Fluid management in kidney disease patients for nontransplant and transplantation surgeries

Amal Francis Sam; Sandeep Sahu; Karthik T Ponnappan

doi:10.4103/BJOA.BJOA_203_20

REVIEW ARTICLE

Year : 2021 | Volume : 5 | Issue : 1 | Page : 26-32

Fluid management in kidney disease patients for nontransplant and transplantation surgeries

Amal Francis Sam¹, Sandeep Sahu¹, Karthik T Ponnappan²
¹ Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
² Institute of Liver and Biliary Sciences, New Delhi, India

Date of Submission	01-Sep-2020
Date of Decision	29-Oct-2020
Date of Acceptance	30-Oct-2020
Date of Web Publication	8-Feb-2021

Correspondence Address:
Prof. Sandeep Sahu
Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/BJOA.BJOA_203_20

Abstract

Kidneys play an essential role in the regulation of water homeostasis, electrolyte balance, and acid–base balance. Anesthesiologists are frequently involved in the perioperative care of patients with kidney disease in elective and emergency scenarios. Fluid therapy is a main component of resuscitation to improve cardiac output, blood pressure, and perfusion pressure. This sometimes comes at a cost of increased risk of tissue edema due to fluid overload. Both during the transplant and nontransplant surgeries, the use or choice of fluid may influence the biochemical environment or homeostasis of human body and clinical outcomes. In this narrative review, we address the electrolyte and acid–base changes in renal disease, pharmacology of fluids, hemodynamic monitoring, and their applications.

Keywords: Fluid management, kidney diseases, nontransplantation, perioperative, transplantation surgeries

How to cite this article:
Sam AF, Sahu S, Ponnappan KT. Fluid management in kidney disease patients for nontransplant and transplantation surgeries. Bali J Anaesthesiol 2021;5:26-32

How to cite this URL:
Sam AF, Sahu S, Ponnappan KT. Fluid management in kidney disease patients for nontransplant and transplantation surgeries. Bali J Anaesthesiol [serial online] 2021 [cited 2023 Mar 22];5:26-32. Available from: https://www.bjoaonline.com/text.asp?2021/5/1/26/308891

Introduction

Anesthesiologists are frequently involved in the perioperative care of kidney disease patients in both transplant and nontransplant surgeries. Common surgeries performed in this group of patients are access for dialysis, surgery for cardiovascular diseases, and renal transplantation.^[1] After progression to end-stage kidney disease, kidney transplantation is the treatment of choice, and successful transplantation improves the quality of life.^[2] Kidney transplantation is the most performed organ transplantation.^[3]

Surgeries unrelated to kidney diseases include surgery for gallstone diseases, hernia repair, and orthopedic surgeries among others. In the patients undergoing joint replacement, 27% had chronic kidney disease (CKD) because of analgesic overuse or abuse and it was associated with increased morbidity.^[4] Thereby, it is important for the anesthesiologist to know the pathophysiology of the disease and the management strategies to improve the outcome in these patients. Fluid management is a critical aspect of patient care in patients with renal impairment, due to the narrow margin of safety regarding fluid and electrolytes. if less fluid is given may cause acute kidney injury (AKI) or if more is transfused may cause fluid overload causing pulmonary edema and congestive heart failure.

Fluid Therapy

Fluids are like drug therapy; we need to choose the specific type of fluid for the individual patient and not as generalized therapy, just any fluid to expand the intravascular space. Indications of fluid therapy can be divided into resuscitation, maintenance, replacement, and nutrition. This classification is based on the clinical scenario for which the fluid is administered.

Resuscitation fluids are used during hypovolemia or shock to expand the intravascular volume, for improving cardiac output and perfusion pressures. Expected characteristics of ideal intravenous fluid for resuscitation are given in [Table 1].^[5] Maintenance fluids are for daily basal requirements and for replacing the renal and insensible losses of water and electrolytes. It also supplies the daily basal needs of dextrose, sodium, and potassium. Replacement fluids are for the replacement of special losses such as diabetes insipidus, and parenteral nutrition is considered as nutritional fluid.

