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Enhanced Recovery Pathways in Living Organ Donation and Solid Organ...
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Enhanced Recovery Pathways in Living Organ Donation and Solid Organ Transplantation

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Nephrology & Urology".

Deadline for manuscript submissions: closed (10 October 2021) | Viewed by 23759

Special Issue Editor

Prof. Dr. Vassilios Papalois

E-Mail Website
Guest Editor
Department of Surgery, Imperial College, London W12 0HS, UK
Interests: high risk kidney and pancreas transplantation; organ assessment and reconditioning; improvement of clinical pathways; clinical ethics; health policy

Special Issue Information

Dear Colleagues,

Solid organ transplantation is the treatment of choice for end-stage organ failure with truly excellent long-term results. All modern transplant centres have developed protocols for the perioperative management of transplant patients.  However, the vast majority of those protocols are centre-specific and disparate in their content. Enhanced Recovery After Surgery (ERAS) within elective surgery has revolutionised surgical practice over recent years since its introduction by Henrik Kehlet in the 1990s. The ERAS program is about improving patients’ outcomes and speeding up patients’ recovery after surgery. It also aims to ensure that patients always receive evidence-based care at the right time and have the best possible in-hospital experience related to their care. Compared with traditional perioperative care, the ERAS program represents a fundamental shift in the process of care, by including multiple interventions that attenuate surgical stress, maintain physiological function and expedite a return to the baseline state. While each intervention has a small effect, all together they have a stronger synergistic impact. Although the principles of the pathway were originally developed and integrated for colorectal surgical patients, they have also been used in numerous operative procedures, including general, vascular, and thoracic surgery, as well as orthopaedic, urologic, and gynaecologic operations. Transplant patients are frail, they have challenging operations, experience increased rates of post-operative complications and prolonged admissions compared to the majority of surgical patients.  Furthermore, ERAS is massively important for living organ donors who are healthy individuals coming forward altruistically to help their loved ones and deserve the safest and best care including of course their post-operative treatment. The aim of this Special Issue by the Journal of Clinical Medicine (JCM) is to set the scene in ERAS for living organ donation and solid organ transplantation (LD-SOT) by inviting authors to contribute their experience and expertise in the field via submitting articles that fulfil the following (although the list can be expanded to accommodate all ideas offered by authors):

  • Present and appraise current successful paradigms of ERAS in LD-SOT;
  • Appraise existing research efforts in the field and suggest new research models;
  • Analyse published literature in the context of a meta-analysis or a systematic review;
  • Analyse current guidelines and protocols for post-operative recovery and offer structured opinion papers as to how they could be improved in the context of ERAS.

We would like to cordially invite you to contribute your well known and respected experience in this Special Issue of the JCM; your contribution can really help the transplant community to shape the future in this game-changing field for the care of our patients.

Prof. Dr. Vassilios Papalois
Guest Editor

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Journal of Clinical Medicine is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • enhanced recovery after surgery
  • clinical pathways
  • solid organ transplantation
  • living organ donation
  • post-operative clinical protocols
  • guidelines for post-operative transplant care
  • post-transplant complications
  • length of hospital stay
  • transplant outcomes
  • patient experience
  • patient quality of life

Published Papers (8 papers)

