Surgical approach, cost, and complications of appendectomy in kidney transplant recipients

Clinical and financial outcomes of transplant recipients following emergency general surgery operations

Introduction

Due to immunosuppression and underlying comorbidities, transplant recipients represent a vulnerable population following emergency general surgery (EGS) operations. The present study sought to evaluate clinical and financial outcomes of transplant patients undergoing EGS.

Methods

The 2010-2020 Nationwide Readmissions Database was queried for adults (≥18 years) with non-elective EGS. Operations included bowel resection, perforated ulcer repair, cholecystectomy, appendectomy and lysis of adhesions. Patients were classified by transplant history (Non-transplant, Kidney/Pancreas, Liver, Heart/Lung). The primary outcome was in-hospital mortality while perioperative complications, resource utilization and readmissions were secondarily considered. Multivariable regression models evaluated the association of transplant status on outcomes. Entropy balancing was employed to obtain a weighted comparison to adjust for intergroup differences.

Results

Of 7,914,815 patients undergoing EGS, 25,278 (0.32 %) had prior transplantation. The incidence of transplant patients increased temporally (2010: 0.23 %, 2020: 0.36 %, p < 0.001) with Kidney/Pancreas comprising the largest proportion (63.5 %). Non-transplant more frequently underwent appendectomy and cholecystectomy while transplant patients more commonly received bowel resections. Following entropy balancing, Liver was associated with decreased odds of mortality (AOR: 0.67, 95 % CI: 0.54-0.83, Reference: Non-transplant). Incremental hospitalization duration was longer in Liver and Heart/Lung compared to Non-transplant. Odds of acute kidney injury, readmissions and costs were higher in all transplant types.

Conclusion

The incidence of transplant recipients undergoing EGS operations has increased. Liver was observed to have lower mortality compared to Non-transplant. Transplant recipient status, regardless of organ, was associated with greater resource utilization and non-elective readmissions. Multidisciplinary care coordination is warranted to mitigate outcomes in this high-risk population.

Incidence and Mortality of Emergency General Surgery Conditions Among Solid Organ Transplant Recipients in Ontario, Canada: A Population-based Analysis

BACKGROUND

Emergency general surgery (EGS) conditions and their outcomes are perceived to be disproportionately high among solid organ transplant recipients (SOTRs). However, this has not been adequately investigated at a population level. We characterized the incidence and mortality of EGS conditions among SOTRs compared with nontransplant patients.

METHODS

Data were collected through linked administrative population-based databases in Ontario, Canada. We included all adult SOTRs (kidney, liver, heart, and lung) who underwent transplantation between 2002 and 2017. We then identified posttransplantation emergency department visits for EGS conditions (appendicitis, cholecystitis, choledocolithiasis, perforated diverticulitis, incarcerated/strangulated hernias, small bowel obstruction, and perforated peptic ulcer). Age-, sex-, and year-standardized incidence rate ratios (SIRRs) were generated. Logistic regression models were used to evaluate association between transplantation status and 30 d mortality after adjusting for demographics, year, and comorbidities.

RESULTS

Ten thousand seventy-three SOTRs and 12 608 135 persons were analyzed. SOTRs developed 881 EGS conditions (non-SOTRs: 552 194 events). The incidence of all EGS conditions among SOTR was significantly higher compared with the nontransplant patients [SIRR 3.56 (95% confidence interval [CI] 3.32-3.82)], even among those with high Aggregated Diagnosis Groups scores ( > 10) [SIRR 2.76 (95% CI 2.53-3.00)]. SOTRs were 1.4 times more likely to die at 30 d [adjusted odds ratio 1.44 (95% CI 1.08-1.91)] after an EGS event compared with nontransplant patients, predominantly amongst lung transplant recipients [adjusted odds ratio 3.28 (95% CI 1.72-6.24)].

CONCLUSIONS

The incidence of EGS conditions is significantly higher in SOTRs even after stratifying by comorbidity burden. This is of particular importance as SOTRs also have a higher likelihood of death after an EGS condition, especially lung transplant recipients.

Abdominal infection combined with pneumoperitoneum after renal transplantation: A case report

INTRODUCTION

Abdominal infection combined with pneumoperitoneum after renal transplantation is rare, clinically confusing, and easily misdiagnosed by physicians as gastrointestinal perforation.

PATIENT CONCERNS

A 54-year-old man experienced abdominal pain and distension together with signs of peritoneal irritation after cadaveric renal transplantation. CT and standing abdominal plain film showed a large pneumoperitoneum in the abdominal cavity and the patient underwent an exploratory laparotomy but no gastrointestinal perforation was found.

DIAGNOSIS

No gastrointestinal perforation was found during the operation. In the search for the infectious agent, ascites culture was negative while next-generation sequencing was positive, suggesting the presence of intestinal flora ectopic to abdominal infection with anaerobic respiration fermentation leading to large amounts of gas.

