Judicious fluid management is one of the key factors of successful renal transplantation. Lack of understanding of the importance of adequate maintenance of intravascular volume may lead to graft failure or even patient death in the peri-operative transplant period [1]. We address in this short summary two review articles published recently by two different groups [2,3]. Both manuscripts provided an in-depth review of this vital topic, which remains unfortunately undermined. However, they handled the topic from two different aspects.

Calixto et al. [2] addressed that optimising perioperative fluid management is likely to improve morbidity and mortality, and thereby, health care costs. On the other hand, Aref et al. [3] explored the different opinions in monitoring fluid therapy in the perioperative period of renal transplantation. Although peri-operative fluid management is of crucial importance, yet there are very few well-conducted randomised controlled trials that are powerful enough to define acceptable guidelines [2-5].

Calixto et al. [2] also addressed the role of Transoesophageal Echocardiography and technologies relying on pulse contour analysis (PCA) as a more precise alternative to static CO monitoring which was proved to be unreliable and correlate poorly with the intravascular volume. In contrast, Aref et al. [3] focused on the comparison of fluid therapy guided by central venous pressure (CVP) versus novel modern techniques. They also highlighted the limitations in monitoring fluid therapy on the basis of CVP trends in different population groups as shown in Table 1. Furthermore, the kidney transplant recipient is exposed to Calixto et al. [2] also referred to the work of Ferris et al. [9]. They documented an unexplained drop of CVP readings in the early post-transplant period despite vigorous fluid resuscitation. Undoubtly, this could mislead the clinicians if CVP is used to guid fluid management.

It is worth highlighting those Marik et al. [10] article was the first systematic review that suggested the need to change the traditional glorification of CVP role in perioperative fluid management. Moreover, they also concluded in 2013 in their updated meta-analysis that CVP use to guide fluid resuscitation should be abandoned [11].

We strongly agree that measuring the CVP as a surrogate marker of intravascular volume is a myth in modern medical practice and, therefore, should be abandoned. We also recommend using intra-operative and post-operative cardiac output monitoring devices for guiding fluid therapy in renal transplant recipients.

Several intra-operative confounders that counteract the reliability of CVP measurements like the use of abdominal retractors, the position of the patient (which is not always in flat supine position), in addition to the use of positive pressure ventilation (PPV) during the operation [7,8]. They concluded that CVP should not play any role in monitoring fluid therapy in renal transplantation. They also addressed the alternative non-invasive cardiac output monitoring devices and their specific limitations as summarised in Table 2 [3].

Finally, we add our voice to Calixto et al. [2] to call for more prospective comparative clinical studies to address the role of the new techniques in the field of renal transplantation.

1.       Shah RB, Shah VR, Butala BP, Parikh GP (2014) Effect of intraoperative human albumin on early graft function in renal transplantation. Saudi J Kidney Dis Transpl 25: 1148-1153.

2.       Calixto MHF, Schricker T, Magder S, Hatzakorzian R (2018) Perioperative fluid management in kidney transplantation: A black box. Crit Care 22: 14.

3.       Aref A, Zayan T, Sharma A, Halawa A (2018) Utility of central venous pressure measurement in renal transplantation: Is it evidence based? World J Transplant 8: 61-67.

4.       Chin JH, Jun IG, Lee J, Seo H, Hwang GS et al. (2014). Can stroke volume variation be an alternative to central venous pressure in patients undergoing kidney transplantation? Transplant Proc 46: 3363-3366.

5.       Toyoda D, Fukuda M, Iwasaki R, Terada T, Sato N, et al. (2015) The comparison between stroke volume variation and filling pressure as an estimate of right ventricular preload in patients undergoing renal transplantation. J Anesth 29: 40-46.

6.       Fluid Resuscitation and Assessment of Fluid Responsiveness. Accessed from: https://derangedphysiology.com/main/required-reading/equipment-and-procedures/Chapter%202.4.1.1/fluid-resuscitation-and-assessment-fluid-responsiveness

7.       Amoroso P, Greenwood RN (1989) Posture and central venous pressure measurement in circulatory volume depletion. Lancet 2: 258-260.

8.       Pilat J, Dabrowski W, Biernacka J, Bicki J, Rudzki S, et al. (2010) Changes in intra-abdominal, iliac venous and central venous pressures in patients undergoing abdominal surgery due to large tumors of the colon - A pilot study. Acta Clin Croat 49: 381-388.

9.       Ferris RL, Kittur DS, Wilasrusmee C, Shah G, Krause E, et al. (2003) Early hemodynamic changes after renal transplantation: Determinants of low central venouspressure in the recipients and correlation with acute renal dysfunction. Med Sci Monit 9: CR61-66.

10.    Marik PE, Baram M, Vahid B (2008) Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest 134: 172-178.

11.    Marik PE, Cavallazzi R (2013) Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med 41: 1774-1781.