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Research

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17 pages, 2851 KiB  
Article
The Evolution of Living Donor Nephrectomy Program at A Hellenic Transplant Center. Laparoscopic vs. Open Donor Nephrectomy: Single-Center Experience
by Spyridon Vernadakis, Smaragdi Marinaki, Maria Darema, Ioanna Soukouli, Ioannis El. Michelakis, Chrysoula Beletsioti, Georgios Zavvos, Ioannis Bokos and Ioannis N. Boletis
J. Clin. Med. 2021, 10(6), 1195; https://0-doi-org.brum.beds.ac.uk/10.3390/jcm10061195 - 12 Mar 2021
Cited by 7 | Viewed by 3094
Abstract
Since its introduction in 1995, laparoscopic nephrectomy has emerged as the preferred surgical approach for living donor nephrectomy. Given the ubiquity of the surgical procedure and the need for favorable outcomes, as it is an elective operation on otherwise healthy individuals, it is [...] Read more.
Since its introduction in 1995, laparoscopic nephrectomy has emerged as the preferred surgical approach for living donor nephrectomy. Given the ubiquity of the surgical procedure and the need for favorable outcomes, as it is an elective operation on otherwise healthy individuals, it is imperative to ensure appropriate preoperative risk stratification and anticipate intraoperative challenges. The aim of the present study was to compare peri-and postoperative outcomes of living kidney donors (LD), who had undergone laparoscopic nephrectomy (LDN), with a control group of those who had undergone open nephrectomy (ODN). Health-related quality of life (QoL) was also assessed using the validated SF-36 questionnaire. Data from 252 LD from a single transplant center from March 2015 to December 2020 were analyzed retrospectively. In total, 117 donors in the LDN and 135 in the ODN groups were assessed. Demographics, type of transplantation, BMI, duration of surgery, length of hospital stay, peri- and postoperative complications, renal function at discharge and QoL were recorded and compared between the two groups using Stata 13.0 software. There was no difference in baseline characteristics, nor in the prevalence of peri-and postoperative complications, with a total complication rate of 16% (mostly minor, Clavien–Dindo grade II) in both groups, while a different pattern of surgical complications was noticed between them. Duration of surgery was significantly longer in the ODN group (median 240 min vs. 160 min in LDN, p < 0.01), warm ischemia time was longer in the LDN group (median 6 min vs.2 min in ODN, p < 0.01) and length of hospital stay shorter in the LDN group (median 3 days vs. 7 days in ODN). Conversion rate from laparoscopic to open surgery was 2.5%. There was a drop in estimated glomerular filtration rate (eGFR) at discharge of 36 mL/min in the LDN and 32 mL/min in the ODN groups, respectively (p = 0.03). No death, readmission or reoperation were recorded. There was a significant difference in favor of LDN group for each one of the eight items of the questionnaire (SF1–SF8). As for the two summary scores, while the total physical component summary (PCS) score was comparable between the two groups (57.87 in the LDN group and 57.07 in the ODN group), the mental component summary (MCS) score was significantly higher (62.14 vs. 45.22, p < 0.001) in the LDN group. This study provides evidence that minimally invasive surgery can be performed safely, with very good short-term outcomes, providing several benefits for the living kidney donor, thereby contributing to expanding the living donor pool, which is essential, especially in countries with deceased-donor organ shortage. Full article
(This article belongs to the Special Issue Enhanced Recovery Pathways in Living Organ Donation and Solid Organ Transplantation)
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12 pages, 1488 KiB  
Article
Transfusion Status in Liver and Kidney Transplantation Recipients—Results from Nationwide Claims Database
by Boyoung Park, Junghyun Yoon, Han Joon Kim, Yun Kyung Jung, Kyeong Geun Lee and Dongho Choi
J. Clin. Med. 2020, 9(11), 3613; https://0-doi-org.brum.beds.ac.uk/10.3390/jcm9113613 - 10 Nov 2020
Cited by 5 | Viewed by 1564
Abstract
Background: This study analyzed the status and trends of transfusion and its associated factors among liver and kidney transplantation recipients. Methods: A total of 10,858 and 16,191 naïve liver or kidney transplantation recipients from 2008 to 2017 were identified through the National Health [...] Read more.
Background: This study analyzed the status and trends of transfusion and its associated factors among liver and kidney transplantation recipients. Methods: A total of 10,858 and 16,191 naïve liver or kidney transplantation recipients from 2008 to 2017 were identified through the National Health Insurance Service database. The prescription code for transfusion and the presence, number, and amount of each type of transfusion were noted. The odds ratios and 95% confidence intervals were determined to identify significant differences in transfusion and blood components by liver and kidney transplantation recipient characteristics. Results: In this study, 96.4% of liver recipients and 59.7% of kidney recipients received transfusions related to the transplantation operation, mostly platelet and fresh frozen plasma. Higher perioperative transfusion in women and declining transfusion rates from 2008 to 2017 were observed in both liver and kidney recipients. In liver recipients, the transfusion rate in those who received organs from deceased donors was much higher than that in those who received organs from living donors; however, the mortality rate according to transfusion was higher only in recipients of deceased donor organs. In kidney recipients, a higher mortality rate was observed in those receiving transfusion than that in patients without transfusion. Conclusions: In Korea, the transfusion rates in liver and kidney recipients were relatively higher than those in other countries. Sociodemographic factors, especially sex and year of transplantation, were associated with transfusion in solid organ recipients, possibly as surrogates for other causal clinical factors. Full article
(This article belongs to the Special Issue Enhanced Recovery Pathways in Living Organ Donation and Solid Organ Transplantation)
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Review