Table 1: Characteristics of an ideal intravenous fluid

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Crystalloids

Crystalloids are the first-line of choice in fluid therapy. They are solutions that contain small molecules, cheap, and easy to use. These solutes are freely permeable through capillary membranes.^[6] Crystalloids have tonicity as same as of plasma, with most of the solutions having osmolality between 240 and 340 mOsm/kg.^[7]

Normal saline

In renal disease patients, it is a common practice to prefer normal saline (0.9%NaCl, also called as NS), as it is devoid of potassium. However, studies have shown that potassium levels are higher with the use of NS when compared to potassium-containing balanced crystalloids.^[8] Another disadvantage of NS is its high chloride content when compared to plasma. The supraphysiological levels of chloride in NS inhibit blood flow to the glomerulus and decrease urine output.^[9] Furthermore, NS infusion causes hyperchloremic metabolic acidosis which can be explained by the “strong ion difference (SID)” theory.^[10] The strong cations in the body are sodium and potassium, and the strong anion is chloride.

SID of plasma is around 40 mEq/L due to the higher concentration of sodium. Lowering of SID (towards zero) causes acidosis, and an increase in SID is associated with alkalosis. Chloride content is 98 to 106 mEq/L in plasma and 154 mEq/L in NS. When we do resuscitation with large amount of NS, the chloride levels tend to increase in blood. This decreases the SID and causes hyperchloremic metabolic acidosis. Furthermore, an increase in serum chloride levels of more than 7 mEq/L during the hospital stay is associated with higher mortality.^[11]

Balanced crystalloids

Ringer's solution was introduced in 1882 and later Hartmann modified it in 1934 by adding lactate.^[12],[13] Lactate (or acetate– in Ringer's acetate) gets converted to bicarbonate in the liver. There were unsubstantiated concerns regarding higher blood lactate levels compared to NS resuscitation. The largest rise in lactate levels reported is 2 mmol/L after infusing 60 ml/kg of RL over 2 h and this mild-to-moderate hyperlactatemia was not associated with acidosis.^[14]

Other balanced crystalloids, such as multiple electrolyte solution type 1 Plasma-Lyte^® (PL) and Sterofundin^®, have chloride content of around 111–127 mEq/L and have precursors of bicarbonates such as lactate, acetate, and malate. When compared to lactate, acetate is converted to bicarbonate much faster (within 15 min) and is also not dependent on the liver for its metabolism.^[15]

SPLIT trial shows no differences between NS and balanced crystalloid resuscitation in the incidence of AKI and mortality in ICU.^[16] In a study involving patients with diabetic ketoacidosis, those treated with PL^® had higher serum bicarbonate, better base deficit, lower chloride levels, lower potassium levels, higher mean arterial pressure (MAP), and higher urine output when compared to those resuscitated with NS.^[17] Despite better biochemical parameters, balanced crystalloids such as PL have not shown a reduction in mortality, when compared with NS.^[18]

Colloids

Colloid stays in the intravascular compartment for a longer time and it minimizes the volume infused during resuscitation compared to crystalloids. The volume of expansion of colloids is 5 times than crystalloids studying its properties, whereas in the clinical setting, the expansion is just 1.2–1.4 times.^[19] The endothelial glycocalyx model has suggested that at low capillary filling pressures (hypovolemia), crystalloids tend to stay in the intravascular compartment and colloid is not superior in expanding the intravascular volume.^[20]

In achieving a hemodynamic endpoint, colloids are superior to crystalloids. Meta-analysis has shown that targets such as CVP, MAP, and cardiac index were achieved effectively, with lower volumes of colloids compared to crystalloids. However, colloids failed to show any mortality benefit at 30 and 90 days.^[21],[22] If the clinician has decided to use colloid, “what would be the ideal colloid in kidney disease patients?”, will be the next question. For Hydroxyl ethyl starch (HES), most of the studies showed an increased incidence of AKI , renal replacement therapy (RRT), and mortality in critical ill patients in ICU.^[23] In a retrospective study, 6% HES 130/0.4 was associated with a higher incidence of AKI, but with a 50% lower incidence of RRT when compared with saline.^[24]

Gelatin is another commonly used colloid. With the gelatin use, the risk ratios (outcome in exposed to unexposed) was 1.15 for mortality, 1.10 for need of blood transfusion, 1.35 for acute kidney injury (AKI), and 3.01 for anaphylaxis compared to albumin and crystalloid use.^[25] HES and gelatin colloids are clearly not for patients with pre-existing renal disease. Albumin has been found to be safe among colloids and also found to decrease new-onset AKI in sepsis.^[26],[27] Proposed mechanisms by which albumin provides nephroprotection in sepsis are maintaining the integrity of endothelial glycocalyx, improvement in microcirculation, buffering property, anti-inflammatory property, and antioxidant.^[28] To our knowledge, there is no evidence for the use of albumin in CKD and in renal transplant surgery. Attention should be paid to the large amount of volume infused or fast rate of infusion as hypervolemia, is a common problem in CKD / ESRD group of patients perioperatively.

