Impact of early surgical complications on kidney transplant outcomes.

BACKGROUND: Kidney transplantation (KT) improves clinical outcomes of patients with end stage renal disease. Little has been reported on the impact of early post-operative surgical complications (SC) on long-term clinical outcomes following KT. We sought to determine the impact of vascular complications, urological complications, surgical site complications, and peri-graft collections within 30 days of transplantation on patient survival, graft function, and hospital readmissions. METHODS: We conducted a single-centre, observational cohort study examining adult patients (≥ 18 years) who received a kidney transplant from living and deceased donors between January 1st, 2005 and December 31st, 2015 with follow-up until December 31st, 2016 (n = 1,334). Univariable and multivariable analyses were performed with Cox proportional hazards models to analyze the outcomes of SC in the early post-operative period after KT. RESULTS: The cumulative probability of SC within 30 days of transplant was 25%, the most common SC being peri-graft collections (66.8%). Multivariable analyses showed significant relationships between Clavien Grade 1 SC and death with graft function (HR 1.78 [95% CI: 1.11, 2.86]), and between Clavien Grades 3 to 4 and hospital readmissions (HR 1.95 [95% CI: 1.37, 2.77]). CONCLUSIONS: Early SC following KT are common and have a significant influence on long-term patient outcomes.

Selective Elimination and Rationalization of Cell-based Assays in Deceased Donor Kidney Transplant Crossmatching.

Background: While there is increasing reliance on a negative virtual crossmatch to proceed with deceased donor kidney transplantation, a flow cytometry crossmatch (FCXM) is still usually performed after the transplant has already occurred. Our center has eliminated pretransplant physical crossmatches for most patients, and since 2018, we have eliminated the systematic performance of posttransplant FCXMs. Methods: We studied all deceased donor kidney transplants in our program between June 1, 2018, and March 31, 2021, to evaluate the impact of eliminating retrospective FCXMs on resource utilization and graft outcomes (ie, the occurrence of antibody-mediated rejection [AMR] in the first 3-mo posttransplant). Results: A total of 358 kidney transplants occurred during the study period, and approximately 70% of these transplants proceeded without the performance of any FCXM. Incidence rates of AMR were low (9.63 per 1000 person-months), which compared favorably with the incidence rate of AMR during the 3-y period preceding the policy (4.82 per 1000 person-months, P = 0.21). Conclusions: Our results suggest that moving away from retrospective FCXM and relying exclusively on the virtual crossmatch is safe and efficient for kidney allocation.

Renal cell carcinoma in kidney transplant recipients: incidence, trends, clinical management & outcomes.

OBJECTIVE: To describe the incidence, characteristics, clinical management, and outcomes of renal cell carcinoma (RCC) among a large, single-centre cohort of kidney transplant recipients (KTR). METHODS: We conducted an observational cohort study looking at KTR transplanted between January 2000-December 2017 (n = 2443) with ≥ 1 year of follow-up. Simultaneous kidney/pancreas transplants were excluded. The Kaplan-Meier product-limit method was used to determine the incidence of RCC. Characteristics and management of RCC were examined using descriptive statistics. Risk factors and clinical outcomes were analyzed using Cox regression models. RESULTS: The incidence of RCC among our cohort was 0.32 per 100 person-years, 2.1% of all KTRs. Almost half (47.1%) of cases occurred within 4 years post-transplant. The majority of cases were T1a (86.3%), clear-cell (45.1%), and in the native kidney (80.4%). KTR diagnosed with RCC had a twofold higher incidence of other malignancies versus KTR without RCC. Overall mortality, but not cancer-specific mortality, at 2- and 5-years post-transplant was threefold higher among KTR with RCC than those without. CONCLUSIONS: Incidence of RCC among our KTR was slightly higher than the general population; majority of cases occur in the native kidneys and are low stage, low grade. Indolent histologic variants were more common than the general population. KTR with RCC had a higher incidence of other malignancies. Overall, but not cancer-specific, mortality was higher among KTRs diagnosed with RCC.

The epidemiology of early deep vein thrombosis in kidney transplant recipients.

