Reducing length of stay in patients following liver transplantation using the model for continuous improvement.

Length of stay (LOS) is a significant contributor to overall patient outcomes for patients undergoing liver transplantation. This study documents a quality improvement project aiming to reduce the median post-transplant LOS for liver transplant patients. We instituted five Plan-Do-Study-Act cycles with the goal of reducing LOS by 3 days from a baseline median of 18.4 days over 1 year. Balancing measures such as readmission rates ensured any decrease in stay was not associated with significantly increased patient complications. Over the 28-month intervention period and 24-month follow-up period, there were 193 patients discharged from hospital with a median LOS of 9 days. The changes appreciated during quality improvement interventions carried over to sustained improvements, with no significant variability in LOS postintervention. Discharge within 10 days increased from 18.4% to 60% over the study period, with intensive care unit stay decreasing from a median of 3.4-1.9 days. Thus, the development of a multidisciplinary care pathway, with patient engagement, led to improved and sustained discharge rates with no significant differences in readmission rates.

Hepatitis C positive organ transplantation to negative recipients at a multiorgan Canadian transplant centre: ready for prime time.

BACKGROUND: Transplantation offers the best survival for patients with end stage organ disease. Transplant of hepatitis C virus (HCV) nucleic acid test (NAT) positive organs into negative recipients is a novel strategy that can expand the donor pool. We aim to evaluate our centre's experience. METHODS: We preformed a retrospective review of anti-HCV NAT positive and negative organs into negative recipients transplanted over 27 months. Primary outcome was the success rate of eradication of HCV post-transplant. Secondary outcomes were rate of transmission of HCV, treatment adverse events, and graft failure. RESULTS: 33 anti-HCV positive organs were transplanted into negative recipients. 22 (66.7%) were NAT positive. Median recipients age was 49 years (interquartile range [IQR] 44.5-62.0) with the majority being males (57.6%). NAT positive organ transplantations included 16 kidneys, 3 livers, 1 kidney-pancreas, 1 liver-kidney, and 1 heart. The most common HCV genotype was 1a (59.1%). The median time to initiating therapy was 41.5 days. SVR12 was 100% in patients who finished therapy. There were no adverse events with therapy and no graft failure. CONCLUSIONS: Anti-HCV NAT positive organ transplantation into negative recipients is safe with excellent eradication rates and no significant adverse events or graft failure. This would expand donor pool to close the gap between supply and demand.

Donation after Circulatory Death Renal Allografts--Does Donor Age Greater than 50 Years Affect Recipient Outcomes?

PURPOSE: Donation after circulatory death renal allografts are associated with excellent outcomes. We performed a retrospective chart review to investigate the impact of donor age on postoperative and intermediate term outcomes. MATERIALS AND METHODS: We compared recipient outcomes of donation after circulatory death allografts from donors older vs younger than 50 years. A total of 118 single donations after circulatory death renal transplants were performed at our institution between July 2006 and September 2013. Outcome variables (creatinine clearance, readmission rate, length of hospital stay, delayed graft function, graft loss and rejection) were compared between the 2 age categories using the Student t-test and the Pearson chi-square test. Independent prognosticators of creatinine clearance at 12 months were assessed with multivariate linear regression modeling. RESULTS: Mean ± SD recipient age was 53.8 ± 14.7 years and 45.8% of donation after circulatory death donors were older than 50 years. Median followup was 21 months (range 1 to 87). Recipients of kidney transplants from donation after circulatory death donors older than 50 years demonstrated lower creatinine clearance at 1 month (mean 50.3 ± 25.3 vs 72.7 ± 31.7 ml per minute, p <0.001), 3 months (62.5 ± 22.9 vs 87.9 ± 36.4, p <0.001) and 1 year (66.2 ± 26.8 vs 87.8 ± 38.7, p = 0.013). However, the 2 groups did not differ with regard to delayed graft function, graft loss, hospital readmissions or length of hospital stay. Multivariate linear regression demonstrated that donor age, recipient age, recipient gender and cold ischemia time were independent predictors of creatinine clearance at 12 months. CONCLUSIONS: Recipients of allografts from donors older than 50 years showed inferior renal function at 1 year but the 2 groups had similar graft survival and short-term outcomes. Longer followup is required to determine long-term allograft survival.

Donation after cardiac death pediatric en bloc renal transplantation.

PURPOSE: Use of small pediatric kidneys obtained from extremely young donors after cardiac death has been limited. This potential organ source remains under used by transplant teams. MATERIALS AND METHODS: We reviewed all renal transplants at our institution from 2000 to 2013 to identify recipients of an en bloc pair of kidneys from deceased pediatric donors younger than 4 years. The outcomes of donation after cardiac death en bloc allografts were compared with neurological determination of death en bloc allografts. RESULTS: A total of 21 recipients of en bloc renal allografts were identified, of which 4 organ pairs were obtained through donation after cardiac death. Mean ± SD donor age was 20.6 ± 11.6 months and weight was 12.4 ± 3.7 kg. Delayed allograft function occurred in 2 of 4 recipients of allografts obtained from donation after cardiac death en bloc and 3 of 17 recipients of allografts from neurological determination of death en bloc. One year after transplantation mean ± SD glomerular filtration rates were similar, at 80.7 ± 15.3 and 85.7 ± 33.4 ml/minute/1.73 m(2) in the cardiac and neurological allograft groups, respectively (difference not significant). Surgical complications occurred in 3 patients, and no allograft was lost to thrombosis. CONCLUSIONS: We report successful transplantation of a small cohort of pediatric en bloc kidneys obtained through donation after cardiac death from donors younger than 4 years. Outcomes at 1 year are comparable to those in neurological determination of death en bloc allograft recipients.

Five-year experience with donation after cardiac death kidney transplantation in a Canadian transplant program: Factors affecting outcomes.

BACKGROUND: : Donation after cardiac death (DCD) has led to an increase of up to 40% in the number of kidney transplants in some programs. Unfortunately, the increase in warm ischemic time results in higher rates of delayed graft function (DGF). The purpose of our study was to examine our initial 5-year experience with DCD kidney transplantation and to determine the factors involved in early postoperative function and function at 1 year. METHODS: : This retrospective study included a review of the recipient and donor charts of 63 DCD kidneys retrieved and transplanted by the London Multi-Organ Transplant Program between July 2006 and October 2011. Comparisons were carried out between our early (n=31, July 2006 to January 2009) and our recent experience (n=32, March 2009 to October 2011). DGF and creatinine clearance at 3, 7 and 365 days were examined with regression analyses. RESULTS: : DGF was seen in 65% of transplanted kidneys. Mean creatinine clearance (CrCl) at 1 year was 66.7 mL/min. Low pre-transplant recipient daily urine output was the most statistically significant predictor of DGF in multivariate analysis (p < 0.001). In comparisons between our early and more recent results, improvements were noted in time from asystole to flush (16.0 vs. 12.0 minutes, p = 0.003), while cold ischemic time increased (464 vs. 725 minutes, p = 0.006). Experience contributed to a significant reduction in hospital length of stay (16 vs. 13 days, p = 0.035) and improved early renal function (CrCl at 3 days 7.8 vs. 11.9 mL/min, p = 0.027). The use of machine cold perfusion and higher recipient preoperative daily urine output predicted improved early renal function, while increasing donor age predicted poorer function at 1 year. DISCUSSION: : Despite early DGF, our results justify the continued transplantation of kidneys from DCD donors.