Practice Variations in Intraoperative Fluid
Therapy during Kidney Transplantation A
Multicenter Analysis.
Dieter Adelmann, Rania Elkhateb, Jamie Yang, David Chen, Kerstin Kolodzie,
Sachin Kheterpal, Matthieu M Legrand, Nicholas Douville
Dieter Adelmann, MD, PhD
MPOG 2024 Outcome Research Fellows
University of California, San Francisco
Adelmann | MPOG Emerging Scholars | MPOG Retreat 2025
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Disclosures | Conflict of Interest:
Haemonetics Corporation
- Reimbursement for participation in a clinical trial (completed)
- Speaker honoraria (ongoing)
- not related to the content of this presentation
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Anesthesia Subspecialities:
Kidney Transplant
neglected or overlooked(?)
Adelmann | MPOG Emerging Scholars | MPOG Retreat 2025
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Background
The kidney is vulnerable to ischemic injury from organ donation through the
intraoperative period and beyond.
Donor Critical
Illness
Donor Warm
Ischemia Time
(Donation after Circulatory
Death)
Cold
Ischemia
Time
Warm
Ischemia
Time
Additional
Intraoperative
Ischemia
Donor
ICU Management
in-situ Regional
Perfusion Machine
perfusion Surgical
Technique Intraoperative
Management
Adelmann | MPOG Emerging Scholars | MPOG Retreat 2025
5Adelmann | MPOG Emerging Scholars | MPOG Retreat 2025
Acute Kidney Injury of the Graft
Delayed Graft Function (DGF)
clinical manifestation of ischemia-reperfusion
injury in the transplanted kidney
need for dialysis within seven days of
transplant.
dose-dependent effect between DGF duration
and graft loss
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Delayed Graft Function
most risk factors cannot be modified:
- Donor- and Recipient Comorbidities
- Cold and Warm Ischemia Time (logistics & surgical techniques)
- Organ Preservation (Machine Perfusion is protective)
Intraoperative care presents an opportunity to
minimize additional ischemic injury to the graft.
Adelmann | MPOG Emerging Scholars | MPOG Retreat 2025
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Targets for Intraoperative Management
Fluids
•To use the right
type and the right
amount of fluids
Blood
Pressure
•Maintain
adequate
renal perfusion
pressure.
Vasopressors
•Maintain
perfusion pressure
without impairing
glomerular
microcirculation.
Adelmann | MPOG Emerging Scholars | MPOG Retreat 2025
t
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Fluid Therapy
Normal saline was historically the preferred
fluid during kidney transplantation
- lacks potassium, reducing concerns about hyperkalemia
however, it causes hyperchloremic metabolic
acidosis can contribute to hyperkalemia
Adelmann | MPOG Emerging Scholars | MPOG Retreat 2025
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Intraoperative Fluid Therapy
Current Evidence –2023: Randomized controlled Trial.
Patients: 808 Kidney Transplant Recipients, randomized to receive …
Intervention: intravenous balanced crystalloid solution (Plasma-Lyte 148)
or saline during surgery and up until 48 h after transplantation.
Outcome: Reduced incidence of DGF in the balanced crystalloid group.
(adjusted risk difference 10·1% [95% CI 3·5 to 16·6])
Adelmann | MPOG Emerging Scholars | MPOG Retreat 2025
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But how does this
translate to current
care?
2025 Survey –55 US Institutions
Which fluid do you use
intraoperatively during Kidney
Transplantation
Balanced
Crystalloids
Normal Saline
Menon, Douville, Adelmann, Manuscript under Review.
Adelmann | MPOG Emerging Scholars | MPOG Retreat 2025
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Practice Variations in Intraoperative Fluid Therapy
during Kidney Transplantation.
Adelmann, Douville, Preliminary Data, Manuscript in preparation.
Outcome:
𝑖𝑛𝑡𝑟𝑎𝑜𝑝𝑒𝑟𝑎𝑡𝑖𝑣𝑒 𝐵𝑎𝑙𝑎𝑛𝑐𝑒𝑑 𝐶𝑟𝑦𝑠𝑡𝑎𝑙𝑙𝑜𝑖𝑑 (𝑚𝑙)
𝑖𝑛𝑡𝑟𝑎𝑜𝑝𝑒𝑟𝑎𝑡𝑖𝑣𝑒 𝑇𝑜𝑡𝑎𝑙 𝐶𝑦𝑟𝑠𝑡𝑙𝑎𝑙𝑜𝑖𝑑 (𝑚𝑙)
Ratio 1: Patient received Balanced Crystalloids only
Ratio 0: Patient received Normal Saline only
Patient level data:
19,165 Kidney Transplants
33 US Institutions
2018 -2023
Adelmann | MPOG Emerging Scholars | MPOG Retreat 2025
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Practice Variations in Intraoperative Fluid Therapy
during Kidney Transplantation.
