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Outcomes Following Colorectal Resection in Kidney Transplant Recipients

  • Original Article
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Background

Kidney transplant recipients (KTR) are at increased risk of requiring colorectal resection compared to the general population. Given the need for lifelong immunosuppression and the physiologic impact of years of renal replacement, we hypothesized that colorectal resection may be riskier for this unique population.

Methods

We investigated the differences in mortality, morbidity, length of stay (LOS), and cost between 2410 KTR and 1,433,437 non-KTR undergoing colorectal resection at both transplant and non-transplant centers using the National Inpatient Sample between 2000 and 2013, adjusting for patient and hospital level factors.

Results

In hospital, mortality was higher for KTR in comparison to non-KTR (11.1 vs 4.3%, p < 0.001; adjusted odds ratio [aOR] 2.683.594.81) as were overall complications (38.5 vs 31.5%, p = 0.001; aOR 1.081.301.56). LOS was significantly longer (10 vs 7 days, p < 0.001; ratio 1.421.531.65) and cost was significantly greater ($23,056 vs $14,139, p < 0.001; ratio 1.421.541.63) for KTR compared to non-KTR. While LOS was longer for KTR undergoing resection at transplant centers compared to non-transplant centers (aOR 1.68 vs 1.53, p = 0.03), there were no statistically significant differences in mortality, overall morbidity, or cost by center type.

Conclusions

KTR have higher mortality, higher incidence of overall complications, longer LOS, and higher cost than non-KTR following colorectal resection, regardless of center type. Physicians should consider these elevated risks when planning for surgery in the KTR population and counsel patients accordingly.

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Funding

This work was supported by the following grants from the National Institute of Diabetes, Digestive and Kidney Disease: F32DK105600 (DiBrito), F32DK109662 (Holscher), F32AG053025 (Haugen), K24DK101828 (Segev); the National Cancer Institute: 5T32CA126607 (Alimi); and the American College of Surgeons Resident Research Scholarship (Holscher).

Author information

Authors and Affiliations

  1. Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Sandra R. DiBrito, Israel O. Olorundare, Courtenay M. Holscher, Christine E. Haugen, Dorry L. Segev & Jacqueline Garonzik-Wang

  2. Department of Surgery, Georgetown University School of Medicine, Washington, DC, USA

    Yewande Alimi

  3. Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA

    Dorry L. Segev

Authors
  1. Sandra R. DiBrito
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  2. Yewande Alimi
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  3. Israel O. Olorundare
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  4. Courtenay M. Holscher
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  5. Christine E. Haugen
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  6. Dorry L. Segev
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  7. Jacqueline Garonzik-Wang
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Contributions

Sandra R. DiBrito MD: study design, data analysis and interpretation, manuscript drafting, critical revision, final approval, and complete accountability.

Yewande Alimi MD MS: study design, data acquisition and analysis, manuscript drafting, critical revision, final approval, and complete accountability.

Israel O. Olorundare MD MPH: study design, data acquisition, critical revision, final approval and complete accountability.

Courtenay M. Holscher MD: data analysis and interpretation, manuscript drafting, critical revision, final approval and complete accountability.

Christine E. Haugen MD: data analysis and interpretation, manuscript drafting, critical revision, final approval, and complete accountability.

Dorry L. Segev MD PhD: study design, data interpretation, critical revision, and final approval.

Jacqueline Garonzik-Wang MD PhD: study design, data interpretation, critical revision, final approval and complete accountability.

Corresponding author

Correspondence to Jacqueline Garonzik-Wang.

Ethics declarations

All study methods were approved by the Johns Hopkins Hospital Institutional Review Board.

Appendices

Appendix 1

International Classification of Diseases, 9th Revision, codes for procedure, inclusion, and exclusion criteria. Procedure codes for laparoscopic resections are nested as subcodes of the applicable resection in cases where the name reads “open and other”. For cases that are not specifically listed as “open and other”, specific subcodes for laparoscopic procedures have been listed.

Procedure

 Total intra-abdominal colectomy 45.8

 Laparoscopic total intra-abdominal colectomy 45.81

 Open and other partial excision of large intestine 45.7

 Open and other multiple segmental resection of large intestine 45.71

 Open and other cecectomy 45.72

 Open and other right hemicolectomy 45.73

 Open and other resection of transverse colon 45.74

 Open and other left hemicolectomy 45.75

 Open and other sigmoidectomy 45.76

 Open and unspecified partial excision of large intestine 45.79

 Laparoscopic partial excision of large intestine 17.31–17.39

 Pull through resection of rectum 48.4

 Laparoscopic pull through resection of rectum 48.42

 Abdominoperineal resection of rectum 48.5

 Laparoscopic abdominoperineal resection of rectum 48.51

Inclusion

 Kidney transplant recipient: V42.0

Exclusion

 Other (non-kidney) transplant recipients: V42.1, V42.2, V42.6, V42.7, V42.8, V42.81, V42.82, V42.83, V42.84, V42.89, V42.9

 Complications from history of other (non-kidney) transplant: 996.80, 996.82, 996.83, 996.84, 996.85, 996.86, 996.87, 996.88, 996.89

Appendix 2

International Classification of Diseases, 9th Revision, clinical modification codes for postoperative in-hospital complications. Adapted from Guller et al.

Mechanical wound

 Delayed wound healing, 998.83

 Postoperative hematoma, 998.12

 Postoperative seroma (non-infected), 998.13

 Disruption of operative wound, 998.3

 Persistent postoperative fistula, 998.6

Infectious

 Postoperative infection, 998.5

 Postoperative skin abscess, 998.59

 Postoperative septic wound complications, 998.59

 Postoperative skin infection, 998.59

 Postoperative intra-abdominal abscess, 998.59

 Postoperative subdiaphragmatic abscess, 998.59

 Postoperative infected seroma, 998.51

Cardiovascular

 Postoperative stroke, 997.02

 Phlebitis or thrombophlebitis from procedure, 997.2

 Cardiac arrest/insufficiency during or resulting from a procedure, 997.1

Thromboembolic

 Postoperative deep venous thrombosis, 997.79

 Postoperative pulmonary embolism, 415.11

Pulmonary

 Postoperative atelectasis, 997.3

 Postoperative pneumonia, 997.3

 Postoperative acute respiratory insufficiency, 518.5

 Postoperative acute pneumothorax, 512.1

 Adult respiratory distress syndrome, 518.5

 Postoperative pulmonary edema, 518.4

Gastrointestinal tract

 Postoperative small-bowel obstruction, 997.4

 Postoperative ileus, 997.4

 Postoperative ileus requiring nasogastric tube, 997.4

 Postoperative nausea, 997.4

 Postoperative vomiting, 997.4

 Postoperative pancreatitis, 997.4

 Complication of anastomosis of gastrointestinal tract, 997.4

Urinary

 Postoperative urinary retention, 997.5

 Postoperative urinary tract infection, 997.5

Intraoperative

 Accidental puncture or laceration, complicating surgery, 998.2

 Foreign body accidentally left during procedure, 998.4

 Hemorrhage/bleeding complicating procedure, 998.11

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DiBrito, S.R., Alimi, Y., Olorundare, I.O. et al. Outcomes Following Colorectal Resection in Kidney Transplant Recipients. J Gastrointest Surg 22, 1603–1610 (2018). https://doi.org/10.1007/s11605-018-3801-2

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