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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
LETTER TO THE EDITOR  
Year : 2012  |  Volume : 23  |  Issue : 1  |  Page : 135-137
A comparative study of impact of infusion of ringer's lactate solution versus normal saline on acid-base balance and serum electrolytes during live related renal transplantation


Department of Anaesthesia and Critical Care, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Centre & Dr. H. L. Trivedi Institute of Transplantation Sciences Civil Hospital Campus, Asarwa, Ahmedabad State, Gujarat, India

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Date of Web Publication3-Jan-2012
 

How to cite this article:
Modi MP, Vora KS, Parikh GP, Shah VR. A comparative study of impact of infusion of ringer's lactate solution versus normal saline on acid-base balance and serum electrolytes during live related renal transplantation. Saudi J Kidney Dis Transpl 2012;23:135-7

How to cite this URL:
Modi MP, Vora KS, Parikh GP, Shah VR. A comparative study of impact of infusion of ringer's lactate solution versus normal saline on acid-base balance and serum electrolytes during live related renal transplantation. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2019 Jul 22];23:135-7. Available from: http://www.sjkdt.org/text.asp?2012/23/1/135/91320
To the Editor,

Acid-base imbalance, electrolyte disturbances and hemodynamic instability are common in patients with chronic renal failure (CRF). Optimization of intravascular volume status is crucial to ensure early graft function in patients undergoing renal transplantation. The general consensus is to administer normal saline (NS) and avoid potassium (K+)-containing fluids like Ringer's Lactate (RL) because of the risk of hyperkalemia. However, recent evidence suggests that infusion of a large volume of NS is associated with hyperchloremic metabolic acidosis, which can aggravate pre-existing acidosis and result in hyperkalemia through extra-cellular shift of K+. [1],[2] Also, the high chloride (Cl¯) content of NS may cause vasoconstriction of afferent and efferent arteriolar beds of the kidney and may result in a decrease in the urine output. Therefore, we conducted this prospective, randomized, double­blind clinical trial in patients with CRF undergoing live related renal transplantation.

After obtaining approval of our institute and written informed consent, 74 adult patients aged 18-62 years scheduled for live related renal transplantation were enrolled in the study. Exclusion criteria were severe cardiovascular disease, liver dysfunction, diabetes mellitus and pre-operative serum K+ >5.5 meq/L. A computer randomization program was used for patient group assignments. Group I (n = 37) received RL and group II (n = 37) received NS. The solutions were supplied by our hospital pharmacy after completely covering each bag with opaque tape to ensure blinding to study personnel and patients.

After pre-oxygenation, balanced general anesthesia was induced using intravenous thiopental sodium (5-8 mg/kg), fentanyl (2 ug/kg) and atracurium (10-12 ug/kg), and was maintained with isoflurane (0.5-1%) in an O2-N2O mixture at a 1:1 ratio. It is routine at our center to insert an internal jugular vein catheter after induction of anesthesia to assess preload. Intravenous fluids were administered to maintain the central venous pressure at 12-15 mm, and the total volume of fluid administered was recorded.

Each recipient was given methylprednisolone 500 mg intra-operatively after induction of anesthesia. The right or left kidney was procured from donors via a laparoscopic approach. The donor kidney was flushed with ice cold RL mixed with xylocard before implantation. Mannitol (0.5 g/kg) and frusemide (3 mg/kg) were administered to all patients before release of vascular clamps. At the end of surgery, the study fluid was discontinued and patients were shifted to the intensive care unit where the post-operative fluid therapy was left to the discretion of the nephrologist.

Arterial blood samples were sent for analysis after induction of anesthesia and at hourly intervals throughout the surgical procedure and at the end of surgery. The treatment of hyperkalemia, metabolic acidosis and any other metabolic derangement was left to the discretion of the anesthesiologist. The total urine output on the operation table as well as the total urine volume and serum creatinine on the first postoperative day was recorded.

All data are shown as mean ± SD. Statistical analysis was performed using SPSS 12 for Windows. Comparison of data between groups was determined by using Students "t" test. Intra-group analyses were performed with paired t-tests. For all tests, P-value <0.05 was considered statistically significant.

The demographic characteristics of the recipients were similar in both groups. Both groups received a similar volume of fluid during surgery (RL = 5.25 L, NS = 5.1 L). There were no significant differences between groups with respect to duration of anastomosis and dose of intra-operative mannitol and frusemide. The pH decreased from 7.43 to 7.33 in patients receiving saline, and showed no change in the RL group. There was a significant fall in base excess from -2.73 to -4.97 in the NS group, with a decrease in bicarbonate level [Table 1]. The urine output on the table and total urine output were similar in both groups, while the serum creatinine on day one post-surgery was 2.43 ± 0.87 mg/dL in the RL group and 2.82 ± 0.75 mg/dL in the NS group.
Table 1: Serum electrolytes during serial examinations in the study groups.

