Combined Heart-kidney Transplantation Research Articles

Combined Heart Kidney Transplantation Versus Heart Transplant in Patients with Renal Failure: Contemporary Insights and Future Perspectives.

In this review, we aim to outline the criteria regarding the evaluation of patients with chronic renal disease (CKD) awaiting heart transplantation and discuss the outcomes of combined heart/kidney transplantation. Herein, we also review pathophysiology and risk factors that predispose to chronic kidney disease (CKD) and acute kidney injury (AKI) in patients with HF and after OHT. In patients with end-stage systolic heart failure (HF) and an estimated glomerular filtration rate (eGFR) < 30mL/min/1.73 m2, orthotopic heart transplantation (OHT) alone is a relative contraindication, with a consensus that these patients are better served with heart-kidney transplant (HKT). However, there is significant variation between institutions regarding timing and indication for heart/kidney transplantation, with little data available to predict post-transplant outcomes. A Scientific Statement from American Heart Association was published detailing the indications, evaluation, and outcomes for Heart-Kidney Transplantation, and noted a steady rise in the incidence of heart/kidney dual organ transplants. Recently, the Organ Procurement and Transplantation Network (OPTN) Multi-Organ Transplantation Committee implemented a safety net policy for heart transplant recipients who do need meet criteria for simultaneous heart-kidney transplant in 2023 but with a likely need for sequential kidney transplantation. Optimization of organ distribution and patient outcomes after cardiac transplantation requires appropriate recipient selection. This review also outlines the criteria regarding the evaluation of patients with CKD awaiting heart transplantation and outcomes of combined HKT.

Axillary mechanical circulatory support improves renal function prior to heart transplantation in patients with chronic kidney disease

Impaired kidney function is often associated with acute decompensation of chronic heart failure and portends a poor prognosis. Unfortunately, current data have demonstrated worse survival in patients with acute kidney injury than in patients with chronic kidney disease during durable LVAD placement as bridge therapy. Furthermore, end-stage heart failure patients undergoing combined heart-kidney transplantation have poorer short- and long-term survival than heart transplants alone. We evaluated the kidney function recovery in our heart failure population awaiting heart transplantation at our institution, supported by temporary Mechanical Circulatory Support (tMCS) with Impella 5.5. The protocol (#22004000) was approved by the Mayo Clinic institutional review board, after which we performed a retrospective review of all patients with acute on chronic heart failure and kidney disease in patients considered for only heart and kidney combined organ transplant and supported by tMCS between January 2020 and February 2021. Hemodynamic and kidney function trends were recorded and analyzed before and after tMCS placement and transplantation. After placement of tMCS, we observed a trend towards improvement in creatinine, Fick cardiac index, mixed venous saturation, and glomerular filtration rate (GFR), which persisted through transplantation and discharge. The average duration of support with tMCS was 16.5 days before organ transplantation. The median pre-tMCS creatinine was 2.1 mg/dL (IQR 1.75–2.3). Median hematocrit at the time of tMCS placement was 32% (IQR 32–34), and the median estimated glomerular filtration rate was 34 mL/min/BSA (34–40). The median GFR improved to 44 mL/min/BSA (IQR 45–51), and serum creatinine improved to 1.5 mg/dL (1.5–1.8) after tMCS. Median discharge creatinine was 1.1 mg/dL (1.19–1.25) with a GFR of 72 (65–74). None of these six patients supported with tMCS required renal replacement therapy after heart transplantation. Early adoption of Impella 5.5 in this patient population resulted in renal recovery without needing renal replacement therapies or dual organ transplantation and should be further evaluated.

Outcomes of Patients Undergoing Combined Heart–Kidney Transplantation With or Without Prior Ventricular Assist Device

