Kidney transplantation is cost-effective therapy for end-stage renal disease relative to dialysis (1). The most significant contributors to the overall expense are the costs associated with the transplant procedure itself and the length of the initial hospitalization (2, 3). We hypothesized that early removal of the urethral (Foley) catheter would lead to faster recovery and earlier discharge from the hospital. At our center, Foley catheter removal is dictated by individual surgeon preference and occurs on postoperative days 2, 3, or 5.
We performed a retrospective analysis of 141 consecutive renal transplants at the University of Pittsburgh Medical Center from 1 July, 2005 to 1 January, 2006. Kidney transplant recipients were divided into two groups: group A, in whom Foley catheter removal occurred on postoperative day 2; and group B, in whom removal occurred on postoperative days >2. Exclusions included patients who expired within the perioperative period prior to discharge (one in each group). The following endpoints were analyzed: length of stay, acute urinary retention requiring reinsertion of Foley catheter, urine leak, and readmission within 30 days of transplantation. All patients had double J ureteral stents (6 F×12 cm) placed at the time of transplantation. Stents were removed approximately 6 weeks posttransplant. The immunosuppressive regimen included 30 mg alemtuzumab (Campath-1H; Berlex, Seattle, WA) followed by steroid-free posttransplant low-dose tacrolimus monotherapy.
There were 66 patients in group A and 75 patients in group B. The 66 patients who underwent urethral catheter removal at day 2 (group A) were similar to the 75 patients who underwent urethral catheter removal >day 2 (group B) in terms of recipient age, race, and sex, and cold ischemia time (Table 1). Group A comprised proportionately more deceased donor kidney transplantations (100% vs. 49%) and exhibited more delayed graft function (33% vs. 16% P=0.0164). The median length of stay was 3.2 days in group A compared to 5.0 days in group B (P=0.0014). Urinary retention requiring reinsertion of the urethral catheter occurred once in group A (1.5%) and twice in group B (2.6%). There were no urine leaks. Readmission within 30 days of transplantation was significantly associated with delayed graft function (P=0.0164) and longer posttransplant length of stay (P=0.0014), but not day of urethral catheter removal (P=0.1430).
This analysis of adult kidney transplant recipients demonstrated that Foley catheter removal on posttransplant day 2 is safe and optimizes length of stay, compared to Foley removal on posttransplant days 3–5. Length of stay is a large factor contributing to the cost of kidney transplantation; successful efforts to decrease length of stay, including establishment of an intensive outpatient unit (1) and implementation of clinical pathways (2) have optimized costs of kidney transplantation (1–3). The practice in many institutions is to remove the Foley catheter between 3–6 days after transplantation (4, 5). We have demonstrated that earlier removal is a simple and inexpensive means of reducing length of stay without compromising safety and quality of care.
Department of Surgery
Conemaugh Memorial Medical Center
Liise K. Kayler
Thomas E. Starzl Transplant Institute
University of Pittsburgh Medical Center
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