Financial impact of delayed graft function in kidney transplantation.

Increased utilization of suboptimal organs in response to organ shortage has resulted in increased incidence of delayed graft function (DGF) after transplantation. Although presumed increased costs associated with DGF are a deterrent to the utilization of these organs, the financial burden of DGF has not been established. We used the Premier Healthcare Database to conduct a retrospective analysis of healthcare resource utilization and costs in kidney transplant patients (n = 12 097) between 1/1/2014 and 12/31/2018. We compared cost and hospital resource utilization for transplants in high-volume (n = 8715) vs low-volume hospitals (n = 3382), DGF (n = 3087) vs non-DGF (n = 9010), and recipients receiving 1 dialysis (n = 1485) vs multiple dialysis (n = 1602). High-volume hospitals costs were lower than low-volume hospitals ($103 946 vs $123 571, P < .0001). DGF was associated with approximately $18 000 (10%) increase in mean costs ($130 492 vs $112 598, P < .0001), 6 additional days of hospitalization (14.7 vs 8.7, P < .0001), and 2 additional ICU days (4.3 vs 2.1, P < .0001). Multiple dialysis sessions were associated with an additional $10 000 compared to those with only 1. In conclusion, DGF is associated with increased costs and length of stay for index kidney transplant hospitalizations and payment schemes taking this into account may reduce clinicians' reluctance to utilize less-than-ideal kidneys.

Assessment of Hemoglobin Levels in Patients Qualified for Kidney Transplantation in the Perioperative Period and Its Impact on the Occurrence of Delayed Graft Function.

BACKGROUND: Anesthesia in patients undergoing kidney transplantation (KTx) should be aimed at creating optimal hemodynamic conditions for the newly implanted kidney. Changes in of blood count, caused mainly by intraoperative hemodilution, may adversely affect the perioperative course by strengthening the pathologic mechanisms of ischemia-reperfusion syndrome. METHODS: A total of 86 patients (mean age: 49.4 ± 14.0 years, 66% men) with end-stage renal disease who underwent KTx between 2012 and 2015 were included in this retrospective study. Our aim was to assess the hemoglobin level and the effect of fluctuations caused by the implemented fluid therapy on graft function and the occurrence of delayed graft failure. RESULTS: There was no difference in baseline characteristics, indication for transplantation, and surgical technique used among study population. Among the whole observation group, no correlation was found between fluid therapy causing hemodilution with a decrease in hemoglobin concentration and the occurrence of delayed graft failure. CONCLUSIONS: In our observations, we paid special attention to the problem of hemodilution in patients undergoing KTx. It is important to emphasize the importance of proper preparation of the patient for KTx by earlier implementation of anemia therapy, thus preventing exacerbation of anemia in the postoperative period, especially because the perioperative use of blood products is associated with numerous complications and a worse prognosis for the newly implanted kidney.

Pre-emptive deceased-donor kidney transplant: A matched cohort study. / Una aproximación al trasplante renal anticipado de donante cadáver. Estudio de cohortes emparejadas.

INTRODUCTION: Currently, kidney transplantation is the treatment of choice for patients with kidney disease who require replacement therapy. Dialysis is a necessary step, but not mandatory prior to transplantation. There is the possibility of pre-emptive transplantation or transplantation in pre-dialysis, that is, without previous dialysis. The aim of the present study is to evaluate the result of our experience with a pre-emptive kidney transplant from a deceased donor. MATERIALS AND METHODS: Retrospective, observational, matched cohort study. We compared 66 pre-emptive with 66 non pre-emptive recipients, who received a first renal graft performed at our centre, matched by age and gender of donors and recipients, time of transplant, immunological risk, immunosuppression and cold ischaemia time. Early graft loss, incidence of acute rejection, delayed graft function, renal function at 12 and 36 months and graft and recipient survival were assessed in this period. RESULTS: The percentage of recipients who presented early graft loss, delayed graft function and acute rejection was similar in both groups. No differences were observed in their renal function at 12 and 36 months after transplantation, as well as the actuarial survival of patients (P=0.801) and grafts (P=0.693) in the studied period. The total calculated cost of the period on dialysis for the control group was 8,033,893.16 euros. CONCLUSIONS: Pre-emptive transplantation can yield comparable outcomes to those for post-dialysis kidney transplantation, and results in better quality of life for patients with end-stage kidney disease, as well as a reduced cost.

Posttransplant Outcomes for cPRA-100% Recipients Under the New Kidney Allocation System.

