The Enhanced Recovery After Surgery Pathway Is Safe, Feasible and Cost-Effective in Delayed Graft Function After Kidney Transplant

Abstract

Background/Objectives: Enhanced recovery after surgery (ERAS) pathways are still underutilized in kidney transplantation (KT), and their feasibility after delayed graft function (DGF) is unknown. We aimed to evaluate safety and cost savings after ERAS implementation in KT recipients with DGF. Methods: A retrospective analysis of KT recipients enrolled in the ERAS program with DGF (≥1 dialytic treatment during the first postoperative week or creatinine≥ 2.5 mg/dL on postoperative day 10) between 2010 and 2019 was performed. Recipient, donor, and transplant data, outcomes, and 1-year post-KT costs were collected, comparing recipients within the ERAS target (≤5 days, "early discharge group") to those discharged later (>5 days, "late discharge group"). Results: Out of 170 KT recipients with DGF, 33 (19.4%) were in the "early discharge group" and 137 (80.5%) in the "late discharge group". Recipient, donor, and transplant characteristics were similar in the two groups. The length of hospital stay (LOS) of the "early discharge group" was significantly shorter, with fewer in-hospital dialysis sessions (p < 0.001) compared to the "late discharge group". One year post-KT, no significant differences were observed in postoperative complications, readmissions, or number of outpatient visits. Five-year graft and patient survival along with five-year graft function were similar between the two cohorts. First-year costs were significantly higher in the "late discharge group" (p < 0.001), with a median excess cost (Δ) of EUR 4515.76/patient. Factors influencing first-year costs post-KT were LOS for KT, recipient age, and use of expanded-criteria grafts. Conclusions: The ERAS approach is safe in KT recipients with DGF and allows for economic savings, while its implementation does not cause worse clinical outcomes in recipients.

Keywords: cost-effectiveness; delayed graft function; enhanced recovery after surgery protocols; healthcare costs; kidney transplantation.

Figure 1

Flow-chart of the enhanced recovery after surgery pathway. Abbreviations: kidney transplant (KT); blood pressure (BP); mean arterial pressure (MAP); intravenous (IV); 0.9% saline fluid solution (NS); postoperative day (POD); ultrasound (US); and central venous catheter (CVC).

Figure 2

Study population. Abbreviations: kidney transplant (KT); number (n); liver transplant (LT); pancreas transplant (PT); years (y); delayed graft function (DGF); length of hospital stay (LOS).

Figure 3

The 5-year patient survival (A) and 5-year graft survival (B) in kidney transplant recipients who developed delayed graft function. “Early discharge group” refers to patients discharged within 5 days of kidney transplantation, while the “late discharge group” comprises recipients with hospital stays longer than 5 days after transplantation. The survival times of the two groups are compared using the log-rank test. Abbreviations: enhanced recovery after surgery (ERAS).

Figure 4

Correlation between the length of hospital stay (when kidney transplant was performed) and cost of the first year after transplantation. The term “Total costs” refers to the cost of the first year after kidney transplantation; “hospitalization length” refers to the length of the hospital stay when kidney transplantation was performed.