We present a series of 3 cases of next-day discharge after kidney transplant during the SARS-CoV-2 pandemic; these patients were discharged early to prevent inpatient exposure to the virus at a time when hospitals were overwhelmed with patients infected with SARS-CoV-2 and at a time of significant shortage of nursing staff to take care of these patients. We learned that, if protocols were followed, next-day discharge could be achieved without increasing the readmission rates in carefully selected patients with good family support.
A multidisciplinary approach to decrease length of stay, or Enhanced Recovery After Surgery (ERAS), has been adopted in different forms to shorten the length of stay and to improve outcomes. The elements of this protocol reduce the stress of operation to retain anabolic homeostasis.1 Early postoperative discharge after major inpatient surgery is associated with lower total surgical episode payments, translating to lower costs for health insurance companies.2 The ability to reduce cost through length of stay reduction by implementation of a kidney transplant outpatient unit was described by Shapiro and colleagues in 1998.3 The implementation of a clinical pathway for deceased donor kidney transplant was found to be effective in reducing the length of stay.4 The feasibility of a modified ERAS protocol that had low morbidity and reasonable readmission rates was demonstrated in kidney transplant recipients.5 Here, we present 3 patients at a single center who had successful posttransplant day 1 discharge after kidney transplant without a high rate of readmission.
Patient 1 was 33-year-old African American woman with chronic kidney disease stage IV secondary to diabetes mellitus type 2 who had received a preemptive deceased donor kidney transplant from a 19-year-old African American man who died in a motorcycle accident. The recipient’s panel reactive antibody (PRA) was 57, and the donor’s Kidney Donor Profile Index was 21%. The donor’s serum creatinine level on admission was 1.21 mg/dL, which peaked at 1.53 mg/dL and then was 1.0 mg/dL before organ retrieval. Warm ischemia time was 32 minutes, and cold ischemia time was 26 hours and 47 minutes. The recipient’s creatinine on admission was 9.01 mg/dL. Her postoperative course was uncomplicated, and patient 1 was discharged home on posttransplant day 1 with a creatinine level of 5.44 mg/dL. Induction immunosuppression included 3 mg/kg thymoglobulin divided into 2 doses along with methylprednisolone. A second dose of thymoglobulin was given on posttransplant day 1 prior to discharge. Maintenance immunosuppression included tacrolimus, mycophenolate mofetil, and prednisone. On posttransplant day 4 in the clinic, the patient’s creatinine level was 1.76 mg/dL. She was readmitted to the hospital on posttransplant day 11 with acute kidney injury, hyperglycemia, Escherichia coli urinary tract infection, and bacteremia, with creatinine level of 3.56 mg/dL and blood glucose of 314 mg/dL. The patient was treated with antibiotics and intravenous fluids, and her insulin dose was adjusted to achieve euglycemia. After 5 days, the patient was discharged home. At 14 months posttransplant, the patient’s creatinine level was 1.09 mg/dL, with no other hospital admissions.
Patient 2 was a 49-year-old African American man with end-stage renal disease due to hypertension who had been on hemodialysis for 2 years; he had received a kidney transplant from a living related (ex-wife) 48-year-old female donor. The recipient’s PRA was 0 and creatinine level was 15.01 mg/dL on day of transplant. His postoperative course was uncomplicated, and he was discharged home on posttransplant day 1. Induction immunosuppression included basiliximab and methylprednisolone. A second dose of basiliximab was given on posttransplant day 1 prior to discharge. Maintenance immunosuppression included tacrolimus, mycophenolate mofetil, and prednisone. Creatinine level at the time of discharge was 8.64 mg/dL. Since transplant, patient 2 has not been readmitted to the hospital. At 10 months posttransplant, his creatinine level was 1.58 mg/dL.
