Objective To test whether frailty, a novel measure of physiologic reserve, is associated with longer kidney transplant (KT) length of stay (LOS), and modifies the association between LOS and mortality. Background Better understanding of LOS is necessary for informed consent and discharge planning. Mortality resulting from longer LOS has important regulatory implications for hospital and transplant programs. Which recipients are at risk of prolonged LOS and its impact on mortality are unclear. Frailty is a novel preoperative predictor of poor KT outcomes including DGF, early hospital readmission, immunosuppression intolerance, and mortality. Methods We used registry-augmented hybrid methods, a novel approach to risk adjustment, to adjust for LOS risk factors from the Scientific Registry of Transplant Recipients (n=74,859) and tested whether 1) frailty, measured immediately prior to KT in a novel cohort (n=589), was associated with LOS (LOS: negative binomial regression; LOS≥2 weeks: logistic regression) and 2) whether frailty modified the association between LOS and mortality (interaction term analysis). Results Frailty was independently associated with longer LOS (RR=1.15, 95%CI: 1.03-1.29; P=0.01) and LOS≥2 weeks (OR=1.57, 95%CI:1.06-2.33; P=0.03) after accounting for registry-based risk factors, including DGF. Frailty also attenuated the association between LOS and mortality (nonfrail HR:1.55 95%CI:1.30-1.86, P<0.001; frail HR=0.97, 95%CI:0.79-1.19, P=0.80; P for interaction=0.001). Conclusions Frail KT recipients are more likely to experience a longer LOS. Longer LOS among nonfrail recipients may be a marker of increased mortality risk. Frailty is a measure of physiologic reserve that may be an important clinical marker of longer surgical length of stay.

It is imperative to identify and act on potential barriers to the equitable treatment of women, and racial, ethnic, and sexual minorities within our professional surgical community. This includes the identification and counteraction of implicit biases, which are unconscious beliefs and attitudes that often drive our behaviors and decision-making, and eventually determine the climate of relative opportunity and challenge for those who are underrepresented within our field. Increasing diversity in universities, medical schools, residencies, and surgical departments will ultimately heighten the quality of our care, deepen our connection with patients, and further our achievements as surgeons and leaders in medicine and society. A tradition of excellence in surgery includes a rigorous pursuit of intellectual development and the questioning of implicit dogma, and for this reason we must actively work to eradicate unconscious biases that compromise the integrity of this pursuit. We recommend the following steps with an aim towards this goal: 1.Commit to a Culture Shift 2.Introduce Bias Literacy 3.Provide Counter-Stereotypic Exposure 4.Conduct an Introspective Departmental Assessment 5.Implement Deliberative Processing Strategies for Hiring and Promotion 6.Encourage Mentoring and Sponsorship 7.

Transplant center involvement and support for social media may influence clinician perceptions and practices. Increasing use of social media among transplant professionals may provide an opportunity to deliver high quality information to patients.

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