Kidney Diseases and Nontransplant Surgery

The changes that occur in CKD are listed in [Table 2], and almost all types of electrolyte imbalance occur in CKD. Preoperatively, in CKD patients, the history of dialysis, type, frequency of dialysis, and daily urine output should be noted. Physicians should be aware of volume removed as ultrafiltration in the last hemodialysis (HD). Kidney disease patients can be hypervolemic or hypovolemic. CKD patients who are noncompliant to maintenance HD can be in a hypervolemic state. On the other hand, a patient who is in the recovery phase of AKI or obstructive uropathy can be a dehydrated polyuric patient.^[35] The patient's dry weight and current weight provide objective information on the current volume status. Clinical signs, including sunken eyeballs, skin turgor, dryness of tongue, orthostatic difference in blood pressure, and collapsed neck veins, may suggest volume depletion.^[36]

Table 2: Electrolyte imbalance and its incidence in the kidney disease patients

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Intraoperative Management

Hemodynamic monitoring varies from response to a simple fluid challenge^[37] to more advance transoesophageal echocardiography (TEE).^[38] Recently used parameters are stroke volume variation (SVV), pulse pressure variation (PPV).^[39] The benefits of minimally invasive hemodynamic monitors need to be weighed against their potential unnecessary use in low-risk surgeries. In the case of intermediate-to-high-risk surgeries, use of invasive and minimally invasive cardiac monitors is justified.

Goal-directed fluid therapy, guided through either PPV, SVV, TEE, or transesophageal Doppler (TED), is followed. PPV monitoring is relatively simpler, with the need for an arterial cannula and a compatible monitor, Whereas SVV needs arterial cannula and advanced cardiac output monitor to continuously calculate stroke volume and SVV.^[40] In both SVV and PPV, a value of more than 13% implicates fluid responsiveness. TEE needs expertise and had learning curve for the anaesthesiologist. Eyeball assessment of left ventricular volume, velocity-time integral, and respiratory variation of aortic flow velocity can be used to determine fluid responsiveness in TEE.^[41] TED is relatively easier when compared to TEE, with respect to the interpretation of data and the learning curve. However, obtaining optimal waveform in TED might be difficult in a few patients. Flow time (corrected) is monitored in TED and its normal value is 330 to 360 milliseconds.^[42] Reduction in FTc is a marker of reduced preload and fluid responsiveness. In both SVV and PPV, a value of more than 13% implicates fluid responsiveness. Fluid challenges if needed are better to be given in increments of 250 ml. Maintenance fluids are aimed at renal and insensible losses for a positive balance of 500 ml/day. Hourly input is calculated from the previous hour's urine output plus a 25–30 ml for insensible losses [Table 3].^[43] Loss from the nasogastric tube, intraoperative blood loss, and other losses should be additionally calculated and replaced. Intraoperative weight gain of more than 10 kg, which reflects volume gain, is associated with adverse outcomes postoperatively.^[44]

Table 3: Approach to the fluid management in chronic kidney disease

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In the case of neuraxial anaesthesia/ block in CKD patients, it is better to manage hypotension with vasopressors rather than fluid boluses. Once the effect wears off, return of the vasomotor tone will cause return of administered fluid to the central compartment and might lead to hypervolemia.

Fluid Therapy in Renal Transplantation

Intraoperative period of renal transplantation can be divided into two phases. The first phase is the one prior to the reperfusion and the second is after reperfusion of the graft. Prior to reperfusion, physicians should not assume the patients as hypervolemic as they are usually adequately dialyzed. Frequency of HD and weight gain between HD and the amount of ultrafiltration during each session will decide the patients' volume status. The patient is equally liable to be hypovolemic.

Choice of Fluid in Renal Transplantation

In the second phase of surgery, reperfusion introduces metabolites from the graft, leading to acidosis in the recipient. Moreover, preexisting acidosis in the recipients warrants the careful selection of crystalloid. Hadimioglu et al.^[45] performed a randomized clinical trial comparing PL, Hartmann's solution, and NS as an intraoperative fluid replacement in ninety patients undergoing renal transplantation. Those receiving NS had higher chloride, lower pH, and lower base excess. Moreover, those patients receiving Hartmann's had elevated lactate levels. Potassium levels, urine output, and creatinine were similar between groups.

