Heart-kidney Transplantation Research Articles

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.

Heart-Kidney Transplantation and Hepatitis C Virus Positive Donors

<h3>Purpose</h3> Novel hepatitis C virus (HCV) therapies have expanded the donor pool for heart transplantation (HT). However, multi-center data for heart-kidney transplant (HKT) recipients of HCV(+) donors is not yet available. <h3>Methods</h3> We analyzed adults undergoing first-time HKT between October 16^th, 2014 & December 31^st, 2019 using United Network for Organ Sharing (UNOS) registry; follow-up was available through March 4^th 2021. Data on recipient & donor characteristics were compared by donor's HCV status (defined as presence of either positive HCV antibody (Ab) or Nucleic Acid Test (NAT); Kaplan-Meier survival & Cox-proportional hazard estimates were computed. We also conducted a propensity score matching (PSM) analysis by matching HCV(+) donors with non-HCV donors. A separate sub-group analysis stratified by donor's HCV-Ab & NAT status was also performed. <h3>Results</h3> A total of 785 recipients (n=60 HCV(+) and n=725 non-HCV donors) were identified (age: 59 years (interquartile range (IQR): 51, 64), 82.4% males, 34.4% blacks). Recipients of HCV(+) donors were more likely to be from UNOS regions 1, 5, 10 or 11 & were transplanted at high-volume centers (p<0.05). HCV(+) donors were more likely to be older, Caucasians, smoker, dying of drug-overdose & with lower body-mass index (p<0.05). Distance between recipient & donor centers was significantly greater, resulting in longer ischemic times, & predicted heart-mass ratio was significantly lower among recipients with HCV(+) donors (p<0.05). Despite of these unfavorable factors, 1-year survival was similar between HCV(+) & non-HCV donors; similar trends were observed upon PSM analysis & sub-group analysis (<b>FIGURE</b>). Post-HKT length of stay (25 days (IQR: 14, 52) Vs 22 days (IQR: 15, 34), p=0.256) & index-hospital need for dialysis (32% Vs 33%, p=0.784) did not differ between recipients of HCV(+) and non-HCV donors, respectively. <h3>Conclusion</h3> Given excellent 1-year survival and short-term outcomes, HCV(+) donors offer an opportunity to expand the donor pool for recipients in need of HKT.

Outcomes Of Total Artificial Heart Placement - The Learning Curve From A Single-Center Experience

<h3>Introduction</h3> Total artificial heart (TAH) placement is performed for patients with end-stage biventricular heart failure. TAH placement is often utilized as a bridge to heart transplantation (HT). Identifying risk factors for poor outcomes following TAH placement is necessary to select ideal candidates who may benefit from TAH placement as a bridge to HT. <h3>Hypothesis</h3> Advanced age, renal insufficiency (RI), and INTERMACS (IM) profile 1 at the time of TAH placement are poor prognostic factors for six-month survival (SMS) and bridge to HT in patients with end-stage biventricular heart failure. <h3>Methods</h3> In a single-center retrospective analysis between 2012 and 2019, 91 heart failure patients who underwent TAH placement were identified. Patient demographics including age, RI, and IM profile at the time of TAH placement were assessed. Patients were divided into four age quartiles (less than age 35 [quartile 1], age 35 to 49 [quartile 2], age 50 to 64 [quartile 3], and age 65 or greater [quartile 4]). SMS, HT, and heart-kidney transplantation (HKT) rates were compared among the age quartiles and demographic factors. <h3>Results</h3> Among the 91 patients who underwent TAH placement, 59 patients survived and 32 patients did not survive six months following TAH placement. Patients in age quartile 1 had a SMS rate of 91.7% compared to 59.5% in age quartile 3 (p=0.04) and 40% in age quartile 4 (p=0.009). SMS rates decreased with increasing age quartile with rates of 91.7%, 66.7%, 59.5%, and 40%, respectively (p=0.07). IM profile 1 patients had a SMS rate of 58.3% compared to 72.1% in IM profile ≥ 2 patients (p=0.03). Patients in age quartile 4 who were also IM profile 1 had a SMS rate of 0% compared to 100% in age quartile 4 patients who were IM profile ≥ 2 (p=0.001). Patients with RI at the time of TAH placement had a SMS rate of 60% compared to 74.2% in patients without RI (p=0.17). A total of 54 patients underwent HT including 15 patients undergoing HKT. Patients in age quartile 1 underwent HT in 83.3% of cases compared to 30% in age quartile 4 patients (p=0.01). No patients in age quartile 4 who were IM profile 1 underwent HT. IM profile 1 patients underwent HT in 52.1% of cases compared to 67.4% in IM profile ≥ 2 patients (p=0.13). Patients with RI underwent HT in 51.7% of cases compared to 74.2% in patients without RI (p=0.03). <h3>Conclusions</h3> In this single-center study, advanced age was associated with increased six-month mortality and decreased rate of HT following TAH placement. IM profile 1 was also associated with increased six-month mortality after TAH placement, but not decreased rate of HT. When combined with IM profile 1, age ≥ 65 was found to be a significant risk factor for increased six-month mortality following TAH placement and unsuccessful TAH bridge to HT. RI at the time of TAH placement was associated with decreased rate of TAH bridge to HT, but not increased six-month mortality. Larger studies are needed to further assess the effects of these risk factors on TAH placement outcomes.

