Use of Extended Criteria Donor Hearts in Simultaneous Heart-Kidney Transplantation

Abstract

PurposeInsufficiency of donor organ supply has led to the utilization of extended criteria donor (ECD) hearts. Several groups have demonstrated that careful use of ECD hearts has acceptable outcomes in select patients. However, the use of ECD hearts has yet to be studied in patients undergoing simultaneous heart-kidney transplantation (SKHT). This study evaluates the outcomes of patients receiving standard criteria donor (SCD) vs. ECD hearts in the setting of SHKT.MethodsRetrospective review of the Organ Procurement and Transplantation Network database was performed for adults undergoing SHKT since 1/1/2010. Patients were stratified by receipt of an ECD heart. SCD hearts were defined by the 2020 International Society for Heart and Lung Transplantation Consensus Statement on Donor Heart and Lung Procurement. ECD hearts were defined as those that failed to meet any of these criteria. The primary outcome was patient survival. Secondary outcomes included several post-operative complications.ResultsOverall 1,389 SHKTs were performed during the study period, of which 345 (24.8%) utilized ECD hearts. Recipients of ECD hearts were more likely to have a higher body mass index (25.6 vs. 29.5, p<0.001) and were more likely to have diabetes (39.5% vs. 48.5%, p=0.005). Postoperatively, the SCD and ECD cohorts experienced similar rates of pacemaker implantation (2.1% vs. 0.9%, p=0.16), hemodialysis (29.9% vs. 32.2%, p=0.42), and stroke (3.3% vs. 3.5%, p=0.86). However, the ECD cohort experienced greater incidence of cardiac graft failure due to primary nonfunction (0.7% vs. 2.9%). ECD patients experienced decreased survival at 30 days (96.6% vs. 91.2%, p=0.001) and at 5 years (80.2% vs. 72.5%, p=0.002) as shown in Figure 1.ConclusionUse of ECD hearts in the setting of SHKT is associated with increased mortality. Careful consideration should be given before accepting an ECD heart for SHKT given the increased consequences of recipient death on responsible organ allocation in dual organ transplantation. Insufficiency of donor organ supply has led to the utilization of extended criteria donor (ECD) hearts. Several groups have demonstrated that careful use of ECD hearts has acceptable outcomes in select patients. However, the use of ECD hearts has yet to be studied in patients undergoing simultaneous heart-kidney transplantation (SKHT). This study evaluates the outcomes of patients receiving standard criteria donor (SCD) vs. ECD hearts in the setting of SHKT. Retrospective review of the Organ Procurement and Transplantation Network database was performed for adults undergoing SHKT since 1/1/2010. Patients were stratified by receipt of an ECD heart. SCD hearts were defined by the 2020 International Society for Heart and Lung Transplantation Consensus Statement on Donor Heart and Lung Procurement. ECD hearts were defined as those that failed to meet any of these criteria. The primary outcome was patient survival. Secondary outcomes included several post-operative complications. Overall 1,389 SHKTs were performed during the study period, of which 345 (24.8%) utilized ECD hearts. Recipients of ECD hearts were more likely to have a higher body mass index (25.6 vs. 29.5, p<0.001) and were more likely to have diabetes (39.5% vs. 48.5%, p=0.005). Postoperatively, the SCD and ECD cohorts experienced similar rates of pacemaker implantation (2.1% vs. 0.9%, p=0.16), hemodialysis (29.9% vs. 32.2%, p=0.42), and stroke (3.3% vs. 3.5%, p=0.86). However, the ECD cohort experienced greater incidence of cardiac graft failure due to primary nonfunction (0.7% vs. 2.9%). ECD patients experienced decreased survival at 30 days (96.6% vs. 91.2%, p=0.001) and at 5 years (80.2% vs. 72.5%, p=0.002) as shown in Figure 1. Use of ECD hearts in the setting of SHKT is associated with increased mortality. Careful consideration should be given before accepting an ECD heart for SHKT given the increased consequences of recipient death on responsible organ allocation in dual organ transplantation.