Enhanced Recovery after Surgery in Kidney Transplantation: Shorter is Better

Dear Editors, Peri-operative management in kidney transplantation hasn't evolved in years, whereas in other fields it is constantly changing and improving. The implantation of Enhanced Recovery After Surgery (ERAS) in oncological urology have significantly improved postoperative outcomes by reducing complication rates, shortening hospital stays, accelerating functional recovery, and facilitating earlier initiation of adjuvant therapies, without compromising oncological safety, and has now become a standard in perioperative care for patients1. We aimed to transpose this approach to kidney transplantation, which is mostly an emergency procedure, except for living donor transplants. To this end, we conducted a historical-prospective study to assess the feasibility and effectiveness of an ERAS protocol in kidney transplantation at our center, which is a pioneer in the field of renal transplantation. There are few studies in the literature on this subjet2-5. We retrospectively analyzed a cohort of 130 patients who underwent their first kidney transplant without ERAS protocol. After analyzing this cohort, we implemented a multidisciplinary ERAS protocol in 2023 (surgical, nephrological, anesthetic, paramedical, with explanations for patients provided through documents and a patient video) and applied it to 130 consecutive patients hospitalized for their first kidney transplant. Living Donor (LD) transplant patients were also included (16% of the population, No-ERAS Group 15% vs ERAS Group 16%, p=0,86). For deceased donor, 73% were DNC and 27% DCC. The two cohorts did not show any statistically significant differences, except for a higher rate of grafts on perfusion machines in the ERAS group (No-ERAS Group 54% vs ERAS Group 68%, p=0,027), which correspond to the increase in the use of perfusion machine for kidney graft in recent years. Median age was 57 years (44.8-67.2) The implementation of this ERAS protocol led to a reduction in the median hospital stay (LOS) by 2 days (Non-ERAS 7 days vs. ERAS 5 days, p<0.001). This reduction of LOS was also observed in both living donor (No-ERAS 6 days vs. ERAS 5 days, p<0.001) and deceased donor subgroups (Non-ERAS 7 days vs. ERAS 5 days, p<0.01). The reduction of LOS has been possible, without increasing postoperative morbidity excluding transfusion (Non-ERAS 12% vs. ERAS 16%, p=0.37), transfusion rate (Non-ERAS 12% vs. ERAS 18%, p=0.17), surgical re-intervention rate (Non-ERAS 10% vs. ERAS 8.5%, p=0.67), or the rate of re-hospitalization before day 30 (Non-ERAS 15% vs. ERAS 24%, p=0.086). There was, however, a trend toward increased re-hospitalizations among ERAS patients, with the majority (60%) being due to medical causes such as renal insufficiency (7 cases), infection (6 cases) or cardiac decompensation (4 cases). This may possibly be explained by the reduced length of hospital stay, as these complications now tend to occur at home, whereas they would have previously arisen during hospitalization. Graft outcomes, including time to recovery (median of 2 days), delayed graft function (14%), and graft failure rate (4.2%, 6.2% in the non-ERAS group vs. 2.3% in the ERAS group), were comparable between the ERAS and no-ERAS groups, with no statistically significant differences observed (p = 0.36, p = 0.82, and p = 0.12) respectively. Thus, our ERAS protocol in kidney transplantation led to a reduction in hospital stay without increasing postoperative morbidity or early re-hospitalization rates. These positive results have allowed us to expand this protocol to all our kidney transplant patients, and will become our new standard in kidney transplantation care. There are still areas for improvement in kidney transplantation, as recently demonstrated by an American unit, with an awake kidney transplantation, with discharge on the next day6. Although this is not yet published, this encouraging outcome may represent a potentiel future direction.