PL has shown a lesser incidence of postoperative dialysis, shorter length of stay, lower potassium levels, and lesser acidosis, in patients undergoing renal transplantation.^[46] PL is also associated with better MAP compared to the NS group.^[47] The use of NS alternating with balanced crystalloids showed lower serum chloride; lower serum creatinine levels at day 2, 3, and 7; and higher urine output when compared with patients who got NS alone.^[48] Other studies comparing different crystalloids are shown in [Table 4]. Nonlactate containing balanced crystalloid solutions are the preferred choice of fluids in renal transplantation.

Table 4: Comparison of crystalloids

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Phases of Fluid Therapy in Renal Transplantation

Malbrain et al. defined fluid management with the “ROSE” approach.^[56] It is an acronym for resuscitation, optimization, stabilization, and evacuation (deresuscitation). Each phase is distinct and dynamic. We have applied this concept in renal transplantation where all the four phases can be observed.

Resuscitation is for the first hit of hypotension or hypovolemia, in the general population. In renal transplantation, mostly, it occurs during induction of general anesthesia and immediate postreperfusion in [Table 5]. Adequate dialysis and morning dose of antihypertensives with the vasodilatory action of anesthetic agents cause a transient hypovolemic and hypotensive state. Fluid challenges are advised in this phase. Reperfusion is also associated with similar changes. The second phase of “ROSE” is optimization. Postreperfusion, volume status, and the perfusion pressure of the patient should be optimum to aid in the proper function of the neograft. Hemodynamic monitors can aid the physician in this phase and mostly it results in a slight positive balance. The third phase of “ROSE” is stabilization, and it involves fluid therapy for maintenance and replacement of ongoing losses (if present). The fourth phase is evacuation (de-escalation or deresuscitation) and it is as important as resuscitation because the excess positive fluid balance might hinder renal function by edema and might hinder renal perfusion by increasing CVP and renal venous pressure.

Table 5: ROSE approach for fluid management in the different phases of renal transplantation

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Fluid Therapy and Hemodynamic Monitoring in Renal Transplantation

Central venous pressure, pulse contour analysis, and TED have been used in renal transplant surgeries.^[57] Evidence for these goal-directed therapies is listed in [Table 6]. CVP is popular among the targets used in fluid management in renal transplantation. CVP more than 12 mmHg is the target in renal transplantation and CVP less than 8 mmHg was strongly associated with graft dysfunction.^[59],[61] Dynamic indices such as SVV and PPV replaced CVP in most of the ICU protocols for predicting the volume responsiveness of the patient. In renal transplantation, SVV predicts and correlates better with the volume status of the patient better than CVP.^[62] TED is another tool to predict the volume status of the patient. In a study comparing TED-guided fluid management compared with historical controls of CVP-based fluid management, the use of TED was associated with lesser total fluid infused intraoperatively. In the TED group, fluid was guided by FTc and the CVP in the TED group was less than CVP of the historical control. With similar graft function, the TED group had a lesser incidence of edema-related complications.^[63] In another randomized trial, there was no difference in the volume of intraoperative fluid administered between the TED group and conventional fluid management group and no difference in other complications.^[64]

Table 6: Studies in the renal transplantation for goal-directed fluid therapies

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MAP targets after reperfusion of the graft are still a debate. The lower limit of MAP that must be maintained differs from 70 to 93 mmHg according to different observations on graft dysfunction.^[65],[66] However, one has to remember that the renal blood flow changes may not always follow the changes in MAP. Moreover, increasing the systemic vascular resistance may or may not improve renal perfusion.^[57]

Conclusion

In managing patients with CKD for nontransplant surgeries, anesthesiologists aim to minimize the risk of perioperative complications. Balanced crystalloids are preferred over NS. Among colloids, albumin has been found to be safe. In renal transplantation, optimum fluid management is finding the tipping point, above which there are complications related to tissue edema, and below which there is an increased incidence of graft dysfunction. CVP is the most popular monitoring used. It is noteworthy that there may be a little change in CVP for a large volume of fluids infused and factors such as open abdomen, surgical manipulations, retractors, and positive pressure ventilation make CVP an imprecise method. Studies supporting goal-directed therapy (SVV and TED) were in small sample size or in comparison to the historical cohort. Prospective studies with larger sample sizes are warranted for confirmation of their usefulness. Further studies are required to strengthen the evidence for supporting their use and to find the optimal cutoff points in these devices.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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