Using the Clavien-Dindo classification to identify risk factors in kidney transplantation
Christopher Seet1, Shraddha Shetty1, Prashanth Chowdary1, Muhammad Khurram1, Ismail H. Mohamed1.
1Renal and Transplant, Royal London Hospital, London, United Kingdom
Introduction: Multiple different quality metrics in kidney transplantation have previously been described, but most of them have not been appropriately tested and evaluated. The Clavien-Dindo classification is an objective 5-scale classification used to report post operative complications and has been validated in multiple surgical specialties. We aimed to identify risk factors associated with major or minor complications in kidney transplantation using this system. In our centre, we use ATG (2.5mg/kg at induction and 1.5mg/kg at day 4) or Basiliximab (20mg at induction, 20mg at Day 4) induction for immunosuppressive induction depending on patient-specific risk factors. We aimed to assess our use of ATG compared to basiliximab in post-operative complications, but also in infectious and rejection related complications.
Materials and Methods: 130 kidney transplants from April 2017-March 2018 at our hospital were included. We analysed the effect of type of induction (ATG vs Basiliximab), long cold ischaemia time (>18 hours), long warm ischaemia time (>35 minutes), type of transplant (live/DBD/DCD), incidence of immediate, slow, or delayed graft function, age, and previous renal replacement therapy modality on complications rates at 7 days and 30 days. Complications were graded as either none/minor (Clavien-Dindo 0-2), or major (Clavien-Dindo 3-5). We also compared CMV and BKV viraemia, biopsy proven rejection, leucopenia, and UTIs in Basiliximab vs ATG.
Results and Discussion: Patients with immediate graft function had fewer major post-operative complications at 7 days (p=0.03), but this difference was not significant at 30 days. Delayed graft function or slow graft function may therefore have more significant effects in the early post operative period. There were more major complications in patients with long cold ischaemia times at 30 days (p=0.04), but no difference in long cold or warm ischaemia times at 7 days, which suggests cold ischaemic times may have significant longer term impact. Transplant type, previous renal replacement therapy modality, and recipient age did not have a significant effect on post operative complications at 7 or 30 days.
ATG induction was associated with more major complications at 30 days (p<0.01), but not at 7 days. Patients with ATG induction had a significantly increased incidence of leucopenia (p<0.001) over a 1 year period and UTIs over the first 3 months (p=0.02). There was no difference in biopsy proven rejection, CMV, or BKV viraemia in the 1 year post operative period.
Conclusion: There is an increased risk of major complications in kidneys with increased cold ischaemia time, delayed or slow graft function, and ATG induction. ATG is also associated with an increased incidence of UTIs and leucopaenia in our cohort of patients.
 Brett K, Ritchie LJ, Ertel E, Bennett A, Knoll GA. Quality Metrics in Solid Organ Transplantation: A Systematic Review. Transplantation. 2018; 102(7):e308-e330.
 Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004; 240(2):205-13.
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