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Volume: 17 Issue: 1 January 2019 - Supplement - 1

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Emergency Department Visits After Kidney, Liver, and Heart Transplantation in a Hospital of a University in Turkey: A Retrospective Study

Objectives: In our country, there are few publications evaluating emergency department visits among kidney, liver, and heart transplant recipients. Here, we examined emergency department visits of transplant recipients after initial hospital discharge following organ transplant performed in a medical faculty hospital in Ankara, Turkey.

Materials and Methods: We retrospectively analyzed hospital records of 1144 transplant recipients (700 kidney, 332 liver, and 112 heart) who underwent living-donor and deceased-donor organ transplant procedures in a university hospital between 2007 and 2017 and were admitted to the emergency depart-ment during the same period.

Results: The study population (1144 organ transplants) consisted of kidney (61.2%), liver (29.0%), and heart (9.8%) transplant recipients. Among them, 67.9% of kidney transplant recipients and 62.0% of liver transplant recipients were male, whereas 65.2% of heart transplant recipients were female. Average ages were 32.8 ± 15.5, 24.26 ± 21.6, and 29.9 ± 18.7 years, respectively. Among all groups, 41.4% visited the emergency department within 2 years after trans-plant. Median time to emergency department visit for kidney, liver, and heart transplant recipients was 4.7 months, 3.5 months, and 11.5 months, respectively. Emergency department admissions were due to complaints of abdominal/pelvic pain, fever, nausea/vomiting, hypertension, and nonspecific chest pain. Among all groups, the main diagnoses were most commonly classified by fluid and electrolyte disorders, abnormal results of renal function, urinary tract infections, and acute respiratory infections. One-third of patients were hospitalized.

Conclusions: Nearly one-quarter of kidney transplant recipients, one-fifth of liver transplant recipients, and one-tenth of heart transplant recipients visited the emergency department within 30 days of transplantation. Considering that one-third were rehospitalized, the recipients could be targeted for better transitions of care and for earlier or more frequent outpatient follow-up and also be informed about what symptoms are not normal and in which situations they should seek emergency care.


Key words : Hospital readmission, Outpatient follow-up, Posttransplant care

Introduction

Organ transplantation is a treatment method for patients with end-stage liver disease.1-3 The first renal transplant in Turkey was performed in 1975 with a kidney donated from mother to son. This was fol-lowed by the first deceased-donor kidney transplant, which was carried out in 1978, using an organ supplied by the Eurotransplant Foundation. In 1990, the first pediatric segmental living-related liver transplant in Turkey and in the Middle Eastern region was performed by Haberal and colleagues.4-7 From 2008 to 2017, more than 20 thousand renal transplant procedures and about 1500 liver trans-plant procedures were performed; in addition, from 2016 to 2017, more than 100 heart transplants were performed nationwide in 99 different centers.8

Since the introduction of effective immunosup-pressive agents, organ transplant recipients survive longer. These effective agents have resulted in an increase in the number of patients undergoing organ transplant.1,9 However, these therapies have caused other distinct health problems such as chronic immunosuppression and high rates of postoperative complications.10,11 Due to these reasons, organ trans-plant recipients may present to emergency depart-ments (ED) for problems related to adverse effects of organ transplant surgery, acute rejection episodes, infections, cardiovascular diseases, and adverse effects of immunosuppressive drugs. As a result, the possibility of emergency physicians encountering transplant patients is increasing.11-13 The lack of knowledge and approach to transplant patients may be an important problem in the care of these patients in ED.9,11 Therefore, it is important to develop more patient-centered emergency care and to mitigate the risks and costs of ED visits.

Although there is considerable research in the literature, in Turkey, there are few publications evaluating ED visits among kidney, liver, and heart transplant recipients. This study aimed to determine the reasons for ED visits by renal, liver, and heart transplant recipients after initial hospital discharge and to share the experiences of the ED of a university hospital in Ankara, Turkey.

Materials and Methods

We retrospectively analyzed the hospital records of all 1144 transplant recipients (700 kidney, 332 liver, and 112 heart) who underwent living-donor and deceased-donor organ transplant procedures in a university hospital between January 1, 2007 and December 31, 2017. Data of all transplant patients who presented to our ED were obtained from the records of the Nucleus Program used for the Hospital Registration System. Demographic characteristics (age, male/female), ED presenting complaints, number of ED admissions, and final diagnosis and outcomes (including hospitalization or discharge from ED) were evaluated. The time between trans-plant and ED visit and the cumulative incidences of ED visits at 1, 6, 12, and 24 months for all transplant recipients (kidney, liver and heart) were calculated.