Adelmann, Douville, Preliminary Data, Manuscript in preparation.
Outcome:
𝑖𝑛𝑡𝑟𝑎𝑜𝑝𝑒𝑟𝑎𝑡𝑖𝑣𝑒 𝐵𝑎𝑙𝑎𝑛𝑐𝑒𝑑 𝐶𝑟𝑦𝑠𝑡𝑎𝑙𝑙𝑜𝑖𝑑 (𝑚𝑙)
𝑖𝑛𝑡𝑟𝑎𝑜𝑝𝑒𝑟𝑎𝑡𝑖𝑣𝑒 𝑇𝑜𝑡𝑎𝑙 𝐶𝑦𝑟𝑠𝑡𝑙𝑎𝑙𝑜𝑖𝑑 (𝑚𝑙)
Ratio 1: Patient received Balanced Crystalloids only
Ratio 0: Patient received Normal Saline only
Adelmann | MPOG Emerging Scholars | MPOG Retreat 2025
The primary aim was to quantify the intraoperative use of balanced crystalloids —
expressed as their percentage of the total crystalloid volume per case —and to assess
the contribution of institution-, clinician-, and patient-level factors to variation in
practice.
13 Adelmann, Douville, Preliminary Data, Manuscript in preparation.
Practice Variations in Intraoperative Fluid Therapy during Kidney
Transplantation.
Updated Phenotype: Total Crystalloid Administered
Adelmann | MPOG Emerging Scholars | MPOG Retreat 2025
14 Adelmann, Douville, Preliminary Data, Manuscript in preparation.
Practice Variations in Intraoperative Fluid Therapy during Kidney
Transplantation.
Updated Phenotype: Total Crystalloid Administered
Adelmann | MPOG Emerging Scholars | MPOG Retreat 2025
Practice Variations in Intraoperative Fluid Therapy during Kidney
Transplantation.
Adelmann | MPOG Emerging Scholars | MPOG Retreat 2025
Practice Variations in Intraoperative Fluid Therapy during Kidney
Transplantation.
Adelmann | MPOG Emerging Scholars | MPOG Retreat 2025
Practice Variations in Intraoperative Fluid Therapy during Kidney
Transplantation.
Adelmann | MPOG Emerging Scholars | MPOG Retreat 2025
Results:
Balanced crystalloid ratio
At the patient level, the mean balanced crystalloid ratio was 72% (SD 38%), with a median
of 100% (IQR 46%–100%).
At the institution level, mean ratios ranged from 0% to 99%.
In the random-effects model with institution as the random intercept, we found that 50.9% of
the variation in the balanced crystalloid ratio was explained by the institution, while
the remaining 49.1% was attributable to patient-level variability.
Adelmann, Douville, Preliminary Data, Manuscript in preparation.
Ratio 1: Balanced Crystalloids only
Ratio 0: Normal Saline only
Ratio 0: Normal Saline only
Ratio 1: Balanced Crystalloids only
Patient level data:
19,165 Kidney Transplants / 33 US institutions
Variation in the Balanced Crystalloid Ratio across Institutions
Adelmann, Douville, Preliminary Data, Manuscript in preparation.
Patient level data:
19,165 Kidney Transplants / 33 US institutions
Changes in the Balanced Crystalloid Ratio Over Time
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What is next?
Fluids
•Balanced
Crystalloids reduce
the risk of DGF.
Blood
Pressure
•PCRC 292
approved
Vasopressors
•PCRC 292
approved
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What is next?
Perioperative Data Donor Data
Recipient Data
Outcomes Data
Adelmann | MPOG Emerging Scholars | MPOG Retreat 2025
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Summary
- established a cohort of Kidney Transplant
Patients in MPOG.
- established a new phenotype to assess classify
Crystalloids.
- preparing the first manuscript for publication.
- this is just the beginning of Transplant related
research in MPOG.
Adelmann | MPOG Emerging Scholars | MPOG Retreat 2025
