The use of mannitol as a protective agent during renal transplantation stems from its ability to increase renal blood flow. This is thought to be due to the release of intrarenal vasodilating prostaglandins and atrial natriuretic peptide (ANP). A second perceived benefit of mannitol is related to its role as an oxygen free-radical scavenger that may impart some protection to the kidney following reperfusion of the renal allograft. Finally, when administered early in the course of acute renal failure (ARF), mannitol tends to flush out cellular debris and prevent tubular cast formation. These actions may convert a patient from oliguric ARF to nonoliguric ARF. A randomized study of hydration with mannitol vs. hydration without mannitol in cadaveric renal transplant demonstrated a significant reduction in postoperative acute tubular necrosis in patients treated with mannitol. However, 3 months after transplantation no difference was found in kidney function. The commonly used dose of mannitol for renal protection is 12.5 to 25 grams. It has become common practice to give mannitol, as well as adequate volume expansion with crystalloid prior to vessel clamp in order to decrease postoperative ATN. The studies cited are all limited, i.e. retrospective, single-center, and/or small number of patients.
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