Both combined heart-kidney transplantation and ventricular assist devices (VADs) pose significant challenges, including sensitization, immunosuppressive treatment, and infrastructure demands. Despite these challenges, we hypothesized that the recipients of combined heart-kidney transplants with and without VADs would have equivalent survival. We aimed to compare the survival of heart-kidney transplant recipients with and without prior VAD placement. We retrospectively analyzed all patients enrolled in the United Network for Organ Sharing database who underwent heart-kidney transplants. We created a matched cohort of patients undergoing heart-kidney transplantation with or without prior VAD using 1:1 nearest propensity-score matching with preoperative variables. In the propensity-matched cohort, 399 patients underwent heart-kidney transplantation with prior VAD, and 399 underwent heart-kidney transplantation without prior VAD. The estimated survival of heart--kidney recipients with prior VAD was 84.8% at one year, 81.2% at 3 years, and 75.3% at 5 years. The estimated survival of heart-kidney recipients without prior VAD was 86.8.7% at one year, 84.0% at 3 years, and 78.8% at 5 years. There was no statistically significant difference in the survival of heart-kidney transplant recipients with or without prior VAD at one year (P=.42; Figure 2), 3 years (P=.34), or 5 years (P=.30). Despite the increased challenge of heart-kidney transplantation in recipients with prior VAD, we demonstrated that these patients have similar survival to those who underwent heart-kidney transplantation without previous VAD placement.

Outcomes of Combined Heart-Kidney Transplantation in Older Recipients.

The upper limit of recipient age for combined heart-kidney transplantation (HKT) remains controversial. This study evaluated the outcomes of HKT in patients aged ≥65 years. The United Network of Organ Sharing (UNOS) was used to identify patients undergoing HKT from 2005 to 2021. Patients were stratified by age at transplantation: <65 and ≥ 65 years. The primary outcome was one-year mortality. Secondary outcomes included 90-day and 5-year mortality, postoperative new-onset dialysis, postoperative stroke, acute rejection prior to discharge, and rejection within one-year of HKT. Survival was compared using Kaplan-Meier analysis, and risk adjustment for mortality was performed using Cox proportional hazards modeling. HKT in recipients aged ≥65 significantly increased from 5.6% of all recipients in 2005 to 23.7% in 2021 (p=0.002). Of 2,022 HKT patients in the study period, 372 (18.40%) were aged ≥65. Older recipients were more likely to be male and white, and fewer required dialysis prior to HKT. There were no differences between cohorts in unadjusted 90-day, 1-year, or 5-year survival in Kaplan-Meier analysis. These findings persisted after risk-adjustment, with an adjusted hazard for one-year mortality for age ≥65 of 0.91 (95% CI (0.63-1.29), p=0.572). As a continuous variable, increasing age was not associated with one-year mortality (HR 1.01 (95% CI (1.00-1.02), p=0.236) per year). Patients aged ≥65 more frequently required new-onset dialysis prior to discharge (11.56% vs. 7.82%, p=0.051). Stroke and rejection rates were comparable. Combined HKT is increasing in older recipients, and advanced age ≥65 should not preclude HKT.

(84) Combined Heart Kidney Transplant: Risk Factors and Outcomes

(84) Combined Heart Kidney Transplant: Risk Factors and Outcomes

(509) What Should the GFR Threshold Be for Redo Heart Transplant Patients to Qualify for Combined Heart-Kidney Transplantation

(509) What Should the GFR Threshold Be for Redo Heart Transplant Patients to Qualify for Combined Heart-Kidney Transplantation

Use of extended criteria donor hearts in combined heart-kidney transplant confers greater risk of mortality

Extended criteria donors (ECD) hearts have demonstrated acceptable outcomes in select populations. However, their use in patients undergoing simultaneous heart-kidney transplantation (SHKT) has not been explored. This study is assessed the effect of ECD hearts in patients undergoing SHKT vs isolated heart transplants (IHT). The United Network for Organ Sharing (UNOS) database was queried for all adult patients undergoing IHT and SHKT. Patients were stratified by receipt of ECD heart, defined as donor hearts failing to meet established acceptable use criteria. Interaction effects between ECDs and simultaneous kidney transplants were generated. Postoperative outcomes, risk factors, and patient/graft survival were compared across cohorts using Fine-Gray, Kaplan Meier, and Cox Proportional Hazards analyses. Among 26,207 patients included, 1,766 (7%) underwent SHKT. ECD hearts were used in 25% of both IHT and SHKT cohorts. Five-year survival among SHKT/ECD patients (67.3%) was reduced (p < 0.01) compared to SHKT/SDC (80.3%), IHT/ECD (78.1%) and IHT/SCD (80.0%) groups. Among SHKT patients, use of ECD hearts was associated with increased risk (SHR: 1.48; p < 0.01) of renal graft failure compared to SCD hearts. Among SHKT patients, receipt of an ECD heart, and individual ECD criteria (coronary disease and size mismatch >20%), predicted mortality. The interaction effect of receiving both ECD and SHKT predicted mortality and graft failure (HR 1.43; p < 0.01). Patients undergoing SHKT with an ECD heart face greater risks of mortality and graft failure in comparison to those undergoing IHT with ECD hearts. Careful selection of donor organs should be applied to this high-risk cohort.