Patient 3 was a 64-year-old African American man with end-stage renal disease after a failed first deceased donor kidney transplant. His initial cause of kidney failure was focal segmental glomerulosclerosis. He also had a history of hypertension, dyslipidemia, coronary artery disease, and cerebrovascular accident. Patient 3 was on hemodialysis for 2 years after the first transplant failed and before he received the second kidney transplant. He received a second deceased donor kidney transplant from a 50-year-old female donor with Kidney Donor Profile Index of 53%. At the time of second transplant, the patient’s PRA was 7 and his creatinine level was 5.13 mg/dL. Cold ischemia time was 12 hours and 18 minutes. Induction immunosuppression included 3 mg/kg thymoglobulin divided into 2 doses along with methylprednisolone. The second dose of thymoglobulin was given on posttransplant day 1. Maintenance immunosuppression included tacrolimus, mycophenolic acid, and prednisone. Patient 3 was discharged home on posttransplant day 1 with a creatinine level of 4.32 mg/dL. He was never readmitted to the hospital following discharge. At 10 months posttransplant, his creatinine level was 1.9 mg/dL.
According to the Organ Procurement and Transplantation Network, transplant date is determined as “the start of the organ anastomosis during transplant or the start of the islet infusion” (https://optn.transplant.hrsa.gov/media/1200/optn_policies.pdf; accessed May 23, 2021). We followed this definition to determine the day of transplant. All patients in our series were African American. Our program serves the metropolitan Detroit area, and 90% of our patients are African American. During early 2020, transplant activities in our hospital were suspended for about 3 months due to the SARS-CoV-2 pandemic. In addition, there was a significant nursing staff shortage. To limit the exposure of transplant patients to the hospital environment and SARS-CoV-2 infection, and because of the nursing staff shortage, we decided to discharge patients early. We did not have an ERAS program in place. Of 21 kidney transplants performed from January through November 2020, 3 patients were discharged the next day after kidney transplant. All patients were discharged with a Foley catheter, which was removed in the clinic around posttransplant day 7. All patients had ureteral stents that were removed 4 to 6 weeks after transplant.
Patient 1, who received preemptive transplant, was readmitted for acute kidney injury, hyperglycemia and Escherichia coli urinary tract infection with bacteremia. This could be related to prolonged catheterization and poor catheter care at home in the setting of poorly controlled diabetes mellitus type 2 and immunosuppression. However, this was successfully managed, and patient 1 was discharged home after 5 days without any more readmissions. Patient 2 and patient 3 had uncomplicated postoperative coursed without any hospital readmissions.
The success of these 3 cases was related to strong family support and support by the entire transplant team. We discussed the possibility of early discharge with the patients and their families, nursing staff, social work, pharmacist, and other transplant team members. Strong family support was essential for discharge. Early ambulation and efficient pain control helped achieve this goal. Induction immunosuppression protocols were modified to enable early discharge. Patients were called by the transplant coordinator on the day after discharge, and all patients were seen in clinic within a few days of discharge.The concept of early discharge, where patients are discharged 2 days after kidney transplant without additional morbidity or higher readmission rates, has been previously demonstrated in large transplant programs in the United States with good resources6,7; however, this concept has not been reported with smaller programs. Although our sample size was small, our results underscore the possibility of performing kidney transplant surgeries in appropriately selected candidates with an overnight stay in smaller transplant programs with limited resources. Given changes in kidney allocation with longer anticipated cold ischemia time, there will be higher rates of delayed graft function, which is associated with longer length of stay.8 None of the patients in our series had delayed graft function, enabling us to discharge them early. To prevent readmissions after discharge, greater attention is needed on medical comorbidities and on discharge-level factors like electrolyte abnormalities, surgical complications, and delayed graft function.9
In conclusion, next-day discharge after kidney transplant is possible in carefully selected transplant recipients, even in smaller programs with limited resources without any additional morbidity or higher readmission rates.
DOI : 10.6002/ect.2021.0309
From the 1Detroit Medical Center, Harper University Hospital, Detroit, Michigan; and 2ChristianaCare, Newark, Delaware, USA
Acknowledgements: The authors have not received any funding or grants in support of the presented research or for the preparation of this work and have no declarations of potential conflicts of interest.
Corresponding author: Shakir Hussein, Detroit Medical Center – Harper University Hospital, 3990 John R Street, Professional Bldg., Suite 400, Detroit, MI 48201, USA