title: Utility of the Surgical Apgar Score in Kidney Transplantation: Is it Feasible to Predict ICU Admission, Hospital Readmission, Length of Stay, and Cost in This Patient Population?
abstract: BACKGROUND
  This study analyzed the utility of the Surgical Apgar Scoring (SAS) system in predicting morbidity in kidney transplantation. Recipient comorbidities were evaluated for any effect on the SAS and then globally assessed for any relationship with intensive care unit (ICU) admission, need for dialysis, creatinine at discharge, length of stay, incremental, and total cost of transplantation. The hypothesis for this study is that a low SAS will be a statistically significant predictor of postoperative morbidity and associated costs.
  
  
  METHODS
  This was an institutional review board (IRB)-approved retrospective longitudinal cohort study on 204 solitary kidney transplant recipients (2009-2011). Patients were divided into 2 groups: low to moderate = SAS ≤ 7 and high = SAS ≥ 8. These groups were then analyzed against a host of variables.
  
  
  RESULTS
  Sixty-five percent of patients had an SAS of 7 or lower, while 35% had an SAS of 8 and higher. Recipients with a history of stroke were 88% more likely to be in the low-moderate SAS group (P = .017). Patients with lower SASs trended toward having less extended criteria donors (0.097) but were more likely to be admitted to the ICU (P = .043), leading to significantly higher transplant event hospitalization costs. Higher SASs were more likely to be readmitted to the hospital within 30 days of discharge (P = .027), leading to higher 30-day postdischarge costs (P = .014). Readmission rates, however, and 30-day follow-up costs were similar between SAS groups after controlling for donor characteristics, specifically donor marginality and recipient estimated glomerular filtration rate (eGFR).
  
  
  CONCLUSIONS
  The findings of this study suggest that a history of stroke in the recipient may lend to a lower SAS and that a low SAS is associated with ICU admission following transplant, leading to higher hospital costs.
authors.affiliation: Division of Abdominal Transplant Anesthesia, Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA stollwil@musc.edu.
authors.forename: William D
authors.initials: WD
authors.lastname: Stoll
authors.affiliation: Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA.
authors.forename: David J
authors.initials: DJ
authors.lastname: Taber
authors.affiliation: Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA.
authors.forename: Seth J
authors.initials: SJ
authors.lastname: Palesch
authors.affiliation: Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA.
authors.forename: Latha
authors.initials: L
authors.lastname: Hebbar
mesh_terms: D000328:Adult; D000368:Aged; D001034:Apgar Score; D015331:Cohort Studies; D005240:Feasibility Studies; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data; D017721:Hospital Costs / Q000706:statistics & numerical data*; D006801:Humans; D007362:Intensive Care Units / Q000191:economics / Q000706:statistics & numerical data*; D007676:Kidney Failure, Chronic / Q000601:surgery*; D016030:Kidney Transplantation / Q000191:economics / Q000706:statistics & numerical data*; D007902:Length of Stay / Q000191:economics / Q000706:statistics & numerical data*; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D010359:Patient Readmission / Q000191:economics / Q000706:statistics & numerical data*; D011182:Postoperative Care / Q000191:economics / Q000706:statistics & numerical data; D011184:Postoperative Period; D012189:Retrospective Studies
keywords: anesthesia; kidney transplant; perioperative outcomes; surgical apgar score