Early Rehospitalization Post-Kidney Transplant Due to Infectious Complications: Can We Predict the Patients at Risk?

Early readmissions post kidney transplantation: lessons learned

INTRODUCTION

Kidney transplantation (KT) is the gold standard treatment for end-stage renal disease (ESRD) patients. Hospital readmissions post-transplant is a common complication and can be considered an indication of avoidable morbidity and hospital quality, and there is a significant correlation between EHR and adverse patient outcomes. This study aimed to assess the readmission rate following kidney transplants, the underlying causes, and possible ways to prevent it.

MATERIAL AND METHODS

We retrospectively reviewed the medical records of recipients from January 2016 to December 2021 in a single center. The primary objective of this study is to find the readmission rate for kidney transplants and the variables that contribute to readmission. Post-transplant complications that were resulted in the readmission categorized into surgical complications, graft-related complications, infections, DVT, and other medical complications.

RESULTS

Four hundred seventy-four renal allograft recipients met our inclusion criteria and were included in the study. 248 (52.3%) of the allograft recipients had at least one readmission during the first 90 days after the transplantation. 89 (18.8%) allograft recipients had more than one readmission episode in the first 90 days post-transplant. The perinephric fluid collection was the most common surgical complication (52.4%), and UTI was the most common infection (50%), causing readmission in the first 90 days post-transplant. The readmission odd ratio was significantly higher in patients above 60 years old and in kidneys with KDPI ≥ 85, and in recipients with DGF.

CONCLUSION

Early hospital readmission (EHR) following a kidney transplant is a common complication. Identifying the causes not only helps the transplant centers to take further steps to prevent some incidents and help to improve the patients' morbidities and mortalities, but also it can reduce the unnecessary costs of readmissions.

What Are the Burden, Causes, and Costs of Early Hospital Readmissions After Kidney Transplantation?

Introduction:

Kidney transplant recipients are at risk for complications resulting in early hospital readmission. This study sought to determine the incidences, risk factors, causes, and financial costs of early readmissions.

Design:

This single-centre cohort study included 1461 kidney recipients from 1 Jul 2004 to 31 Dec 2012, with at least 1-year follow-up. Early readmission was defined as hospitalization within 30 or 90-days postdischarge from transplant admission. Associations between various parameters and 30 and 90-days posttransplant were determined using multivariable Cox proportional hazards models. The hospital-associated costs of were assessed.

Results:

The rates of early readmission were 19.4% at 30 days and 26.8% at 90 days posttransplant. Mean cost per 30-day readmission was 11 606 CAD. Infectious complications were the most common reasons and resulted in the greatest cost burden. Factors associated with 30 and 90-days in multivariable models were recipient history of chronic lung disease (hazard ratio or HR 1.78 [95%CI: 1.14, 2.76] and HR 1.68 [1.14, 2.48], respectively), median time on dialysis (HR 1.07 [95% CI: 1.01, 1.13]and HR 1.06 [95% CI: 1.01, 1.11], respectively), being transplanted preemptively (HR 1.75 [95% CI: 1.07, 2.88] and HR 1.66 [95% CI: 1.07, 2.57], respectively), and having a transplant hospitalization lasting of and more than 11 days (HR 1.52 [95% CI: 1.01, 2.27] and HR 1.65 [95% CI: 1.16, 2.34], respectively).

Discussion:

Early hospital readmission after transplantation was common and costly. Strategies to reduce the burden of early hospital readmissions are needed for all patients.

Re-hospitalization after pediatric kidney transplant: A single-center study

BACKGROUND

Little data exist on re-hospitalization rates in pediatric kidney recipients (KTx) particularly with the evolution of transplant immunosuppression.

METHODS

In a single-center, retrospective study of pediatric KTx between 2006 and 2016, we assessed re-hospitalization after KTx admission, stratified by whether the re-admit was early (<30 days post-KTx discharge) or late (>30 days), and compared two different immunosuppression eras (one with and one without steroids).

RESULTS

Of 197 KTx, 156 (79%) patients were re-hospitalized in 1st year, 85 (56%) within 30 days of discharge (total 490 1st year re-hospitalizations). Younger age was associated with early and late re-hospitalizations. African American race was associated with early re-hospitalizations. Of the 123 and 74 discharged on steroid-avoidance (maintenance immunosuppression included MMF in 95%; FK in 50%; CSA in 50%) and steroid-inclusive (AZA in 66%; MMF in 34%; FK in 30%; CSA in 70%), re-hospitalization rates, timing post-transplant, length, and number were not significantly different (P .38; .1; .56; .11). Admission diagnoses analysis demonstrated that steroid-avoidance recipients had anemia/leucopenia/thrombocytopenia, significantly more often, as one of their admission diagnoses (16% vs 4%; P < .001) and had a rejection diagnosis significantly less often (6% vs 18%; P < .001). Infection diagnoses were not statistically different between groups. Re-hospitalization, early or late, did not predict worse graft/ patient survival but predicted further hospitalizations.