The study protocol was approved by the Insti-tutional Review Board. Statistical analyses were performed with SPSS software (SPSS: An IBM Company, version 25, IBM Corporation, Armonk, NY, USA). Descriptive statistics, averages, frequency tables, and dependent group t tests were used to analyze the variables. Significance was identified by 2-sided P value of < .05.

Results

Over the 10-year period (January 2007 to December 2017), there were 1144 total recipients: 700 kidney, 332 liver, and 112 heart transplant recipients (Table 1). Among them, 67.9% of kidney transplant recipients and 62.0% of liver transplant recipients were male, whereas 65.2% of heart transplant recipients were female (Table 1). The average ages of kidney, liver, and heart transplant recipients were 32.8 ± 15.5, 24.2 ± 21.6, and 29.9 ± 18.7 years, respectively (Table 1). Among all transplant recipients, 41.4% (n = 474) presented to the ED within 2 years after transplant: 49.4% (346/700) of kidney, 28.3% (94/332) of liver, and 9.8% (34/112) of heart transplant recipients. The number of transplant recipients who visited the ED increased cumulatively over the years. The average number of visits to the ED was 6.07 ± 6.86 for female recipients and 5.16 ± 6.09 for male recipients, with mean number for both of 3 (range, 1-45). Two-thirds of all the transplant recipients who visited the ED were discharged, and 30.1% (145/474) were hospitalized.

Findings of kidney transplant recipients
The cumulative incidence of ED visits at 1, 6, 12, and 24 months for kidney transplant recipients was 23.1%, 54.9%, 67.1%, and 76.9%, respectively, with a median time of 4.7 months (Table 2). The distribution of cumulative incidence of ED visits between female and male patients showed that female recipients had an incidence rate of 4 months median time compared with 5 months for male patients. The cumulative incidence of ED visits at 1, 6, 12, and 24 months for male patients was 22.8%, 54.3%, 67.2%, and 77.6%, respectively. Respective incidences for female patients were 23.7%, 56.1%, 64.7%, and 75.4%. The difference between female and male patient visits was not significant (P > .05; Table 2).

Most kidney transplant recipients admitted to the ED at 1, 6, 12, and 24 months had complaints of abdominal/pelvic pain (15.3%, 17.4%, 14.9%, and 14.1%, respectively), followed by fever, nausea/-vomiting, hypertension, headache, dizziness, syncope, seizure, and nonspecific chest pain (Table 3).

Main diagnoses of kidney transplant recipients admitted to the ED at 1, 6, 12, and 24 months were most commonly classified by fluid and electrolyte disorders (18.0%, 30.2%, 31.9%, and 33.2%, respectively) and acute upper respiratory tract infections (17.1%, 6.6%, 9.5%, and 10.8%, respectively), followed by urinary tract infections and abnormal results of renal function (Table 3). Visits due to urinary system infections, intestinal infections, and lower respiratory tract infections (pneumonia, bronchiolitis) increased from 6 to 24 months.

Findings of liver transplant recipients
The cumulative incidence of ED visits at 1, 6, 12, and 24 months for liver transplant recipients was 20.2%, 60.6%, 72.3%, and 80.9%, respectively, with a median time of 3.5 months (Table 2). Distribution of cumulative incidence plots of ED visits showed that male patients had higher incidence rate (2.5 mo median time) than female patients (5 mo). The cumulative incidence rate of ED visits at 1, 6, 12, and 24 months for male patients was 21.3%, 65.6%, 75.4%, and 85.2%, respectively. For women, it was 18.2%, 51.5%, 66.7%, and 72.7%, respectively. The difference between male and female visits was not significant (P > .05; Table 2).

Most liver transplant recipients admitted to the ED at 1, 6, 12, and 24 months had complaints of abdominal/pelvic pain (13.6%, 20.7%, 23.7%, and 21.8%, respectively), followed by fever, nausea/-vomiting, headache, dizziness, syncope, seizure, hypertension, and nonspecific chest pain (Table 4). Main diagnoses of liver transplant recipients admitted to the ED at 1, 6, 12, and 24 months were most commonly classified by fluid and electrolyte disorders (18.2%, 27.0%, 27.3%, and 24.3%, respectively), abnormal results of kidney function tests (18.2%, 22.5%, 21.7%, and 18.4, respectively), and urinary system infections (4.5%, 14.4%, 10.6%, and 10.1%, respectively), followed by acute abdominal diseases and complications (cholangitis, cholecystitis, appendicitis, peritonitis) and lower and upper respiratory tract infections (Table 4).