BACKGROUND: Because kidney transplant recipients may be at increased risk for deep vein thrombosis (DVT) following transplantation, we investigated the incidence, risk factors, treatments and outcomes of early DVT among kidney transplant recipients. METHODS: An observational, single-centre cohort study was conducted among adult kidney transplant recipients from Jan. 1, 2005, to Dec. 31, 2016 with 1-year followup. Time to DVT was assessed using the Kaplan-Meier method. Cox proportional hazards and linear regression models were used to analyze risk factors for and outcomes of DVT. RESULTS: The cumulative incidence of DVT was 4.25% at 3 months after transplant. In multivariable analysis, the use of depleting induction agents (hazard ratio [HR] 2.13, 95% confidence interval [CI] 1.05-4.35]), white recipient race (HR 1.84. 95% CI 1.08-3.12), the use of kidneys from expanded criteria donors (HR 2.13, 95% CI 1.05-4.32) and lower recipient body mass index (HR 0.95, 95% CI 0.91-1.00) increased the risk for early DVT. Peritransplant DVT prophylaxis was not associated with early DVT. Early DVT was not associated with reduced graft function, death, graft failure or first hospital readmission. CONCLUSION: Risk factors for early DVT in our cohort of kidney transplant recipients included white recipient race, use of depleting agents, lower recipient body mass index and use of expanded criteria donors. As practice patterns of donor and recipient selection in kidney transplantation evolve, the results of this study may aid in perioperative risk assessments and decision-making about the use of DVT prophylaxis.

Outcomes of early hospital readmission after kidney transplantation: Perspectives from a Canadian transplant centre.

BACKGROUND: Early hospital readmissions (EHRs) after kidney transplantation range in incidence from 18%-47% and are important and substantial healthcare quality indicators. EHR can adversely impact clinical outcomes such as graft function and patient mortality as well as healthcare costs. EHRs have been extensively studied in American healthcare systems, but these associations have not been explored within a Canadian setting. Due to significant differences in the delivery of healthcare and patient outcomes, results from American studies cannot be readily applicable to Canadian populations. A better understanding of EHR can facilitate improved discharge planning and long-term outpatient management post kidney transplant. AIM: To explore the burden of EHR on kidney transplant recipients (KTRs) and the Canadian healthcare system in a large transplant centre. METHODS: This single centre cohort study included 1564 KTRs recruited from January 1, 2009 to December 31, 2017, with a 1-year follow-up. We defined EHR as hospitalizations within 30 d or 90 d of transplant discharge, excluding elective procedures. Multivariable Cox and linear regression models were used to examine EHR, late hospital readmissions (defined as hospitalizations within 31-365 d for 30-d EHR and within 91-365 d for 90-d EHR), and outcomes including graft function and patient mortality. RESULTS: In this study, 307 (22.4%) and 394 (29.6%) KTRs had 30-d and 90-d EHRs, respectively. Factors such as having previous cases of rejection, being transplanted in more recent years, having a longer duration of dialysis pretransplant, and having an expanded criteria donor were associated with EHR post-transplant. The cumulative probability of death censored graft failure, as well as total graft failure, was higher among the 90-d EHR group as compared to patients with no EHR. While multivariable models found no significant association between EHR and patient mortality, patients with EHR were at an increased risk of late hospital readmissions, poorer kidney function throughout the 1st year post-transplant, and higher hospital-based care costs within the 1st year of follow-up. CONCLUSION: EHRs are associated with suboptimal outcomes after kidney transplant and increased financial burden on the healthcare system. The results warrant the need for effective strategies to reduce post-transplant EHR.

Surgical site complications in kidney transplant recipients: incidence, risk factors and outcomes in the modern era.

BACKGROUND: Surgical site complications (SSCs) are an important source of morbidity after kidney transplantation. We assessed the incidence, risk factors, outcomes and economic impact of SSCs in a large, diverse population of kidney transplant recipients. METHODS: We conducted a single-centre, observational cohort study of adult (age ≥ 18 yr) patients who underwent kidney transplantation between Jan. 1, 2005, and Dec. 31, 2015, with a minimum of 1 year of follow-up. Cases of SSC, including infections and wound dehiscence, were determined from patient records. Inpatient and outpatient hospital costs were determined 6 and 12 months after transplantation. We used the Kaplan-Meier product-limit method to determine the cumulative probability of SSCs and other outcomes. We evaluated risk factors and clinical outcomes using Cox proportional hazard ratios. Linear regression models were used to study the effect of SSCs on graft function. RESULTS: The incidence rate of SSCs within 30 days after transplantation was 4.19 per 100 person-months. The cumulative probability of developing an SSC within 30 days after transplantation was 4.13% (95% confidence interval [CI] 3.23%-5.28%). Increased recipient body mass index (BMI) (hazard ratio [HR] 1.07, 95% CI 1.02-1.11), longer cold ischemic time (HR 1.05, 95% CI 1.01-1.09) and transplantation in 2010-2012 versus 2005-2009 (HR 2.20, 95% CI 1.19-4.04) were risk factors for SSC development. In multivariable stepwise Cox proportional hazard models, SSC was a significant risk factor for death-censored graft failure (HR 3.08, 95% CI 1.60-5.90) and total graft failure (HR 2.09, 95% CI 1.32-3.32). Cumulative median hospital costs were $2238.46 greater for patients with an SSC than for those without. CONCLUSION: Increased BMI, longer cold ischemic time and the 2010-2012 transplantation period predisposed to SSCs. The development of SSCs was associated with a higher risk of graft failure. Strategies to minimize SSCs may improve outcomes after kidney transplantation and reduce costs.

