背景:在肾移植围手术期液体管理中使用平衡晶体而不是生理盐水,对酸碱和电解质平衡的益处以及对术后临床结果的影响仍然是一个有争议的话题。因此,我们进行了这篇综述,以评估与生理盐水相比的平衡溶液对肾移植患者结局的影响.
方法:我们搜索了MEDLINE,EMBASE,和Cochrane数据库,用于比较肾移植患者中平衡的低氯化物溶液与生理盐水的随机对照试验(RCT)。我们感兴趣的主要结果是移植物功能延迟(DGF)。此外,我们检查了酸碱和电解质的测量,以及术后肾功能。我们使用Mantel-Haenszel检验计算了二元结果的相对风险(RR),和连续数据的平均差(MD),并应用DerSimonian和Laird随机效应模型来解决异质性问题。此外,我们对所有结局进行了试验序贯分析(TSA).
结果:纳入12个RCTs,共1668名患者;832名(49.9%)被分配接受平衡解决方案。与生理盐水相比,平衡晶体减少了DGF的发生,RR为0.82(95%置信区间[CI],0.71-0.94),P=.005;I²=0%。平衡晶体组的发生率为25%(787个中的194个),生理盐水组为34%(701个中的240个)。此外,我们的TSA支持主要结局结果,并提示样本量足以得出我们的结论.手术结束时的氯化物(MD,-8.80mEq·L-1;95%CI,-13.98至-3.63mEq。L-1;P<.001),碳酸氢盐(MD,2.12mEq·L-1;95%CI,1.02-3.21mEq·L-1;P<.001),pH值(MD,0.06;95%CI,0.04-0.07;P<.001),和碱过量(BE)(MD,2.41mEq·L-1;95%CI,0.88-3.95mEq·L-1;P=.002)显着有利于平衡晶体组和手术结束钾(MD,-0.17mEq·L-1;95%CI,-0.36至0.02mEq·L-1;P=.07)组间没有差异。然而,肌酐在第一次没有差异(MD,-0.06mg·dL-1;95%CI,-0.38至0.26mg·dL-1;P=.71)和第七(MD,-0.06mg·dL-1;95%CI,-0.18至0.06mg·dL-1;P=.30)术后第1天,尿量(MD,-1.12升;95%CI,-3.67至1.43升;P=.39)和第七(MD,-0.01L;95%CI,-0.45至0.42L;P=.95)术后天数。
结论:在接受肾移植的患者中,平衡的低氯溶液显著减少了DGF的发生,并提供了改善的酸碱和电解质控制。
BACKGROUND: The use of balanced crystalloids over normal saline for perioperative fluid management during kidney transplantation and its benefits on acid-base and electrolyte balance along with its influence on postoperative clinical outcomes remains a topic of controversy. Therefore, we conducted this
review to assess the impact of balanced solutions compared to normal saline on outcomes for kidney transplant patients.
METHODS: We searched MEDLINE, EMBASE, and Cochrane databases for randomized controlled trials (RCTs) comparing balanced lower-chloride solutions to normal saline in renal transplant patients. Our main outcome of interest was delayed graft function (DGF). Additionally, we examined acid-base and electrolyte measurements, along with postoperative renal function. We computed relative risk (RR) using the Mantel-Haenszel test for binary outcomes, and mean difference (MD) for continuous data, and applied DerSimonian and Laird random-effects models to address heterogeneity. Furthermore, we performed a trial sequential analysis (TSA) for all outcomes.
RESULTS: Twelve RCTs comprising a total of 1668 patients were included; 832 (49.9%) were assigned to receive balanced solutions. Balanced crystalloids reduced the occurrence of DGF compared to normal saline, with RR of 0.82 (95% confidence interval [CI], 0.71-0.94), P = .005; I² = 0%. The occurrence was 25% (194 of 787) in the balanced crystalloids group and 34% (240 of 701) in the normal saline group. Moreover, our TSA supported the primary outcome result and suggests that the sample size was sufficient for our conclusion. End-of-surgery chloride (MD, -8.80 mEq·L -1 ; 95% CI, -13.98 to -3.63 mEq.L -1 ; P < .001), bicarbonate (MD, 2.12 mEq·L -1 ; 95% CI, 1.02-3.21 mEq·L -1 ; P < .001), pH (MD, 0.06; 95% CI, 0.04-0.07; P < .001), and base excess (BE) (MD, 2.41 mEq·L -1 ; 95% CI, 0.88-3.95 mEq·L -1 ; P = .002) significantly favored the balanced crystalloids groups and the end of surgery potassium (MD, -0.17 mEq·L -1 ; 95% CI, -0.36 to 0.02 mEq·L -1 ; P = .07) did not differ between groups. However, creatinine did not differ in the first (MD, -0.06 mg·dL -1 ; 95% CI, -0.38 to 0.26 mg·dL -1 ; P = .71) and seventh (MD, -0.06 mg·dL -1 ; 95% CI, -0.18 to 0.06 mg·dL -1 ; P = .30) postoperative days nor urine output in the first (MD, -1.12 L; 95% CI, -3.67 to 1.43 L; P = .39) and seventh (MD, -0.01 L; 95% CI, -0.45 to 0.42 L; P = .95) postoperative days.
CONCLUSIONS: Balanced lower-chloride solutions significantly reduce the occurrence of DGF and provide an improved acid-base and electrolyte control in patients undergoing kidney transplantation.