Abstract 14413: Possible Antibody Mediated Cardiac Rejection After Combined Heart-Kidney Transplant in a Sensitized Patient Associated to COVID-19 Pneumonia

Background: Antibody mediated rejection (AMR) starts with the appearance of donor-specific antibodies (DSA), followed by graft injury that may be subclinical and can progress to cardiac allograft vasculopathy (CAV) and chronic graft dysfunction. Case report A 48-year-old man with a past medical history of right nephrectomy due to congenital renal atrophy and dilated cardiomyopathy required heart transplantation at age 31, presented an episode of AMR grade 2 ten years post-transplant developing CAV with graft loss and end-stage renal disease. He was listed for a combined heart-kidney transplant. His panel reactive antibody (PRA) level was 40%, requiring desensitization therapy (plasmapheresis, intravenous gamma globulin and rituximab). At age 44, he received a heart-kidney transplant. Methylprednisolone and rabbit antithymocyte globulin were used for induction and desensitization therapy with plasmapheresis and intravenous gamma globulin at months 0-3-6-12 was continued. Maintenance immunosuppression therapy continued with tacrolimus, mycophenolic acid and prednisone. During follow-up persistent circulating DSA anti-class II HLA were detected and PRA reached 80%. He was admitted with a multifocal COVID-19 pneumonia. He had received 4 doses of the messenger RNA vaccine BNT162b2. Dexamethasone was started and mycophenolic acid was discontinued for 14 days. He did not need mechanical ventilation. Echocardiogram revealed marked concentric LVH, LVEF = 60%, grade II diastolic dysfunction and reduced global longitudinal strain (-7,6%). Pro-BNP was 962 pg/ml, and Troponin T 100 pg/ml. Endomyocardial biopsy showed no signs of cellular rejection nor capillary injury. Immunopathologic findings were negative. Coronary angiogram showed no significant lesions. AMR was suspected, the patient was treated with methylprednisolone, plasmapheresis and intravenous gamma globulin. Clinical response was satisfactory, and he was discharged in functional class I (NYHA). Conclusions Although both histological and immunopathologic studies were negative, clinical suspicion for AMR in a highly sensitized patient prevailed in the context of a recent infectious intercurrence. Other diagnosis cannot be completely ruled out in this clinical scenario.

Combined Heart-Kidney Transplantation: Indications, Outcomes, and Controversies.

Renal dysfunction, a prevalent comorbidity in advanced heart failure, is associated with significant morbidity and mortality after heart transplantation. In the recent era, the field of combined heart-kidney transplantation has experienced great success in the treatment of both renal and cardiac dysfunction in end-stage disease states, and the number of transplants has increased dramatically. In this review, we discuss appropriate indications and selection criteria, overall and organ-specific outcomes, and future perspectives in the field of combined heart-kidney transplantation.

Overcoming challenges in patient selection and monitoring in combined heart and kidney transplantation.

Combined heart-kidney transplantation (HKT) is a growing therapeutic strategy in patients with advanced heart failure (HF) and concomitant chronic kidney disease (CKD). Although patients with advanced HF and need for chronic haemodialysis have a clear indication for combined HKT, challenges to current practice lie in identifying those patients with severely depressed kidney function, which will not recover kidney function after restoration of appropriate haemodynamic conditions following heart transplantation (HT) alone. Because of the paucity of available organs, maximisation of kidney graft utility whilst minimising the operative risks associated with combined transplantation is mandatory. The benefits of HKT go beyond the mere restoration of kidney function. Data from registry analysis show that HKT improves overall survival in patients with CKD, as compared to heart transplant only, and it is associated with reduced incidence of heart allograft rejection, likely through the promotion of host immune tolerance mechanisms. In patients not requiring chronic dialysis, kidney-after-heart strategy may be explored, instead of combined HKT, in particular when the aetiology of CKD is unclear. This indeed allows for monitoring and gaging of indications for combined transplantation in the postoperative period. This approach however should be matched with priority listing for kidney transplantation given the high waitlist mortality in heart transplant recipients with associated CKD. The use of kidney machine perfusion may represent an additional tool to optimise the outcome of HKT, allowing more time to stabilise the patient after HT surgery.