Lymphoceles: impact on kidney transplant recipients, graft, and healthcare system.

INTRODUCTION: Following kidney transplantation, lymphoceles can impact patient and graft outcomes, while resulting in significant hospital resource utilization. We aimed to characterize the incidence, risk factors, outcomes, and clinical management of lymphoceles among kidney transplant recipients and review impact on health system utilization at a high-volume center. MATERIALS AND METHODS: We conducted a single-center, observational cohort study on adults transplanted between January 1, 2005 and December 31, 2017. Incidence, risk factors, and clinical outcomes were assessed using the Kaplan-Meier product-limit method, multivariable logistic regression model, and Cox proportional hazards model, respectively. RESULTS: Lymphoceles developed in 72 of 1881 patients (3.8%). Multivariate analysis demonstrated that a longer time on dialysis before transplant [HR 1.09 (95% CI: 1.02, 1.17)], laparoscopic donor nephrectomy [HR 2.31 (95% CI: 1.04, 5.12)], and depleting induction therapy [HR 0.39 (95% CI: 0.18, 0.87)] were significant risk factors for lymphocele development. Lymphoceles independently increased the likelihood of hospital readmission [HR 3.96 (95% CI: 2.99, 5.25)] but had no significant effect on the likelihood of graft failure or death with graft function. Of 72 cases, 44 received a radiological or surgical intervention. Fifteen of 44 lymphoceles required further intervention due to re-accumulation or complications. CONCLUSION: Patients with longer dialysis times, kidneys from laparoscopic donor nephrectomy, and depleting induction therapy were associated with an increased risk for developing symptomatic lymphoceles. Our center's treatment for symptomatic lymphoceles did not result in significant graft dysfunction, but significantly higher healthcare resource utilization was noted.

Ureteral strictures post-kidney transplantation: Trends, impact on patient outcomes, and clinical management.

INTRODUCTION: Ureteral strictures post-kidney transplantation (KT) can be a significant morbidity to the patient, often requiring surgical intervention and impacting graft function. We sought to investigate the incidence, clinical management, and outcomes of ureteral strictures among kidney transplant recipients (KTRs) at a large, multiorgan transplant center. METHODS: We conducted a single-center cohort study looking at KTRs who had transplant surgery from January 1, 2005 to March 31, 2017 with at least one-year followup (n=1742). Any KTRs done outside of our center or simultaneous multiorgan transplants were excluded. The Kaplan-Meier product-limit method was used to determine the incidence of ureteral strictures. Risk factors for ureteric strictures and clinical outcomes among patients with vs. without ureteric strictures were analyzed using Cox proportional hazards models. RESULTS: The incidence of ureteral strictures was 1.31 (95% confidence interval [CI] 0.85, 2.01) per 100 person-years or a cumulative incidence of 1.2%. We did not find any donor or recipient demographic variables that were independently associated with an increased risk of ureteral stricture development. A large proportion was managed successfully with radiological intervention alone (47.6%). Ureteral strictures were associated with death-censored graft failure (hazard ratio [HR] 7.17, 95% CI 2.81, 18.30), total graft failure (HR 3.04, 95% CI 1.41, 6.59), and hospital re-admission (HR 2.52, 95% CI 1.58, 4.00). CONCLUSIONS: Although uncommon, ureteral strictures can significantly impact patient outcomes after KT. A better understanding of risk factors and clinical management will be important to ensure optimal graft outcomes.

Evaluation of a professional development course on research methods for healthcare professionals.

Healthcare is constantly evolving and thus requires lifelong learning. Evidence-based learning has been shown to lead to better patient outcomes, yet many healthcare professionals report gaps in their research abilities. We sought to evaluate the efficacy of a professional development program in addressing identified gaps.