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25 pages, 423 KiB  
Review
Anaesthetic Approach to Enhanced Recovery after Surgery for Kidney Transplantation: A Narrative Review
by Slawomir Jaszczuk, Shweta Natarajan and Vassilios Papalois
J. Clin. Med. 2022, 11(12), 3435; https://doi.org/10.3390/jcm11123435 - 15 Jun 2022
Cited by 7 | Viewed by 2539
Abstract
Enhanced recovery after surgery (ERAS) protocols are designed to reduce medical complications, the length of hospital stays (LoS), and healthcare costs. ERAS is considered safe and effective for kidney transplant (KTx) surgery. KTx recipients are often frail with multiple comorbidities. As these patients [...] Read more.
Enhanced recovery after surgery (ERAS) protocols are designed to reduce medical complications, the length of hospital stays (LoS), and healthcare costs. ERAS is considered safe and effective for kidney transplant (KTx) surgery. KTx recipients are often frail with multiple comorbidities. As these patients follow an extensive diagnostic pathway preoperatively, the ERAS protocol can ideally be implemented at this stage. Small singular changes in a long perioperative pathway can result in significant positive outcomes. We have investigated the current evidence for an ERAS pathway related to anaesthetic considerations in renal transplant surgery for adult recipients. Full article
(This article belongs to the Special Issue Enhanced Recovery Pathways in Living Organ Donation and Solid Organ Transplantation)
27 pages, 405 KiB  
Review
Preoperative Cardiovascular Assessment of the Renal Transplant Recipient: A Narrative Review
by Prasanti Alekhya Kotta, Madhivanan Elango and Vassilios Papalois
J. Clin. Med. 2021, 10(11), 2525; https://0-doi-org.brum.beds.ac.uk/10.3390/jcm10112525 - 07 Jun 2021
Cited by 4 | Viewed by 3972
Abstract
Patients with end-stage kidney disease (ESKD) have a high prevalence of cardiovascular disease; it is the leading cause of death in these patients and the optimisation of their cardiovascular health may improve their post-transplant outcomes. Patients awaiting renal transplant often spend significant amounts [...] Read more.
Patients with end-stage kidney disease (ESKD) have a high prevalence of cardiovascular disease; it is the leading cause of death in these patients and the optimisation of their cardiovascular health may improve their post-transplant outcomes. Patients awaiting renal transplant often spend significant amounts of time on the waiting list allowing for the assessment and optimisation of their cardiovascular system. Coronary artery disease (CAD) is commonly seen in these patients and we explore the possible functional and anatomical investigations that can help assess and manage CAD in renal transplant candidates. We also discuss other aspects of cardiovascular assessment and management including arrhythmias, impaired ventricular function, valvular disease, lifestyle and pulmonary arterial hypertension. We hope that this review can form a basis for centres hoping to implement an enhanced recovery after surgery (ERAS) protocol for renal transplantation. Full article
(This article belongs to the Special Issue Enhanced Recovery Pathways in Living Organ Donation and Solid Organ Transplantation)
18 pages, 4032 KiB  
Review
Enhanced Recovery after Renal Transplantation Decreases Recipients’ Urological Complications and Hospital Stay: A Systematic Review and Meta-Analysis
by Apostolos Prionas, Charles Craddock and Vassilios Papalois
J. Clin. Med. 2021, 10(11), 2286; https://0-doi-org.brum.beds.ac.uk/10.3390/jcm10112286 - 25 May 2021
Cited by 7 | Viewed by 1982
Abstract
The objective of this study was to compare enhanced recovery after surgery (ERAS) against traditional perioperative care for renal transplant recipients. Outcome measures included complications, length of stay (LOS), readmission rates, graft and patient survival up to one-year post-transplant. We initially screened Medline, [...] Read more.
