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The Relationships Between Cold Ischemia Time, Kidney Transplant Length of Stay, and Transplant-related Costs

Serrano, Oscar K., MD1; Vock, David M., PhD2; Chinnakotla, Srinath, MD1; Dunn, Ty B., MD1; Kandaswamy, Raja, MD1; Pruett, Timothy L., MD1; Feldman, Roger, PhD3; Matas, Arthur J., MD1; Finger, Erik B., MD, PhD1

doi: 10.1097/TP.0000000000002309
Original Clinical Science—General

Background Recent changes in policies guiding allocation of transplant kidneys are predicted to increase sharing between distant geographic regions. The potential exists for an increase in cold ischemia time (CIT) with resulting increases in delayed graft function (DGF) and transplant-related costs (TRC). We sought to explore the impact of CIT on metrics that may influence TRC.

Methods Between 2006 and 2014, 81 945 adult solitary deceased donor kidney transplants were performed in the United States; 477 (0.6%) at our institution. Regression models were constructed to describe the relationship between CIT on DGF and length of stay (LOS). Using hospital accounting data, we created regression models to evaluate the effect of DGF on LOS and TRC.

Results In multivariable models, longer CIT was associated with an increased rate of DGF (odds ratio [OR], 1.41; 95% confidence interval [CI], 1.38-1.44) and increased LOS (OR, 1.04; 95% CI, 1.02-1.05). Recipients at our institution who developed DGF had longer LOS (OR, 1.71; 95% CI, 1.50-1.95), suggesting that the effect is partially mediated by DGF. After adjusting for LOS, neither CIT nor DGF were independently associated with increased TRC. However, an increased LOS resulted in an increase in TRC by US $3422 (95% CI, US $3180 to US $3664) per additional day, indicating that the effect of CIT on TRC is partially mediated through LOS.

Conclusions The prolongation of CIT is associated with an increase in DGF rates and LOS, resulting in increased TRC. This study raises the need to balance increased access of traditionally underserved populations to kidney transplant with the inadvertent increase in TRC.

In the authors' multivariable models, the recent changes in the kidney allocation system is associated with increased cold ischemia time, delayed graft function rates, length of stay, and transplant related costs.

1 Division of Transplantation, Department of Surgery, School of Public Health; University of Minnesota, Minneapolis, MN.

2 Division of Biostatistics, School of Public Health; University of Minnesota, Minneapolis, MN.

3 Division of Health Policy & Management, School of Public Health; University of Minnesota, Minneapolis, MN.

Received 1 January 2018. Revision received 22 May 2018.

Accepted 24 May 2018.

The authors declare no funding or conflicts of interest.

The data reported here have been supplied by the Minneapolis Medical Research Foundation (MMRF) as the contractor for the Scientific Registry of Transplant Recipients (SRTR). The interpretation and reporting of these data are the responsibility of the author(s) and in no way should be seen as an official policy of or interpretation by the SRTR or the U.S. Government.

Presented at the American Transplant Congress 2016 (Boston, MA).

O.K.S., D.M.V., A.J.M., E.B.F. participated in research design. O.K.S., D.M.V., E.B.F. participated in the writing of the article. O.K.S., D.M.V., S.C., T.B.D., R.K., T.L.P., R.F., A.J.M., E.B.F. participated in the editing of the article. O.K.S., S.C., T.B.D., R.K., T.L.P., A.J.M., E.B.F. participated in the performance of the research. D.M.V., R.F. contributed new reagents or analytic tools. O.K.S., D.M.V., A.J.M., E.B.F. participated in data analysis.

Correspondence: Oscar K. Serrano, MD, Division of Transplantation, Department of Surgery, 420 Delaware St SE, Mayo Mail Code 195, Minneapolis, MN 55455. (

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