INTERVENTIONS

The patient underwent exploratory laparotomy without gastrointestinal perforation, and then underwent abdominal lavage, placed abdominal drainage tube, and conducted culture and next-generation sequencing examination of ascites.

OUTCOMES

Postoperative symptoms were relieved and intestinal function recovered. After 3 months of outpatient follow-up, the patient had stable transplanted kidney function and was in good spirits and sleeping well, with a good appetite, soft and regular stools, no abdominal pain and distension, and no fever.

CONCLUSION

Patients after kidney transplantation should be wary of abdominal infection being misdiagnosed as gastrointestinal perforation.

Kidney-Pancreas Transplant Recipients Experience Higher Risk of Complications Compared to the General Population after Undergoing Coronary Artery Bypass Grafting

This retrospective analysis aims to identify differences in surgical outcomes between pancreas and/or kidney transplant recipients compared with the general population undergoing coronary artery bypass grafting (CABG). Using Nationwide Inpatient Sample (NIS) data from 2005 to 2014, patients who underwent CABG were stratified by either no history of transplant, or history of pancreas and/or kidney transplant. Multivariate analysis was used to calculate odds ratio (OR) to evaluate in-hospital mortality, morbidity, length of stay (LOS), and total hospital charge in all centers. The analysis was performed for both nonemergency and emergency CABG. Overall, 2,678 KTx (kidney transplant alone), 184 PTx (pancreas transplant alone), 254 KPTx (kidney-pancreas transplant recipients), and 1,796,186 Non-Tx (nontransplant) met inclusion criteria. KPTx experienced higher complication rates compared with Non-Tx (78.3 vs. 47.8%, p  < 0.01). Those with PTx incurred greater total hospital charge and LOS. On weighted multivariate analysis, KPTx was associated with an increased risk for developing any complication following CABG (OR 3.512, p  < 0.01) and emergency CABG (3.707, p  < 0.01). This risk was even higher at transplant centers (CABG OR 4.302, p  < 0.01; emergency CABG OR 10.072, p  < 0.001). KTx was associated with increased in-hospital mortality following emergency CABG, while PTx and KPTx had no mortality to analyze. KPTx experienced a significantly higher risk of complications compared with the general population after undergoing CABG, in both transplant and nontransplant centers. These outcomes should be considered when providing perioperative care.

Renal Transplant Patients Undergo Abdominal Aortic Aneurysm Repair at a Younger Age and Experience More Complications: Review of the Healthcare Cost and Utilization Project Database

OBJECTIVE

The objective of this study was to determine whether history of kidney transplant is a risk factor for increased complications in patients who undergo abdominal aortic aneurysm (AAA) repair.

BACKGROUND

The incidence of renal failure and subsequent kidney transplant is steadily rising. Many risk factors leading to AAA overlap with those of renal disease. Due to these similarities, a rising incidence of kidney transplant patients undergoing AAA repair is expected. We surmised a notable difference in AAA surgical repair outcomes in renal transplant recipients compared to the general population.

METHODS

A retrospective analysis was performed on 59,836 adult patients with history of AAA repair and kidney transplant from 2008 to 2015. Data were obtained from the Nationwide Inpatient Sample database developed for the Healthcare Cost and Utilization Project.

RESULTS

Significant differences in age, race, hospital characteristics, and complications were identified. The results suggest that patients with prior transplant generally have AAA repair at a significantly younger age (P < .001). A difference in race (P = .017), with 75% vs 87.4% non-Hispanic whites and 5% vs 1.5% Asian/Pacific Islander in the transplant and nontransplant groups, respectively, was shown. Procedures at transplant centers had significantly longer lengths of stay (P < .001) and higher total charges (P < .001). In addition, transplant recipients exhibited a higher in-hospital mortality index (P < .001) than the nontransplanted population.

CONCLUSION

A history of kidney transplant significantly influences multiple aspects of care and complications regarding future AAA repair and is associated with increased in-hospital mortality index. Significant findings include increased total charges, longer lengths of stay, postoperative complications, and differences in age and race.

Renal Transplantation Is Associated with Increased Complications Following Spinal Fusion Operations: Analysis of a National Database

BACKGROUND

Improved postoperative care for renal transplant recipients has advanced both duration and overall quality of life. However, degenerative spinal pathology is increasingly prevalent after transplant. Outcomes following spinal fusion among the renal transplant population in the United States are rarely addressed.

METHODS

The Healthcare Cost and Utilization Project National Inpatient Sample database was employed. Cases in years 2008-2014 for patients ≥18 years old receiving spinal fusion, exploration/decompression, and/or spinal revision/re-fusion surgeries were included. Cases were divided into kidney transplant recipients (KTR) and non-kidney transplant recipients. Complications, demographics, and socioeconomic outcomes were compared between cohorts.