BACKGROUND: There is concern in the transplant community that outcomes for the most highly sensitized recipients might be poor under Kidney Allocation System (KAS) high prioritization. METHODS: To study this, we compared posttransplant outcomes of 525 pre-KAS (December 4, 2009, to December 3, 2014) calculated panel-reactive antibodies (cPRA)-100% recipients to 3026 post-KAS (December 4, 2014, to December 3, 2017) cPRA-100% recipients using SRTR data. We compared mortality and death-censored graft survival using Cox regression, acute rejection, and delayed graft function (DGF) using logistic regression, and length of stay (LOS) using negative binomial regression. RESULTS: Compared with pre-KAS recipients, post-KAS recipients were allocated kidneys with lower Kidney Donor Profile Index (median 30% versus 35%, P < 0.001) but longer cold ischemic time (CIT) (median 21.0 h versus 18.6 h, P < 0.001). Compared with pre-KAS cPRA-100% recipients, those post-KAS had higher 3-year patient survival (93.6% versus 91.4%, P = 0.04) and 3-year death-censored graft survival (93.7% versus 90.6%, P = 0.005). The incidence of DGF (29.3% versus 29.2%, P = 0.9), acute rejection (11.2% versus 11.7%, P = 0.8), and median LOS (5 d versus 5d, P = 0.2) were similar between pre-KAS and post-KAS recipients. After accounting for secular trends and adjusting for recipient characteristics, post-KAS recipients had no difference in mortality (adjusted hazard ratio [aHR]: 0.861.623.06, P = 0.1), death-censored graft failure (aHR: 0.521.001.91, P > 0.9), DGF (adjusted odds ratio [aOR]: 0.580.861.27, P = 0.4), acute rejection (aOR: 0.610.941.43, P = 0.8), and LOS (adjusted LOS ratio: 0.981.161.36, P = 0.08). CONCLUSIONS: We did not find any statistically significant worsening of outcomes for cPRA-100% recipients under KAS, although longer-term monitoring of posttransplant mortality is warranted.

Development and implementation of an enhanced recovery after surgery protocol for renal transplantation.

BACKGROUND: Successful implementation of enhanced recovery after surgery (ERAS) in kidney transplantation requires multidisciplinary consultation, education and attention to protocol. This study discusses the process implementation pathway of the ERAS protocol and its outcome. METHODS: A standardized ERAS protocol was designed for the renal transplant recipient and implemented in July 2017. Data collected prospectively of recipients transplanted from July 2017 to December 2018 were compared to prospectively collected data of recipients who were transplanted prior to ERAS implementation from January 2016 to July 2017 from our renal database. The parameters of interest included length of stay, incidence of delayed graft function and readmission rate. RESULTS: There was no difference in the demographics and the incidence of delayed graft function across both groups, although subgroup analysis suggested a significantly lower incidence of delayed graft function with kidneys donated after circulatory death in the cohort that were managed by the ERAS protocol. The median length of stay for patients on the ERAS protocol was 5 days (range 3-16 days). This was 2 days shorter than the median length of stay for patients not on the ERAS protocol (7 days; range 5-14, P < 0.001). This statistically significant difference in length of stay was consistent across all donor subgroups (living donor, donor after cardiac death and donation after brainstem death). Seventy-nine percent of the patients on the ERAS protocol were discharged on post-operative day 4. CONCLUSION: An ERAS protocol for renal transplant patients is feasible. Our data show that successful implementation of ERAS in kidney transplantation is possible and results in significant cost savings due to shorter length of stay.

Long-term effects of delayed graft function duration on function and survival of deceased donor kidney transplants / Efeitos de longo prazo da duração da função tardia do enxerto sobre a função e sobrevida de transplantes renais com doadores falecidos

Abstract Introduction: Delayed graft function (DGF) is a frequent complication after deceased donor kidney transplantation with an impact on the prognosis of the transplant. Despite this, long-term impact of DGF on graft function after deceased donor kidney transplantation has not been properly evaluated. Objective: The main objective of this study was to evaluate risk factors for DGF and the impact of its occurrence and length on graft survival and function. Methods: A retrospective cohort study was performed in 517 kidney transplant recipients who received a deceased donor organ between January 2008 and December 2013. Results: The incidence of DGF was 69.3% and it was independently associated with donor's final serum creatinine and age, cold ischemia time, use of antibody induction therapy and recipient's diabetes mellitus. The occurrence of DGF was also associated with a higher incidence of Banff ≥ 1A grade acute rejection (P = 0.017), lower graft function up to six years after transplantation and lower death-censored graft survival at 1 and 5 years (P < 0.05). DGF period longer than 14 days was associated with higher incidence of death-censored graft loss (P = 0.038) and poorer graft function (P < 0.001). No differences were found in patient survival. Conclusions: The occurrence of DGF has a long-lasting detrimental impact on graft function and survival and this impact is even more pronounced when DGF lasts longer than two weeks.

