Comparison of nighttime and daytime operation on outcomes of kidney transplant with deceased donors: a retrospective analysis

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Comparison of nighttime and daytime operation on outcomes of kidney transplant with deceased donors: a retrospective analysis

Kidney transplants from deceased donors are race-against-the-clock procedures. Every minute a donated kidney spends without blood flow—called cold ischemia time (CIT)—raises the risk of graft failure. To keep CIT short, surgeons often perform transplants at night. But there’s a catch: doctors working late face fatigue and sleep deprivation, which research links to worse medical outcomes. A 2019 study from Xi’an Jiaotong University set out to answer a critical question: Does nighttime kidney transplant surgery harm patient or graft survival?

The Study: Who, How, and What They Looked For

Researchers led by Qi-Hang Guo and Wu-Jun Xue from the First Affiliated Hospital of Xi’an Jiaotong University (China) analyzed data from 443 patients who received deceased donor kidneys between 2014 and 2016. They split surgeries into two groups:

  • Daytime: Started after 8 AM or ended before 8 PM (52.6% of cases).
  • Nighttime: Ended after 8 PM or started before 8 AM (47.4% of cases).

The team tracked:

  • 1-year recipient survival (patient alive).
  • 1-year graft survival (kidney still functioning, no need for dialysis).
  • Complications like delayed graft function (DGF) (needing dialysis first week or high creatinine at day 7), acute rejection, surgical issues (e.g., blood clots, urine leaks), and infections.
  • Serum creatinine (Scr) at 1 year—a key marker of kidney function.

The Results: Nighttime Surgery Didn’t Hurt Outcomes

The study found no significant difference between daytime and nighttime transplants for most key outcomes:

  • Recipient survival: 95.3% (daytime) vs. 95.2% (nighttime).
  • Graft survival: 88.4% (daytime) vs. 92.4% (nighttime)—a small gap, but not statistically meaningful.
  • Complications: Rates of DGF (17.6% vs. 12.9%), acute rejection (11.2% vs. 9.1%), and surgical issues were similar.
  • Kidney function: Serum creatinine at 1 year was nearly identical (104.2 µmol/L vs. 99.0 µmol/L).

One difference? Nighttime transplants had shorter CIT (5.4 hours vs. 7.97 hours). But crucially, all CITs were under 18 hours—the widely accepted “safe” cutoff for graft survival.

Why Nighttime Surgery Worked (This Time)

Several factors explain why fatigue didn’t harm results:

  1. Short CIT: Even the longest CIT (16 hours) was well below the 18-hour threshold. Prolonged CIT is the biggest graft risk—here, it was minimal.
  2. Experienced Surgeons: All operations were done by chief or vice-chief surgeons with decades of transplant experience. Skill likely offset fatigue.
  3. Machine Perfusion: 78.8% of kidneys used hypothermic machine perfusion (HMP)—a technique that pumps nutrient-rich fluid through the kidney to reduce damage. Daytime cases used HMP more (83.7% vs. 73.3%), which may have balanced the older, higher-BMI donors in that group (factors that usually raise DGF risk).

The Bigger Picture: Doctor Burden and Practical Takeaways

While the study found no harm to patients, it highlighted a growing problem: surgeon overwork. A 2017 report from the Chinese Medical Doctor Association found Chinese doctors often work excessive hours, leading to fatigue and sleep deprivation. Nighttime transplants add to this burden—and research links chronic sleep loss to higher risks of errors, burnout, and even health issues like breast cancer or obesity in medical staff.

The authors’ key recommendation? Postpone nighttime transplants with short CIT to the next day. For kidneys with CIT under 18 hours, waiting a few hours won’t hurt graft survival—but it will give surgeons much-needed rest.

What About High-Risk Donors?

About 21% of grafts came from expanded criteria donors (ECDs)—donors over 60 or 50–59 with conditions like hypertension or high pre-donation creatinine. Even for these high-risk kidneys, outcomes were similar:

  • 1-year recipient survival: 92.9% (daytime) vs. 94.6% (nighttime).
  • 1-year graft survival: 82.1% (daytime) vs. 86.5% (nighttime).

Again, short CIT and HMP likely played a role in protecting these grafts.

Conclusion

Nighttime kidney transplants from deceased donors—when CIT is short—don’t harm patient or graft survival. But the hidden cost is surgeon fatigue. For hospitals, the takeaway is clear: prioritize staff well-being by delaying non-emergent nighttime transplants when CIT is safe. Every kidney matters—but so does the doctor holding the scalpel.

This study was published in the Chinese Medical Journal in 2019 by Qi-Hang Guo, Qian-Long Liu, Xiao-Jun Hu, Yang Li, Jin Zheng, and Wu-Jun Xue from the Department of Renal Transplant and Institute of Organ Transplantation at Xi’an Jiaotong University. doi.org/10.1097/CM9.0000000000000056

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