A sudden increase in delayed graft function in living donor kidney transplantation and a changed peroperative fluid regimen

G.J. Nieuwenhuijs-Moeke, T.M. Huijink, R.A. Pol, M. El Moumni, M.M.R.F. Struys, S.P. Berger

Chair(s): Drs. F.E. van Reekum & dr. M.C. Warlé

Wednesday 8 march 2017

18:06 - 18:18h at Johan de Meesterzaal

Categories: Parallel - Klinisch

Parallel session: Parallelsessie VII - Klinisch 2 - Nazorg na orgaantransplantatie

The first half of 2016 an increase in delayed graft function (DGF) in our living donor kidney transplantation (LDKT) population was noticed. The incidence of DGF (defined as need for dialysis 1st week after transplantation) and functional DGF (fDGF, defined as failure of a fall in serum creatinine of 10% on 3 consecutive days in the 1st week after transplantation) had increased from respectively 1.4%-4.4% (DGF) and 8.4%-8.9% (fDGF) in 2014-2015 up to 11.3% and 26.4% in the first half of 2016. During 2015 we changed our peroperative fluid regimen from a standard amount of 4-5 liter balanced cristalloids to a goal directed fluid therapy approach. This approach aims to optimize the volume state based on the Frank Starling curve and individualized goals. For kidney transplantation the goal was set to a stroke volume variation (SVV) <10% at time of reperfusion. We questioned whether this adjustment in fluid regimen was related to the increase in fDGF. From January 2014 to June 2016 214 LDKT were performed in our center. Donor and recipient characteristics were obtained from hospital records. Intraoperative data were retrieved from our digital patient data monitoring system. Analysis comprised an univariable analysis, analysis over time and multivariable logistic regression.  As half of the population was transplanted preemptively two groups were made: fDGF (n=26, also including patients meeting DGF criteria) and noDGF (n=188). Demographics of donors were comparable with the exception of age and length. Recipients on dialysis were more likely to develop fDGF after transplantation compared to preemptively transplanted patients (P<0.001). Univariable analyses detected various risk factors for fDGF. Recipients developing fDGF received less peroperative fluid, 34.3 (25.3-41.5) ml/kg vs 43,7 (34,2-53,6) ml/kg (P=0.006) and were treated more frequently with noradrenaline, 79% vs 52% (P 0.010). Sacrifice of an artery occurred more frequently in fDGF (P 0.043). In the unadjusted analysis, the effect of the amount of fluid on developing  fDGF was 0.962 (B-0,039, 95% CI 0.932-0.993 P=0.016). When adjusted for dialysis, sacrifice of an artery and the use of noradrenaline, the amount of fluid remained independently associated with DGF (OR=0.96, 95%CI 0.931-0.997, P=0.032)  Goal-directed fluid management towards an SVV of 10% has led to reduced peroperative fluid administration. This seems to be an independent risk factor for development of fDGF in living donor kidney transplantation. A more liberal fluid management using other goals might be more appropriate.