Introduction Pediatric
kidney transplantation requires effective intraoperative fluid management, but standards are lacking. Hypovolemia and hypervolemia can impair graft perfusion, causing DGF or primary non-function. Goal-directed therapy is well-established in adult practice, but child-specific strategies are lacking. In this systematic review, intraoperative fluid management strategies were examined for their effects on early graft function in
pediatric kidney transplant recipients. Methods This review followed PRISMA. From inception to May ۲۰۲۴, PubMed, Embase, CENTRAL and CINAHL were searched extensively. We used "kidney transplantation," "pediatric," "child," "adolescent," "fluid therapy," "hemodynamic monitoring," "goal-directed therapy," "colloids," "crystalloids," "delayed graft function," and "graft survival." RCTs and observational cohort studies on fluid strategies in ۲۱-year-olds were included. These strategies can be liberal, restrictive, crystalloid, colloid, goal-directed, or conventional. Reviews, case reports and adult studies were excluded. To assess bias, we used Cochrane RoB ۲ for randomized controlled trials and the Newcastle-Ottawa Scale for cohort studies. Where feasible, a random-effects model was used to calculate pooled risk ratios (RR) or mean differences (MD) with ۹۵% confidence intervals after narrative data synthesis. Results Eight studies (۲ randomized controlled trials and ۶ cohort studies) with ۱,۲۴۵
pediatric patients were identified from ۲,۱۵۸ records. Goal-directed therapy using stroke volume variation (SVV), liberal versus restrictive crystalloid protocols and albumin-based versus balanced crystalloid fluid regimens were used. This meta-analysis was inappropriate due to clinical and methodological heterogeneity. Four of five studies showed a significant reduction in DGF, favoring goal-directed
fluid therapy over a less structured approach (RR range: ۰.۴۵ to ۰.۶۵). A randomised controlled trial found no difference in
delayed graft function between albumin and balanced crystalloid groups (RR ۱.۱۰, ۹۵% CI ۰.۶۸ to ۱.۷۸). Thrombotic complications are not increased by any strategy. Conclusion hemodynamic-driven fluid management may reduce
delayed graft function in
pediatric kidney transplant recipients compared to liberal fluid administration, according to limited evidence. Addressing hypovolemia and volume status accuracy to avoid over-resuscitation are equally important. However, the evidence is mostly observational and the best fluid has yet to be determined. The findings indicate a significant knowledge gap and the urgent need for comprehensive, rigorously designed randomized controlled trials to develop evidence-based intraoperative fluid protocols for this vulnerable population.