The objective of this study was to compare enhanced recovery after surgery (ERAS) against traditional perioperative care for renal transplant recipients. Outcome measures included complications, length of stay (LOS), readmission rates, graft and patient survival up to one-year post-transplant. We initially screened Medline, Cochrane, Scopus, Embase and Web of Science databases. We identified 3029 records. From these, 114 full texts were scrutinized for inclusion. Finally, 10 studies were included in the meta-analysis corresponding to 2037 renal transplant recipients. ERAS resulted in lower incidence of urological complications (95CI: 0.276, 0.855) (I2 = 53.08%) compared to traditional perioperative practice. This referred to ureteric stenoses (95CI: 0.186–0.868) (I2 = 0%) and urinary tract infections (95CI: 0.230–0.978) (I2 = 71.55%). ERAS decreased recipients’ LOS (95CI: −2.876, −0.835) (I2 = 86.55%). Compared to standard practice, ERAS protocols did not increase unplanned readmissions (95CI:0.800, 1.680) (I2 = 0%). Up to one-year post-transplant, graft survival rates were similar across the ERAS and the control groups (95CI:0.420, 1.722) (I2 = 0%). There was also no difference in recipients’ one-year post-transplant survival (95CI:0.162, 3.586) (I2 = 0%). Our results suggest that ERAS protocols can be safely incorporated in the perioperative care of renal transplant recipients, decrease their urological complications and shorten their length of hospital stay without affecting unplanned readmission rates. Full article
(This article belongs to the Special Issue Enhanced Recovery Pathways in Living Organ Donation and Solid Organ Transplantation)
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14 pages, 306 KiB  
Review
Enhanced Recovery after Surgery: History, Key Advancements and Developments in Transplant Surgery
by Henry John Golder and Vassilios Papalois
J. Clin. Med. 2021, 10(8), 1634; https://0-doi-org.brum.beds.ac.uk/10.3390/jcm10081634 - 12 Apr 2021
Cited by 29 | Viewed by 4834
Abstract
Enhanced recovery after surgery (ERAS) aims to improve patient outcomes by controlling specific aspects of perioperative care. The concept was introduced in 1997 by Henrik Kehlet, who suggested that while minor changes in perioperative practise have no significant impact alone, incorporating multiple changes [...] Read more.
Enhanced recovery after surgery (ERAS) aims to improve patient outcomes by controlling specific aspects of perioperative care. The concept was introduced in 1997 by Henrik Kehlet, who suggested that while minor changes in perioperative practise have no significant impact alone, incorporating multiple changes could drastically improve outcomes. Since 1997, significant advancements have been made through the foundation of the ERAS Society, responsible for creating consensus guidelines on the implementation of enhanced recovery pathways. ERAS reduces length of stay by an average of 2.35 days and healthcare costs by $639.06 per patient, as identified in a 2020 meta-analysis of ERAS across multiple surgical subspecialties. Carbohydrate loading, bowel preparation and patient education in the pre-operative phase, goal-directed fluid therapy in the intra-operative phase, and early mobilisation and enteral nutrition in the post-operative phase are some of the interventions that are commonly implemented in ERAS protocols. While many specialties have been quick to incorporate ERAS, uptake has been slow in the transplantation field, leading to a scarcity of literature. Recent studies reported a 47% reduction in length of hospital stay (LOS) in liver transplantation patients treated with ERAS, while progress in kidney transplantation focuses on pain management and its incorporation into enhanced recovery protocols. Full article
(This article belongs to the Special Issue Enhanced Recovery Pathways in Living Organ Donation and Solid Organ Transplantation)