The experience of hereditary apolipoprotein A-I amyloidosis at the UK National Amyloidosis Centre

Introduction Hereditary apolipoprotein A-I (AApoAI) amyloidosis is a rare heterogeneous disease with variable age of onset and organ involvement. There are few series detailing the natural history and outcomes of solid organ transplantation across a range of causative APOA1 gene mutations. Methods We identified all patients with AApoAI amyloidosis who presented to the National Amyloidosis Centre (NAC) between 1986 and 2019. Results In total, 57 patients with 14 different APOA1 mutations were identified including 18 patients who underwent renal transplantation (5 combined liver-kidney (LKT) and 2 combined heart-kidney (HKT) transplants). Median age of presentation was 43 years and median time from presentation to referral was 3 (0–31 years). Involvement of the kidneys, liver and heart by amyloid was detected in 81%, 67% and 28% of patients, respectively. Renal amyloidosis was universal in association with the most commonly identified variant (Gly26Arg, n = 28). Across all variants, patients with renal amyloidosis had a median creatinine of 159 µmol/L and median urinary protein of 0.3 g/24 h at the time of diagnosis of AApoAI amyloidosis and median time from diagnosis to end-stage renal disease was 15.0 (95% CI: 10.0–20.0) years. Post-renal transplantation, median allograft survival was 22.0 (13.0–31.0) years. There was one early death following transplantation (infection-related at 2 months post-renal transplant) and no episodes of early rejection leading to graft failure. Liver transplantation led to regression of amyloid in all four cases in whom serial 123I-SAP scintigraphy was performed. Conclusions AApoAI amyloidosis is a slowly progressive disease that is challenging to diagnose. The outcomes of transplantation are encouraging and graft survival is excellent.

Combined Heart Kidney Transplantation in a Previous Heart Transplant Recipient with Pheochromocytoma and Monoclonal Gammopathy of Uncertain Significance