CONCLUSIONS

Re-hospitalization is common after pediatric transplant discharge and predicts further hospitalization regardless of discharge on or off steroids.

Unplanned hospital readmissions after kidney transplantation among patients in Hefei, China: Incidence, causes and risk factors

Objectives

Unplanned readmissions severely affect a patient's physical and mental well-being after kidney transplantation (KT), which is also independently associated with morbidity. A retrospective study was conducted to identify the incidence, causes and risk factors for unplanned readmission after KT among Chinese patients.

Methods

Patients who underwent KT were admitted to the organ transplant center of the Affiliated Hospital of University of Science and Technology of China (2017-2018). Medical records for these patients were obtained through the hospital information system (HIS).

Results

In 518 patients, the incidence of unplanned readmissions within 30 days (n = 9) was 1.74%, and 90 days (n = 64) was 12.35%. The one-year unplanned readmission rate was 22.59% (n = 122). Overall, 122 patients were readmitted because of infection, renal events, metabolic disturbances, surgical complications, etc. Hemodialysis (OR = 10.462, 95% CI: 1.355-80.748), peritoneal dialysis (OR = 8.746, 95% CI: 1.074-71.238) and length of stay (OR = 1.023, 95% CI: 1.006-1.040) were independent risk factors for unplanned readmissions.

Conclusion

Unplanned readmission rates increased with time after KT. Certain risk factors related to unplanned readmissions should be deeply excavated. Targeted interventions for controllable factors to alleviate the rate of unplanned readmissions should be identified.

Determinants of Poor Glycemic Control in Patients with Kidney Transplants: A Single-Center Retrospective Cohort Study in Canada

Background:

Kidney transplant immunosuppressive medications are known to impair glucose metabolism, causing worsened glycemic control in patients with pre-transplant diabetes mellitus (PrTDM) and new onset of diabetes after transplant (NODAT).

Objectives:

To determine the incidence, risk factors, and outcomes of both PrTDM and NODAT patients.

Design:

This is a single-center retrospective observational cohort study.

Setting:

The Ottawa Hospital, Ontario, Canada.

Participant:

A total of 132 adult (>18 years) kidney transplant patients from 2013 to 2015 were retrospectively followed 3 years post-transplant.

Measurements:

Patient characteristics, transplant information, pre- and post-transplant HbA1C and random glucose, follow-up appointments, complications, and readmissions.

Methods:

We looked at the prevalence of poor glycemic control (HbA1c >8.5%) in the PrTDM group before and after transplant and compared the prevalence, follow-up appointments, and rate of complications and readmission rates in both the PrTDM and NODAT groups. We determined the risk factors of developing poor glycemic control in PrTDM patients and NODAT. Student t-test was used to compare means, chi-squared test was used to compare percentages, and univariate analysis to determine risk factors was performed by logistical regression.

Results:

A total of 42 patients (31.8%) had PrTDM and 12 patients (13.3%) developed NODAT. Poor glycemic control (HbA1c >8.5%) was more prevalent in the PrTDM (76.4%) patients compared to those with NODAT (16.7%; P < .01). PrTDM patients were more likely to receive follow-up with an endocrinologist (P < .01) and diabetes nurse (P < .01) compared to those with NODAT. There were no differences in the complication and readmission rates for PrTDM and NODAT patients. Receiving a transplant from a deceased donor was associated with having poor glycemic control, odds ratio (OR) = 3.34, confidence interval (CI = 1.08, 10.4), P = .04. Both patient age, OR = 1.07, CI (1.02, 1.3), P < .01, and peritoneal dialysis prior to transplant, OR = 4.57, CI (1.28, 16.3), P = .02, were associated with NODAT.

Limitations:

Our study was limited by our small sample size. We also could not account for any diabetes screening performed outside of our center or follow-up appointments with family physicians or community endocrinologists.

Conclusion:

Poor glycemic control is common in the kidney transplant population. Glycemic targets for patients with PrTDM are not being met in our center and our study highlights the gap in the literature focusing on the prevalence and outcomes of poor glycemic control in these patients. Closer follow-up and attention may be needed for those who are at risk for worse glycemic control, which include older patients, those who received a deceased donor kidney, and/or prior peritoneal dialysis.