24 pages, 411 KiB  
Review
Working towards an ERAS Protocol for Pancreatic Transplantation: A Narrative Review
by Madhivanan Elango and Vassilios Papalois
J. Clin. Med. 2021, 10(7), 1418; https://0-doi-org.brum.beds.ac.uk/10.3390/jcm10071418 - 01 Apr 2021
Cited by 4 | Viewed by 2188
Abstract
Enhanced recovery after surgery (ERAS) initially started in the early 2000s as a series of protocols to improve the perioperative care of surgical patients. They aimed to increase patient satisfaction while reducing postoperative complications and postoperative length of stay. Despite these protocols being [...] Read more.
Enhanced recovery after surgery (ERAS) initially started in the early 2000s as a series of protocols to improve the perioperative care of surgical patients. They aimed to increase patient satisfaction while reducing postoperative complications and postoperative length of stay. Despite these protocols being widely adopted in many fields of surgery, they are yet to be adopted in pancreatic transplantation: a high-risk surgery with often prolonged length of postoperative stay and high rate of complications. We have analysed the literature in pancreatic and transplantation surgery to identify the necessary preoperative, intra-operative and postoperative components of an ERAS pathway in pancreas transplantation. Full article
(This article belongs to the Special Issue Enhanced Recovery Pathways in Living Organ Donation and Solid Organ Transplantation)
20 pages, 2587 KiB  
Review
Feasibility, Safety and Efficacy of Enhanced Recovery after Living Donor Nephrectomy: Systematic Review and Meta-Analysis of Randomized Controlled Trials
by Apostolos Prionas, Charles Craddock and Vassilios Papalois
J. Clin. Med. 2021, 10(1), 21; https://0-doi-org.brum.beds.ac.uk/10.3390/jcm10010021 - 23 Dec 2020
Cited by 10 | Viewed by 2479
Abstract
This meta-analysis aims to compare enhanced recovery after surgery (ERAS) vs. standard perioperative practice in the management of living kidney donors. Primary endpoints included mortality, complications, length of stay (LOS) and quality of life after living donor nephrectomy. Medline, Embase, Scopus, Cochrane and [...] Read more.
This meta-analysis aims to compare enhanced recovery after surgery (ERAS) vs. standard perioperative practice in the management of living kidney donors. Primary endpoints included mortality, complications, length of stay (LOS) and quality of life after living donor nephrectomy. Medline, Embase, Scopus, Cochrane and Web of Science databases were searched. In total, 3029 records were identified. We then screened 114 full texts. Finally, 11 studies were included in the systematic review corresponding to 813 living donors. Of these, four randomized controlled trials were included in the meta-analysis. ERAS resulted in shorter LOS (95CI: −1.144, −0.078, I2 = 87.622%) and lower incidence of post-operative complications (95CI: 0.158, 0.582, I2 = 0%). This referred to Clavien–Dindo I-II complications (95CI: 0.158, 0.582, I2 = 0%). There was no difference in Clavien–Dindo III-V complications (95CI: 0.061,16.173, I2 = 0%). ERAS donors consumed decreased amounts of narcotics during their hospital stay (95CI: −27.694, −8.605, I2 = 0%). They had less bodily pain (95CI: 6.735, 17.07, I2 = 0%) and improved emotional status (95CI: 6.593,13.319, I2 = 75.682%) one month postoperatively. ERAS protocols incorporating multimodal pain control interventions resulted in a mean reduction of 1 day in donors’ LOS (95CI: −1.374, −0.763, I2 = 0%). Our results suggest that ERAS protocols result in reduced perioperative morbidity, shorter length of hospital stay and improved quality of life after living donor nephrectomy. Full article
(This article belongs to the Special Issue Enhanced Recovery Pathways in Living Organ Donation and Solid Organ Transplantation)
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