Introduction Cancer survivors and patients with active malignancies are considered high risk for solid organ transplantation, as there is concern for recurrence and their concurrent co-morbidities. We present a case of combined kidney and repeat heart transplant (HT) for a patient with cardiac allograft vasculopathy (CAV) found to have pheochromocytoma and monoclonal gammopathy of unknown significance (MGUS) on pre-transplant evaluation. Case Report A 47-year-old male with a history of orthotopic HT 20 years prior due to viral myocarditis with post-transplant course complicated by CAV, chronic kidney disease stage 4 (presumed due to tacrolimus), MGUS, and atrial fibrillation presented with acute decompensated heart failure requiring inotropes. Echocardiogram revealed EF of 35%, global hypokinesis; RHC showed RA 19, RV 37/2, PA 38/17/25, PW 27, CI 1.6. LHC showed ISHLT CAV3: 70% mLAD lesion and diffuse 50-80% disease in distal LAD, Cx, and RCA. An IABP was placed and the patient was managed in the cardiac intensive care unit. Imaging revealed a right adrenal mass. He underwent an IR guided adrenal biopsy that demonstrated a pheochromocytoma, with biochemical markers of active tumor. The patient received a laparoscopic adrenalectomy and was listed for dual organ transplant. With worsening hemodynamics, he required peripheral VA-ECMO and received combined heart and renal transplant a month later. His post-operative course was complicated by RV dysfunction requiring central VA-ECMO, transplant pyelonephritis, and delayed renal allograft function requiring transient hemodialysis. Cardiac function recovered in 2 weeks post-transplant. Two and a half months post-transplant, a renal biopsy was performed for worsening acute kidney injury and demonstrated kappa light chain proximal tubulopathy. Given known MGUS, patient was diagnosed with monoclonal gammopathy of renal significance and started on started on Ixazomib-Cytoxan-Dexamethasone. He has shown improvement clinically and is now over one year post-transplant. Summary Combined heart kidney transplantation may be an option for selected patients with active malignancies like localized pheochromocytoma with MGUS. Long term follow up outcomes are unknown in this patient population. Cancer survivors and patients with active malignancies are considered high risk for solid organ transplantation, as there is concern for recurrence and their concurrent co-morbidities. We present a case of combined kidney and repeat heart transplant (HT) for a patient with cardiac allograft vasculopathy (CAV) found to have pheochromocytoma and monoclonal gammopathy of unknown significance (MGUS) on pre-transplant evaluation. A 47-year-old male with a history of orthotopic HT 20 years prior due to viral myocarditis with post-transplant course complicated by CAV, chronic kidney disease stage 4 (presumed due to tacrolimus), MGUS, and atrial fibrillation presented with acute decompensated heart failure requiring inotropes. Echocardiogram revealed EF of 35%, global hypokinesis; RHC showed RA 19, RV 37/2, PA 38/17/25, PW 27, CI 1.6. LHC showed ISHLT CAV3: 70% mLAD lesion and diffuse 50-80% disease in distal LAD, Cx, and RCA. An IABP was placed and the patient was managed in the cardiac intensive care unit. Imaging revealed a right adrenal mass. He underwent an IR guided adrenal biopsy that demonstrated a pheochromocytoma, with biochemical markers of active tumor. The patient received a laparoscopic adrenalectomy and was listed for dual organ transplant. With worsening hemodynamics, he required peripheral VA-ECMO and received combined heart and renal transplant a month later. His post-operative course was complicated by RV dysfunction requiring central VA-ECMO, transplant pyelonephritis, and delayed renal allograft function requiring transient hemodialysis. Cardiac function recovered in 2 weeks post-transplant. Two and a half months post-transplant, a renal biopsy was performed for worsening acute kidney injury and demonstrated kappa light chain proximal tubulopathy. Given known MGUS, patient was diagnosed with monoclonal gammopathy of renal significance and started on started on Ixazomib-Cytoxan-Dexamethasone. He has shown improvement clinically and is now over one year post-transplant. Combined heart kidney transplantation may be an option for selected patients with active malignancies like localized pheochromocytoma with MGUS. Long term follow up outcomes are unknown in this patient population.

Outcomes of Patients Undergoing Combined Heart-Kidney Transplantation with or without Prior Ventricular Assist Device

<h3>Purpose</h3> Both combined heart-kidney transplantation and ventricular assist devices (VAD) pose significant challenges including sensitization, immunosuppressive treatment, and infrastructure demands. Despite these challenges, we hypothesized that the recipients of combined heart-kidney transplants with and without VADs would have equivalent survival. Our aim was to compare the survival of heart-kidney transplant recipients with and without prior VAD placement. <h3>Methods</h3> We retrospectively analyzed all patients enrolled in the United Network for Organ Sharing database who underwent heart-kidney transplants. The heart-kidney transplant recipients were divided into two groups: those patients who had a VAD prior to transplantation and those who did not have a VAD prior to transplantation. We created a matched cohort of patients undergoing heart-kidney transplantation with or without prior VAD using 1:1 optimal propensity-score matching with preoperative variables. <h3>Results</h3> In the propensity-matched cohort, 399 patients (50%) underwent heart-kidney transplantation with prior VAD and 399 (50%) underwent heart-kidney transplantation without prior VAD. The estimated survival of heart-kidney recipients with prior VAD was 84.8% at one year, 81.2% at three years, and 75.3% at five years. The estimated survival of heart-kidney recipients without prior VAD was 88.7% at one year, 86.1% at three years, and 81.4% at five years. There was no statistically significant difference in the survival of heart-kidney transplant recipients with or without prior VAD at one year (p = 0.1; Figure 1), three years (p = 0.065), or five years (p = 0.05). <h3>Conclusion</h3> Despite the increased challenge of heart-kidney transplantation in recipients with prior VAD, we demonstrated that these patients have similar survival to those patients who underwent heart-kidney transplantation without previous VAD placement.