RESULTS

Of 579,726 patients who met inclusion criteria, 685 (0.1%) were KTRs. The KTR population was older and included more men compared with the non-kidney transplant recipient population (60.1 years vs. 56.6 years, P < 0.001; 58% male vs. 45.5% male, P < 0.001). KTRs experienced higher total complication rates (29.8% vs. 18.9%, P < 0.001). Prevalence of acute posthemorrhagic anemia and need for transfusion was markedly higher for KTRs (15.8% vs. 9.1%, P < 0.001; 13.6% vs. 6.2%, P < 0.001). Multivariate analysis revealed longer length of stay (median 1.23 days, interquartile range 0.94-1.53, P < 0.001), lower routine discharge (odds ratio = 0.57, 95% confidence interval 0.48-0.69, P < 0.001), and higher discharge to alternative care facilities (odds ratio = 1.91, 95% confidence interval 1.57-2.33, P < 0.001) for KTRs. The inpatient course for KTRs undergoing spinal operations was significantly costlier ($87,445 vs. $71,589, P < 0.001).

CONCLUSIONS

History of renal transplant was associated with increased inpatient medical and socioeconomic complications following spinal fusion. Physicians and patients must understand and respect the potentially increased perioperative challenges facing KTRs.

Acute Care Surgery for Transplant Recipients: A National Survey of Surgeon Perspectives and Practices

BACKGROUND

Transplant recipients are living longer than ever before, and occasionally require acute care surgery for nontransplant-related issues. We hypothesized that while both acute care surgeons (ACS) and transplant surgeons would feel comfortable operating on this unique patient population, both would believe transplant centers provide superior care.

METHODS

To characterize surgeon perspectives, we conducted a national survey of ACS and transplant surgeons. Surgeon- and center-specific demographics were collected; surgeon preferences were compared using χ2, Fisher's exact, and Kruskal-Wallis tests.

RESULTS

We obtained 230 responses from ACS and 204 from transplant surgeons. ACS and transplant surgeons believed care is better at transplant centers (78% and 100%), and transplant recipients requiring acute care surgery should be transferred to a transplant center (80.2% and 87.2%). ACS felt comfortable operating (97.5%) and performing laparoscopy (94.0%) on transplant recipients. ACS cited transplant medication use as the most important underlying cause of increased surgical complications for transplant recipients. Transplant surgeons felt it was their responsibility to perform acute care surgery on transplant recipients (67.3%), but less so if patient underwent transplant at a different institution (26.5%). Transplant surgeons cited poor transplanted organ resiliency as the most important underlying cause of increased surgical complications for transplant recipients.

CONCLUSIONS

ACS and transplant surgeons feel comfortable performing laparoscopic and open acute care surgery on transplant recipients, and recommend treating transplant recipients at transplant centers, despite the lack of supportive evidence. Elucidating common goals allows surgeons to provide optimal care for this unique patient population.

Burn patients with history of kidney transplant experience increased incidence of wound infection

OBJECTIVE

To determine if history of kidney transplant is an independent risk factor for increased incidence of wound infection and other morbidities in burn patients.

BACKGROUND

While the goal of immunosuppression post-organ transplantation is to prevent graft rejection, it is often associated with significant adverse effects such as increased susceptibility to infection, drug toxicity, and malignancy. Burn injuries lead to a dysregulated hypermetabolic state and a compromised cutaneous barrier, which predisposes to infection and delayed wound healing. We surmise that a history of kidney transplant increases the risk of wound infection in in-hospital burn victims.

METHODS

A retrospective analysis was performed on 57,948 adults diagnosed in-hospital with a burn injury between 2008-2014, obtained from the Nationwide Inpatient Sample (NIS) by Healthcare Cost and Utilization Project (HCUP).

RESULTS

103 burn victims (0.2%) with a history of kidney transplant (KTX) were identified. Compared to burn patients without a history of transplant (No-KTX), they were older (54.3 ± 13.8 vs 49.8 ± 18.7; p = 0.001), more likely be insured under Medicare (69.9% vs 31.1%; p < 0.001), and less likely to have Medicaid (5.8% vs 17.2%; p = 0.002). Higher in-hospital mortality index scores were observed in KTX compared to no-KTX with p < 0.001. The incidence rates of complications such as wound infection (33.0 vs 16.3; p < 0.001) and acute renal failure (18.4 vs 7.7; p < 0.001) were significantly higher in the KTX group. After adjusting for confounding factors in multivariable analysis, the incidence of wound infection remained significantly higher. Burn patients with history of KTX were not more likely to be treated at a transplant (TX) center. TX centers were determined to have higher mortality rate, longer length of stay, and higher total hospital charges.

CONCLUSION

History of kidney transplant is an independent risk factor for increased incidence of wound infection in burn patients.