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Although NS is the first choice for volume restoration during renal transplantation, [3] little attention has been paid to the effect of K + -containing fluids like RL on acid-base status and electrolyte balance. Results of our study suggest that administration of RL is not only safe but may even be superior to NS, as indicated by stable pH, HCO3¯, Cl¯ and K+ levels compared with patients receiving NS.

The development of metabolic acidosis resulting from infusion of a large volume of NS is a well-recognized phenomenon in recent years, and this is believed to be due to its high Cl¯ content. The mechanism and clinical relevance of this acidosis remains controversial. Some investigators call this "dilutional acidosis." An alternative explanation is given by the Steward model, emphasizing the reduction of strong ion difference (SID). [4] Whatever may be the mechanism, the acidosis is of particular significance in patients undergoing renal transplantation who may already have pre-existing acidosis. The use of a balanced solution like RL averts the risk of intravenous fluid-induced hyperchloremic metabolic acidosis. In our study, the RL group showed stable pH and bicarbonate levels compared with the NS group. Our results are similar to the study by Hadimioglu et al; however, in a study by O'Malley et al, 31% of the patients in the NS group required treatment for metabolic acidosis versus 0% in the RL group. This is likely to be due to the longer duration of surgery (>5 h) and higher total volume of fluids infused (>6 L) compared with our study. [5],[6]

Apart from the development of hyperchloremic metabolic acidosis, high chloride content in NS may be detrimental to renal function by increasing renal vascular resistance. In our study, despite hyperchloremia, urine output on post-operative day one was higher in the NS group; however, serum creatinine on the same day was lower in the RL group, which was not statistically significant.

An important aspect of fluid management in patients undergoing renal transplantation is to minimize the risk of hyperkalemia. There is little or no published evidence to suggest that the administration of K+ -containing fluids causes hyperkalemia in patients with renal failure. The concentration of K + in RL is 5 meq/L, which is small and present in a dilute form, and administered slowly. In an earlier study on patients undergoing renal transplantation, treatment for hyperkalemia was more commonly required in patients who received NS rather than RL. The mechanism implicated was presumably through an extra-cellular shift of K+ caused by acute changes in association with hyperchloremic metabolic acidosis. In our study, rise in serum K + was higher in the NS group compared with the RL group.

Our study suggests that the administration of RL during live related renal transplantation is safe and may even be superior to NS because it avoids the risk of metabolic acidosis and clinically significant hyperkalemia.

 
   References Top

1.Scheingraber S, Rehm M, Sehmisch C, Finsterer U. Rapid saline infusion produces hyperchloremic acidosis in patients undergoing gynecologic surgery. Anesthesiology 1999;90 (5):1265-70.  Back to cited text no. 1
    
2.Prough DS, Bidani A. Hyperchloremic metabolic acidosis is a predictable consequence of intraoperative infusion of 0.9% saline. Anesthesiology 1999;90(5):1247-9.  Back to cited text no. 2
    
3.O'Malley CM, Frumento RJ, Bennett-Guerrero E. Bennett-Guerrero Intravenous fluid therapy in renal transplant recipients: Results of a US survey, Transplant Proc 2002;34(8):3142-5.  Back to cited text no. 3
    
4.Prough DS, White RT. Acidosis associated with perioperative saline administration: dilution or delusion? Anesthesiology 2000;93(5): 1167-9.  Back to cited text no. 4
    
5.O'Malley CM, Frumento RJ, Hardy MA, et al. A randomized, double-blind comparison of lactated Ringer's solution and 0.9% NaCl during renal transplantation. Anesth Analg 2005;100(5):1518-24.  Back to cited text no. 5
    
6.Hadimioglu N, Saadawy I, Saglam T, Ertug Z, Dinckan A. The effect of different crystalloid solutions on acid-base balance and early kidney function after kidney transplantation. Anesth Analg 2008;107(1):264-9.  Back to cited text no. 6
    

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Correspondence Address:
Manisha P Modi
Department of Anaesthesia and Critical Care, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Centre & Dr. H. L. Trivedi Institute of Transplantation Sciences Civil Hospital Campus, Asarwa, Ahmedabad State, Gujarat
India
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PMID: 22237237

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