Findings of heart transplant recipients
The cumulative incidence of ED visits at 1, 6, 12, and 24 months for heart transplant recipients was 11.8%, 29.4%, 52.9%, and 67.6%, respectively, with a median time of 11.5 months (Table 2). Distribution of cumulative incidence of ED visits showed that male patients had an incidence rate of 11.5 months median time compared with 11 months for female patients. The cumulative incidence of ED visits at 1, 6, 12, and 24 months for male recipients (n = 26) was 11.5%, 30.8%, 53.8%, and 69.2%, respectively. Eight female recipients were admitted to the ED, with first visit distribution of 1, 2, 4, and 5, respectively. The difference between male and female patient visits was not significant (P > .05; Table 2).

Most heart transplant recipients admitted to the ED at 1, 6, 12, and 24 months had complaints and diagnosis of abnormal renal function tests, other disorders of electrolyte and liquid balance, upper and lower respiratory tract infections, urinary system infections, hypertension, heart disease (angina pectoris, myocardial infarction, myocarditis, pericarditis), and nonspecific chest pain (Table 5).

Discussion

In this retrospective study, 49.4% of kidney, 28.3% of liver, and 9.8% of heart transplant recipients visited the ED within 2 years. The ED admissions of kidney, liver, and heart transplant recipients increased from 23.1% and 54.9% at 30 days and 6 months to 67.1% and 76.9% at 12 months and 2 years; from 20.2% and 60.6% at 30 days and 6 months to 72.3% and 80.9% at 12 months and 2 years; and from 11.8% and 29.4% at 30 days and 6 months to 52.9% and 67.6% at 12 months and 2 years, respectively. In a study from Oh and associates, between 2011 and 2014, ED visits among liver transplant recipients occurred at least once in 53.0% (229/430) and readmissions occurred in 58.6% (252/430) of 430 patients. The probability of ED visit and readmission increased from 15.3% and 16.0% at 30 days to 43.6% and 49% at 1 year, respectively.9

The most common reason for ED admission in kidney and liver transplant recipients was abdominal/pelvic pain and fever; for heart transplant recipients, ED visits were most commonly for urinary and gastrointestinal system-related complaints. Various other studies have reported that the most frequent complaints for kidney and liver transplant recipients who visited the ED were fever and abdominal pain.10,13 Posttransplant complications with fever and abdominal pain due to medical treatment are the most common reasons for ED admissions in kidney and liver transplant patients.12

In our study, the most common diagnosis among all transplant recipients was fluid and electrolyte disorders followed by infections. Acute upper and lower respiratory, urinary tract, and the intestinal infections were the most frequent infectious problems; among noninfectious problems, fluid and electrolyte disorders and abnormal results of kidney function were the most frequent. Infections are usual complications of immunosuppressive therapy.14,15 Previous studies have reported that the most common causes of admission to the ED for kidney transplant patients are infections.10,11 Sources of infections after kidney and liver transplant are most commonly the urinary system, followed by the upper and lower respiratory tract.11,14-16 Our findings were similar to these results. Acute renal failure is a major risk factor of rejection among renal transplant recipients.17 In our study, most kidney transplant recipients were admitted to the ED with abnormal kidney function results, with 30 patients diagnosed with acute renal failure. Among all transplant recipients, the hospitalization rate (30.1%) was lower in our study than in previous investigations.11,13

Conclusions

Because this study is a retrospective survey, there are methodologic limitations. In ad-dition, some kidney, liver, and heart transplant patients may have presented to EDs of other hospitals. Despite these limitations, our study may help to raise awareness among emergency physicians about complications of kidney, liver, and heart transplant procedures.

Nearly one-quarter of kidney transplant recipients, one-fifth of liver transplant recipients, and one-tenth of heart transplant recipients visited the ED within 30 days of transplant. Considering that one-third of patients were hospitalized, these results may have important implications on clinical practice. Improved identification of recipients at risk of hospital read-mission could lead to better targeting for transitions of care and coordination of care at discharge posttransplant. In addition, earlier targeting and more frequent outpatient follow-up, as well as clear information on symptoms that are not normal and in which situations patients should seek emergency care, are needed.


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Volume : 17
Issue : 1
Pages : 264 - 269
DOI : 10.6002/ect.MESOT2018.P120


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From the Departments of 1Public Health, 2Emergency, and 3Transplantation, Baskent University, Ankara, Turkey
Acknowledgements: This study was supported by Research Fund of Baskent University (KA 18/60). The authors have no conflicts of interest to declare.
Corresponding author: Sare Mıhçıokur, Baskent University Department of Public Health, 79.Sokak (Eski 12.Sokak), No 7/7, Bahçelievler, Ankara, Turkey
Phone: +90 535 276 0977
E-mail: saremihciokur@gmail.com