative fluid administration in the LDKT recipients. This intraoperative fluid restriction was associated with the development of fDGF.

Frailty and Kidney Transplantation: A Systematic Review and Meta-analysis

“…Although the exact underlying cause of DGF is not completely understood, the variety of risk factors reported for DGF underscores a complex and multifactorial pathophysiological mechanism. 45 Ischemia and reperfusion injury (IRI), inevitable in kidney transplantation most likely is one of the most important underlying mechanisms for non- or delayed function immediately after transplantation. 46 , 47 It is accompanied by tissue injury and a proinflammatory response, resulting in posttransplantation oliguria, increased allograft immunogenicity and risk of acute rejection episodes, and decreased long-term survival.…”

Intraoperative fluid management and kidney transplantation outcomes: A retrospective cohort study

“…Further, some evidence indicates that use of these modalities to guide intraoperative fluid management may increase risk of DGF. In a retrospective study by Nieuwenhuijs‐Moeke et al., 24 goal‐directed fluid therapy in kidney transplantation was associated with an increased incidence of DGF (from 8.8% to 23%). Given these findings, future large, prospective studies evaluating the effectiveness of these modalities in kidney transplantation are needed.…”

The effect of IGL-1 preservation solution on outcome after kidney transplantation: A retrospective single-center analysis

“…Functional DGF (fDGF) was defined as the absence of three consecutive eGFR decreases of >10% during the first week 15 . To prevent misclassification in patients with good early graft function, a known limitation of this definition 16,17 , creatinine evolutions reaching a value of <2 mg/dL on day 3 were considered to not have fDGF. Graft function was determined at 3 and 12 months posttransplant to reflect the estimated glomerular filtration rate (eGFR; CKD‐EPI) 18 , with a nominal value of 10 mL/min/1.73 m 2 imputed in case the graft had failed.…”