BK Virus Nephropathy in HIV-Positive Heart-Kidney Transplant Recipient

<h3>Introduction</h3> BK viral reactivation is common in immunosuppressed states such as advanced HIV and organ transplantation. An important cause of kidney transplant allograft dysfunction and loss is BK reactivation leading to BK virus-associated nephropathy (BKVAN). We describe a problematic case of BKVAN in a combined heart-kidney transplant (HKT) recipient with well controlled HIV. <h3>Case Report</h3> A 46-year-old man with HIV (CD4 726 cells/mm³, HIV viral load <20 copies/mL) on dolutegravir/rilpivirine, non-ischemic cardiomyopathy, and HIV nephropathy underwent HKT with basiliximab induction and maintenance tacrolimus (goal 5-8 ng/mL), mycophenolate mofetil (MMF), and prednisone. Immediate post-transplant course was complicated by delayed renal graft function with acute tubular necrosis and urine leak. HIV has remained well controlled. Post-transplant nadir CD4 count was 639 cells/mm³. The patient developed BK viuria (90,891,555 copies/mL) and BK viremia (4,500 copies/mL) on post-transplant day (PTD) 55 and 62, respectively. Although MMF dose was reduced from 1,000 mg to 500 mg daily, renal allograft biopsy shortly after showed Class B1 BKVAN with no evidence of rejection. Patient began bi-weekly 5 mg/kg cidofovir infusions. Prednisone was decreased from 10 mg to 5 mg daily. Mycophenolate was further reduced to 250 mg daily and steroids were discontinued due to persistently high BK viral load. However, after decline in ejection fraction (EF) to 50% and suspicion for cardiac graft rejection, MMF dose was increased back to 500 mg daily. Endomyocardial biopsies have shown no evidence of rejection with negative donor specific anti-HLA antibodies. Renal function declined with serum creatinine (SCr) peaking at 2.28 mg/dL. Patient has remained on cidofovir infusions and reduced immunosuppression, on which SCr has stabilized to 1.8 mg/dL on PTD 694. Cardiac allograft function remains normal with an EF of 71% on PTD 644. BK viral load peaked at 16,672,298 copies/mL and remains elevated at 4,821 copies/mL on PTD 702. <h3>Summary</h3> We present a case of BKVAN in a HIV+ HKT recipient. This case demonstrates the difficulty of BKVAN management in dual organ transplant since heart allograft management requires higher levels of maintenance immunosuppression. It is unclear if HIV contributed to development of BKVAN in this recipient. Better antiviral therapies are needed for control of BK virus infections after transplant.

Outcomes of Combined Heart-Kidney Transplantation in Older Recipients

<h3>Purpose</h3> The upper limit of recipient age for combined heart-kidney transplantation (HKT) remains controversial. This study evaluated trends and outcomes of HKT in patients aged 65 years or older. <h3>Methods</h3> The United Network of Organ Sharing (UNOS) registry was used to identify patients undergoing combined HKT from 2005-2021. Patients were stratified by age at the time of transplantation: <65 and ≥65 years. The primary outcome was one-year mortality. Secondary outcomes included 90-day and 5-year mortality, postoperative new-onset dialysis, postoperative stroke, acute rejection prior to discharge, and rejection within one-year of HKT. Survival was compared using Kaplan-Meier analysis, and risk-adjustment for mortality was performed using Cox proportional hazards modeling. <h3>Results</h3> There was a significant annual increase in frequency of HKT in recipients aged ≥65 from 5.6% of all HKT recipients in 2005 to 23.7% in 2021 (<i>p</i> = 0.002). Of 2,022 patients undergoing HKT in the study period, 372 (18.40%) were aged 65 or older. Older HKT recipients were more likely to be male and white and fewer required dialysis prior to HKT compared to younger recipients. There were no differences between cohorts in unadjusted 90-day, 1-year, or 5-year survival in Kaplan-Meier analysis. These findings persisted after risk-adjustment, with an adjusted hazard for one-year mortality for age ≥65 of 0.91 (95% CI [0.63-1.29], <i>p</i> =0.572). When modeled as a continuous variable, increasing age was also not associated with one-year mortality (HR 1.01 (95% CI [1.00-1.02], <i>p</i> = 0.236) per year). There was a trend for patients aged ≥65 to more frequently require new-onset dialysis after HKT prior to discharge (11.56% vs 7.82%, <i>p</i> = 0.051). Stroke and rejection rates were comparable between groups. <h3>Conclusion</h3> Combined HKT is being performed more frequently in older recipients in the United States. Although viewed by many programs as a contraindication, advanced age of 65 years or older should not preclude HKT as similar outcomes can be achieved as compared to younger recipients.