Resumo Introdução: A função tardia do enxerto (FTE) é uma complicação frequente após transplantes renais com doadores falecidos com repercussões sobre o prognóstico do transplante. Contudo, o impacto a longo prazo da FTE sobre a função do enxerto após transplante renal com doador falecido não foi avaliado adequadamente. Objetivo: O principal objetivo do presente estudo foi avaliar os fatores de risco para FTE e o impacto de sua ocorrência e duração na sobrevida e função do enxerto. Métodos: O presente estudo observacional retrospectivo incluiu 517 receptores de transplante renal que receberam órgãos de doadores falecidos entre janeiro de 2008 e dezembro de 2013. Resultados: A incidência de FTE foi de 69,3%. Foi identificada associação independente entre FTE e creatinina sérica final e idade do doador, tempo de isquemia fria, uso de terapia de indução com anticorpos e diabetes mellitus do receptor. A ocorrência de FTE também foi associada a incidência mais elevada de rejeição aguda com classificação de Banff ≥ 1 A (P = 0,017), função reduzida do enxerto até seis anos após o transplante e menor sobrevida do enxerto censurada para óbito em 1 e 5 anos (P <0,05). Períodos de FTE superiores a 14 dias foram associados a maior incidência de perda do enxerto censurada para óbito (P = 0,038) e pior função do enxerto (P <0,001). Não foram identificadas diferenças de sobrevida nos pacientes. Conclusões: A ocorrência de FTE traz prejuízos de longa duração à função e sobrevida do enxerto. Tal impacto é ainda mais pronunciado quando a FTE persiste por mais de duas semanas.

Does Distance to Transplant Center Affect Post Kidney Transplant Readmission Rates?

Many transplant recipients travel long distances to their transplant center with challenging access to their transplant team. As such, many centers keep recipients near to the center for a period immediately after discharge from the transplant admission. Thus far, the correlation between distance to the transplant center, readmission, and outcomes has not been described. The aim of this study was to examine this relationship. Patients undergoing deceased donor kidney transplant at a single center over a three-year period were analyzed via retrospective chart review for factors associated with distance to the transplant center and readmission. P values < 0.05 were considered significant. Of 141 patients, the overall 90-day readmission rate was 38.3 per cent, and rates were similar between nonlocal and local recipients. Nonlocal were more likely whites (66.1% vs 45.6%; P = 0.032) and from rural areas (56.5% vs 13.9%; P < 0.001). Length of stay was similar between groups, as were rates of delayed graft function. Non-death-censored graft survival was higher at one and three years for nonlocal patients (96.8% and 96.8% vs 89.7% and 78.4%; P = 0.016). This remained significant after adjusting for baseline differences between the groups (hazard ratio (HR) for graft failure = 0.195, 95%, P = 0.046). Patients who live remotely from the transplant center do not experience higher rates of readmission or worsened outcomes, and thus may be managed safely at home. Interestingly, graft survival is improved in nonlocal patients. This may reflect the urban nature of the area surrounding our transplant center, but warrants further study for conclusions to be reached.

Long-term effects of delayed graft function duration on function and survival of deceased donor kidney transplants.

INTRODUCTION: Delayed graft function (DGF) is a frequent complication after deceased donor kidney transplantation with an impact on the prognosis of the transplant. Despite this, long-term impact of DGF on graft function after deceased donor kidney transplantation has not been properly evaluated. OBJECTIVE: The main objective of this study was to evaluate risk factors for DGF and the impact of its occurrence and length on graft survival and function. METHODS: A retrospective cohort study was performed in 517 kidney transplant recipients who received a deceased donor organ between January 2008 and December 2013. RESULTS: The incidence of DGF was 69.3% and it was independently associated with donor's final serum creatinine and age, cold ischemia time, use of antibody induction therapy and recipient's diabetes mellitus. The occurrence of DGF was also associated with a higher incidence of Banff ≥ 1A grade acute rejection (P = 0.017), lower graft function up to six years after transplantation and lower death-censored graft survival at 1 and 5 years (P < 0.05). DGF period longer than 14 days was associated with higher incidence of death-censored graft loss (P = 0.038) and poorer graft function (P < 0.001). No differences were found in patient survival. CONCLUSIONS: The occurrence of DGF has a long-lasting detrimental impact on graft function and survival and this impact is even more pronounced when DGF lasts longer than two weeks.

Twenty years of evolving trends in racial disparities for adult kidney transplant recipients.