Early Complications After Kidney Transplantation in Patients Aged 60 Years and Older: A Single-Center, Paired-Kidney Analysis

OBJECTIVES

As the population ages, the number of people suffering from cardiovascular diseases (CVD) and diabetes mellitus (DM) increases. The coexistence of these diseases can affect the results of kidney transplantation (KT) in the elderly. The aim of this study was to analyze surgical and nonsurgical complications in the early period after KT and to identify the factors that influence their development in recipients aged ≥ 60 years compared to younger recipients < 60 years.

METHODS

One hundred seventy-five recipients of KT ≥ 60 years and 175 recipients of KT < 60 years who received kidneys from the same deceased donor were enrolled into the study. The incidence of surgical and nonsurgical complications, factors that may influence their development, early graft function, and patient and kidney-graft survival were analyzed during a 3-month follow-up period. Donor sources complied with the Helsinki Congress and Istanbul Declaration and organs were not procured from prisoners and individuals who were coerced or paid.

RESULTS

Older recipients were characterized by higher body mass index ± SD (26.1 ± 3.5 vs 24.7 ± 3.4 kg/m²) and suffered more often from pretransplant DM (20.6% vs 11.4%) and CVD (34.3% vs 10.3%) and less frequently underwent previous KT (6.3% vs 20.0%). There were no differences between the ≥ 60 year old and < 60 year old groups in reference to surgical (20.6% vs 24%) and nonsurgical complications (28.6% vs 27.4%), early graft function, serum creatinine, and proteinuria. Recipients (95.4% vs 97.1%) and kidney-graft survival (93.1% vs 95.4%) were similar in both groups. The recipient factors that influenced the development of infectious complications were age, dialysis duration, pretransplant DM, and CVD.

CONCLUSIONS

Despite higher co-incidence of CVD and DM, the risk of surgical and nonsurgical complications in elderly recipients is comparable to younger recipients in the early period after KT.

Incidence of and Risk Factors for Multiple Readmissions after Kidney Transplantation

Unplanned readmission is often used as a surgical quality metric. A subset of kidney transplant recipients undergos multiple readmissions (MRs), although the incidence and risk factors are not well described. The aim of this study was to evaluate risk factors for MR after deceased donor kidney transplantation. All patients undergoing deceased donor kidney transplantation at a single center over a three-year period were analyzed via retrospective chart review for factors associated with MR. P values <0.05 were considered significant. Of 141 patients, the 30-day readmission rate was 26.2 per cent. MR occurred in 43 (30.5%) patients. Age, race, gender, initial organ function, and dialysis vintage were not associated with MR. Diabetic recipients, those who received basiliximab induction, those with acute rejection, and those with unplanned reoperations were at increased risk for MR. Infection was the most common reason for initial readmission in patients with MR (23.3%). One-year patient survival and death-censored graft survival were reduced for patients with MR. MRs are required for 30 per cent of kidney transplant recipients, primarily because of infection and immunologic causes. Recipients with diabetes and those who have acute rejection are at greatest risk.

Hospitalization costs and their determining factors among patients undergoing kidney transplantation: a cross-sectional descriptive study

BACKGROUND

Cost evaluation is a key tool in monitoring expenditure for budget management. It increases the efficiency of possible changes through identifying potential savings and estimating the resources required to make such changes. However, there is a lack of knowledge of the total cost of hospitalization up to the clinical outcome, regarding patients admitted for kidney transplantation. Likewise, there is a lack of data on the factors that influence the amounts spent by hospital institutions and healthcare systems.

OBJECTIVES

To describe the costs and determining factors relating to hospitalization of patients undergoing kidney transplantation.

DESIGN AND SETTING

Cross-sectional descriptive study with a quantitative approach based on secondary data from 81 patients who were admitted for kidney transplantation at a leading transplantation center in southern Brazil.

METHODS

The direct costs of healthcare for patients who underwent kidney transplantation were the dependent variable, and included personnel, expenses, third-party services, materials and medicines. The factors that interfered in the cost of the procedure were indirect variables. The items that made up these variables were gathered from the records of the internal transplantation committee and from the electronic medical records. The billing sector provided information on the direct costs per patient.

RESULTS

The estimated total cost of patients' hospitalization was R$ 1,257,639.11 (US$ 571,010.44). Out of this amount, R$ 1,237,338.31 (US$ 561,793.20) was paid by the Brazilian National Health System and R$ 20,300.80 (US$ 9,217.24) by the transplantation center's own resources. The highest costs related to the length of hospital stay and clinical complications such as sepsis and pneumonia.

CONCLUSIONS

The costs of hospitalization for kidney transplantation relate to the length of hospital stay and clinical complications.