Kidney Transplantation in Single Ventricle Palliated Patients: A Pediatric Cardiac Care Consortium Study

<h3>Purpose</h3> Development of chronic kidney disease is well described in patients with complex congenital heart disease such as palliated single ventricle patients. It is also well known that presence of kidney disease contributes to morbidity and mortality in these patients. However, there is no study if the progression of kidney disease in these patients necessitates kidney transplantation and risk factors associated with need for kidney transplantation (KTX). <h3>Methods</h3> A retrospective cohort study of patients undergoing single ventricle palliation in the Pediatric Cardiac Care Consortium (PCCC), a large US-based registry. Outcomes and transplants were captured in the PCCC and by linkage with the Organ Procurement Transplant Network (OPTN) through 2019. <h3>Results</h3> Between 1982 -2019, 7751 patients with SV palliation were seen at US centers and 6385 patients had identifiers allowing appropriate linkage with OPTN database. Of these, 14 patients (0.22%) underwent KTX. Patients undergoing KTX were predominantly male (71%), white race (64.3%) and underwent KTX at a mean age of 21 (±9) years, mean time to KTX from last cardiac surgery 15.2 (±8.7) years. Cardiac diagnostic group was systemic right ventricle in 8/14 (57%). At follow-up, 11/14 (78%) were alive while 3/14 (22%) died at a mean age of 29 (±10.6) years. There were no differences in the demographic and diagnosis between those who received KTX versus those who did not. However, at follow up only 50.4% of patients without KTX were alive compared to 78.6% in the KTX group (p=0.03) while the mean age at death was 1 (0, 14) years in non-KTX group compared to 33.0 (17.0, 37.0) years in the KTX group (p= 0.011). Two patients needed kidney transplantation after heart transplantation. <h3>Conclusion</h3> First of its kind study shows that kidney transplantation is rarely performed in patients with single ventricle palliation although kidney disease is well documented in this population. This study findings potentially reflect selection bias and survival bias. We plan to elucidate the same further. Need for KTX appears to be higher in males with systemic right ventricle anatomy in the second or early third decade. Given that there is high mortality in the overall cohort, and given improved survival of patients undergoing combined heart kidney transplantation, further studies should focus on patient selection and early intervention.

National trends and outcomes of heart-kidney transplantation using hepatitis C positive donors.

This study evaluated the outcomes of combined heart-kidney transplantation in the United States using hepatitis C positive (HCV+) donors. Adults undergoing combined heart-kidney transplantation from 2015 to 2020 were identified in the United Network for Organ Sharing registry. Patients were stratified by donor HCV status. Kaplan-Meier curves with multivariable Cox regression models were used for risk-adjustment in a propensity-matched cohort. A total of 950 patients underwent heart-kidney transplantation of which 7.8% (n=75) used HCV+ donors; 68% (n=51) were viremic and 32% (n=24) were non-viremic donors. Unadjusted 1-year recipient survival was similar between HCV+ versus HCV- donors (84%vs 88%, respectively; P=.33). Risk-adjusted analysis in the propensity-matched cohort showed HCV+ donor use did not confer increased risk of 1-year mortality (hazard ratio .63, 95% CI .17-2.32; P=.49). Sub-group analysis showed viremic and non-viremic HCV+ donors had similar 1-year survival as well (84%vs 84%; P=.95). Compared with recipients of HCV- donor dual heart-kidney transplants, recipients of HCV+ organs had comparable 1-year survival and clinical outcomes after combined transplantation. Although future studies should evaluate other outcomes related to HCV+ donor use, this practice appears safe and should be expanded further in the heart-kidney transplant population.

Evaluation of a cardiac transplanted children cohort: long term pediatric follow-up and transiant to adulthood. Twenty years of monocentric experience