Disparities in outcomes for African American (AA) kidney transplant recipients have persisted for 40 years without a comprehensive analysis of evolving trends in the risks associated with this disparity. Here we analyzed U.S. transplant registry data, which included adult Caucasian or AA solitary kidney recipients undergoing transplantation between 1990 and 2009 comprising 202,085 transplantations. During this 20-year period, the estimated rate of 5-year graft loss decreased from 27.6% to 12.8%. Notable trends in baseline characteristics that significantly differed by race over time included the following: increased prevalence of diabetes from 2001 to 2009 in AAs (5-year slope difference: 3.4%), longer time on the waiting list (76.5 more days per 5 years in AAs), fewer living donors in AAs from 2003 to 2009 (5-year slope difference: -3.36%), more circulatory death donors in AAs from 2000-09 (5-year slope difference: 1.78%), and a slower decline in delayed graft function in AAs (5-year slope difference: 0.85%). The absolute risk difference between AAs and Caucasians for 5-year graft loss significantly declined over time (-0.92% decrease per 5 years), whereas the relative risk difference actually significantly increased (3.4% increase per 5 years). These results provide a mixed picture of both promising and concerning trends in disparities for AA kidney transplant recipients. Thus, although the disparity for graft loss has significantly improved, equity is still far off, and other disparities, including living donation rates and delayed graft function rates, have widened during this time.

Assessment of neutrophil gelatinase-associated lipocalin in the brain-dead organ donor to predict immediate graft function in kidney recipients: a prospective, multicenter study.

BACKGROUND: Delayed graft function is a major determinant of long-term renal allograft survival. Despite considerable efforts to improve donor selection and matching, incidence of delayed graft function remains close to 25%. As neutrophil gelatinase-associated lipocalin (NGAL) has been shown to predict acute renal failure, the authors tested the hypothesis that NGAL measurement in brain-dead donors predicts delayed graft function in kidney recipients. METHODS: In a prospective, multicenter, observational study, serum NGAL was measured in donors at the time of transfer to operating room. The primary endpoint was the delayed graft function, defined as the need for renal replacement therapy during the first week posttransplantation. RESULTS: Among 159 included brain-dead donors, 146 were analyzable leading to 243 renal transplantations. Of these, 56 (23%) needed renal replacement therapy. Donors' NGAL values were similar in case of both delayed and normal graft function in recipients. The area under the receiver-operating curve for NGAL to predict the need for renal replacement therapy before day 8 was 0.50 (95% CI, 0.42 to 0.59). The area under curve for NGAL to predict failure to return to a normal graft function at day 8 was 0.51 (95% CI, 0.44 to 0.59). Using multivariate analysis, NGAL was not associated to the need for renal replacement therapy (odds ratio, 0.99; 95% CI, 0.98 to1.00) or failure to return to a normal graft function at day 8 (odds ratio, 1.00; 95% CI, 0.99 to 1.00). CONCLUSION: NGAL measurement in brain-dead donors at the time of recovery failed to predict delayed or normal graft function in kidney recipients.

Long-term impact of donor-recipient size mismatching in deceased donor kidney transplantation and in expanded criteria donor recipients.

BACKGROUND: The degree to which recipient/donor (R/D) size mismatching leads to nephron underdosing and worse kidney allograft survival remains poorly defined, particularly in the setting of preexisting nephron loss such as the expanded criteria donor (ECD). METHODS: We performed a retrospective analysis of 69,737 deceased donor transplants followed by a subset analysis of ECD transplants using data from the Scientific Registry of Transplant Recipients from 1992 to 2005. Ratios of R/D body surface area (BSA) were used to estimate nephron disparity and segregate pairs. RESULTS: In the entire cohort, severe BSA disparity (R/D BSA>1.38 m) was associated with slightly worse 10-year unadjusted graft survival (35% for severe BSA disparity vs. 39% in pairs of comparable size, P<0.0001). In multivariate analysis, BSA disparity was associated with a 15% increased risk of graft loss (hazard ratio 1.15, P<0.0001). Within ECD cohorts, severe BSA disparity was associated with a decrease in 10-year unadjusted graft survival of greater magnitude than the overall cohort (10% for severe BSA disparity vs. 22% in pairs of comparable size, P<0.0004). On multivariate analysis, severe R/D BSA disparity was associated with worse allograft survival similar to the entire cohort (hazard ratio 1.18, P=0.04). CONCLUSIONS: Recipients receiving kidneys from substantially smaller donors have a statistically higher rate of graft loss that is more pronounced in ECD kidneys. Although severe R/D size disparity is an independent risk factor for graft loss, the magnitude of this risk requires consideration in the context of other risk factors for the graft loss and the hazards of dialysis.