Published June 19, 2018
Improving outcomes for kidney transplant patients is the goal of newly published research led by Liise K. Kayler, clinical professor of surgery.
“After surgery, there is some recovery and healing that happens, and health care providers give medications and other treatments to help patients recover as comfortably and quickly as possible,” says Kayler, senior author on the study and director of the Regional Center of Excellence for Transplantation and Kidney Care at Erie County Medical Center.
In the past decade, health care providers from multiple disciplines — anesthesiologists, surgeons, nurses and pain specialists — have worked together to improve the process by deciding on algorithms — or protocols — to uniformly follow to enhance recovery, she adds.
“For example, patients are likely to have nausea when they are coming out of general anesthesia,” Kayler notes. “The question then becomes, should we wait and see if the nausea develops and then give treatment or should we give everyone an anti-nausea medication to prevent the nausea from happening in the first place.”
These types of questions have been tested and answered in multiple studies that have looked at not only nausea, but also nutrition, pain control, activity and other goals after surgery.
As a result, best practices have been published in different surgeries, especially in colorectal surgery, but not much has been published in the area of kidney transplantation.
“We aimed to create an enhanced recovery after surgery (ERAS) protocol for kidney transplant patients,” Kayler says. “We looked at all of the literature on this topic and we looked at our own experiences and developed a protocol which we then administered to all of the patients.”
ERAS protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the stress response following surgery.
The key elements of ERAS protocols include preoperative counseling, optimization of nutrition, short‐acting anesthetics, effective opioid‐sparing post‐operative pain and nausea control, avoiding unnecessary invasive monitoring, early mobilization and oral nutrition.
For the UB study, researchers compared 139 kidney transplants performed at ECMC after ERAS implementation with a historical cohort of 95 transplants; all patients were followed for 90 days.
“Once you make a change, it is important to look to see if the change resulted in positive outcomes,” says Kayler, chief of transplant surgery.
“Of course we had the sense that things were going well because we could see that as we took care of the patients; however, gathering data and looking at the results of the entire group in aggregate is the truest way of learning from the practice changes you have made.”
Gathering detailed data is a lot of work and requires some level of clinical acumen, Kayler notes.
Third-year medical student Kevin Espino is first author on the paper, titled “Benefits of Multimodal Enhanced Recovery Pathway in Patients Undergoing Kidney Transplantation,” which was published in the journal Clinical Transplantation.
“Kevin spent a summer in our department with the intent of doing research. So his project was to look at all of the outcomes in detail for all of the patients who received the protocol and compare those outcomes to a group of patients that were transplanted in the time period before the ERAS protocol was implemented,” Kayler says.
Espino spent many hours reading charts and collecting information for the statistical analysis. He then “crunched the numbers” with Kayler, interpreted the data and wrote the paper.
“We found that our protocol helped patients recover and heal faster from surgery,” Kayler says. “We demonstrated that despite higher delayed graft function rates, implementation of an ERAS pathway was associated with reduced length of stay without impacting short‐term graft function, mortality and readmission rates.
“Our paper describes in detail the changes that existed in our protocol and our results so that the rest of the transplant community health care providers can learn from our findings,” she adds.
Co-authors on the study are surgical resident John Reinier F. Narvaez and Michael C. Ott of the ECMC Regional Transplantation and Kidney Care Center of Excellence.