Pediatric heart transplantation is commonly performed as a last resort treatment for severe heart dysfunction. We sought to analyze our 20 years’ experience with pediatric heart transplant: long-term outcome and fate at transition to adulthood. Retrospective analysis of all children (< 18 years) who underwent heart transplantation between 01-1999 and 12-2018. Demographic data of donors and recipients, etiology, time on waiting list, hemodynamic data, post-transplantation complications, long-term survival of patient and transplant were collected. Forty-nine transplants were performed in 48 children at median age and weight of 8,3 years [2,9–13,5] and 20,5 kg [13,2–39,5]. 86% had cardiomyopathy (dilated in 57% of those), 8% congenital heart disease and 6% myocarditis. Median time on waiting list was 46 days [19–132] with a trend to increase with time. Global survival reached 88% at 1 year and 80% at 5 years post-transplantation. No death nor organ failure occurred for patients transplanted after January 2011. 9 patients (18%) died, 6(67%) for transplant failure, 2(22%) for septic shock, 1 for post-operative cerebral hypoxia. Graft rejections occurred 32 times in 17 patients (35%). 8 patients of them (47%) were symptomatic, a median of 16 months after transplant [6–30]. 1 patient underwent a second combined heart-kidney transplant, 1 had lymphoma. Median age of transition to adult care was 17,9 years [16,5–18,4] after a mean pediatric care of 6,9 years (0,4 to 19,2). Global median follow-up was 3,8 years [1,5–7,9]. At latest follow-up, 36 children (74%) had normal schooling, 7(14%) had some school adaptations, 1 was in a special institution and 1 did not attend school. Our retrospective analysis shows good survival, when compared to current reported data (ISHLT) with normal schooling in 75% of the children, compared to 94% in the normal French population. Quality of life and exercise capacity are currently being studied in our cohort.

Impact of diabetes and chronic dialysis on post-transplant survival in combined heart-kidney transplant recipients.

Growing research supports an increased survival benefit of combined heart and kidney transplantation in patients with both heart and renal failure. As a result, the frequency of these combined transplants continues to increase. Despite this trend, little has been done to quantify the impact of chronic illness in this population. We identified adult recipients of combined heart-kidney transplant from the Scientific Registry of Transplant Recipients (SRTR) database between 2005 and 2018. We focused on renal disease secondary to diabetes and duration of dialysis as markers of chronic illness. The primary outcome was post-transplant mortality. Our final multivariable Cox proportional hazard model found that diabetes-associated renal disease (HR 1.57, 95% CI 1.14-2.15, p=.01) and dialysis duration (HR 1.08, 95% CI 1.01-1.15, p=.02) were significant predictors of post-transplant mortality. Given the significant impact of dialysis duration and renal disease secondary to diabetes mellitus, these chronically ill patients should be closely examined for conditions such as peripheral vascular disease and frailty, which have been shown to affect mortality in heart transplant recipients and are prevalent in the chronic dialysis population.

Successful Combined Heart-Kidney Transplants Using Donors with Acute Kidney Injury: 15 Year Single-Institution Experience

<h3>Purpose</h3> In patients with NYHA Class IV heart failure, renal disease may limit candidacy for heart transplantation. Combined heart-kidney transplantation has been effective in patients with multi-organ failure, thereby improving long-term cardiac graft function and overall patient survival. Donors with acute kidney injury (AKI) may limit available organs for transplantation. We aimed to report our experience using donor kidneys with AKI in combined heart-kidney transplantation. <h3>Methods</h3> From 2005-2020, a single institutional retrospective chart review of patients undergoing combined heart-kidney transplants was performed. The United Network for Organ Sharing (UNOS) database was used to collect data. Statistical analysis was done using a two-sample T-test and comparison of means test. Results were stratified by age, sex, post-operative length of stay (LOS), episodes of rejection, post-operative CRRT, post-operative delay in renal graft function, and cardiac function. <h3>Results</h3> 35 patients received combined heart-kidney transplants. Average age was 59.37 years. Average follow-up was 50.58 months. In our patient pool, 77.2% were male and 22.8% were female. 5 patients received kidneys from donors who had AKI, of which 1 had delayed graft function (20%). 14 patients who received donor kidneys without AKI had delayed graft function (43.3%) (p=0.88). Average LOS was not statistically different. Current eGFR was not statistically different. 3 patient deaths were not related to graft rejection. See Table 1. <h3>Conclusion</h3> This study demonstrates that combined heart-kidney transplantation can be done safely and effectively using donor kidneys with AKI. Our analysis shows no difference in post-operative delayed graft function of the kidney with AKI, LOS, and renal/cardiac function. Although our experience suggests safe use of donor kidneys with AKI, larger studies are necessary to define the short and long-term outcomes of combined heart-kidney transplantation with AKI donors.