Optimal patient selection for simultaneous heart-kidney transplant: A modified cost-effectiveness analysis

Increasing rates of simultaneous heart-kidney (SHK) transplant in the United States exacerbate the overall shortage of deceased donor kidneys (DDK). Current allocation policy does not impose constraints on SHK eligibility, and how best to do so remains unknown. We apply a decision-analytic model to evaluate options for heart transplant (HT) candidates with comorbid kidney dysfunction. We compare SHK with a "Safety Net" strategy, in which DDK transplant is performed 6months after HT, only if native kidneys do not recover. We identify patient subsets for whom SHK using a DDK is efficient, considering the quality-adjusted life year (QALY) gains from DDKs instead allocated for kidney transplant-only. For an average-aged candidate with a 50% probability of kidney recovery after HT-only, SHK produces 0.64 more QALYs than Safety Net at a cost of 0.58 more kidneys used. SHK is inefficient in this scenario, producing fewer QALYs per DDK used (1.1) than a DDK allocated for KT-only (2.2). SHK is preferred to Safety Net only for candidates with a lower probability of native kidney recovery (24%-38%, varying by recipient age). This finding favors the implementation of a Safety Net provision and should inform the establishment of objective criteria for SHK transplant eligibility.

Primary Graft Dysfunction After Heart Transplantation: Incidence and Current Risk Factors

<h3>Purpose</h3> Primary graft dysfunction (PGD) is a leading cause of perioperative mortality in heart transplant (HT). Yet the impact of the current increased use of high-risk recipients and donors for HT on the incidence of PGD is unknown. <h3>Methods</h3> This is a retrospective single-center study of adult patients who underwent isolated heart or heart-kidney transplant from January 2018 to March 2020 to evaluate the incidence and patient characteristics associated with PGD, as defined by the International Society for Heart and Lung Transplantation consensus guidelines. Baseline characteristics and postoperative outcomes were compared between patients with no/mild PGD versus moderate/severe PGD. Multivariate logistic regression was used to determine independent predictors of PGD. <h3>Results</h3> One-hundred seventeen patients were evaluated: 105 (89.7%) had no/mild PGD and 12 (10.3%) had moderate/severe PGD. Patients with moderate/severe PGD were less likely to be bridged to transplant with temporary mechanical circulatory support (MCS) (8.3% versus 55.2%, p=0.002) and were more likely to receive undersized hearts (donor/recipient weight ratio 0.93±0.14 versus 1.12±0.26, p=0.008). Moderate/severe PGD patients had a higher postoperative median vasoactive inotropic score (24.97 versus 6.50, p<0.001) and only one moderate/severe PGD patient required postoperative extracorporeal membrane oxygenation (ECMO). By multivariate analysis, undersized donor (odds ratio [OR] 1.055; 95% confidence interval [CI] 1.003-1.127, p<0.001) was an independent predictor of PGD and pre-transplant temporary MCS was a negative predictor of PGD (OR 0.075; 95% CI 0.003-0.580, p=0.033). <h3>Conclusion</h3> In this experience with HT in high acuity recipients, the incidence of moderate/severe PGD is low and need for post-transplant ECMO is rare. Interestingly, these data suggest that use of pre-transplant temporary MCS may be protective against moderate/severe PGD, and further investigation of this approach is indicated.

Simultaneous Heart-Kidney Transplant Outcomes Pre- and Post-Heart Allocation System Change: Impact of Temporary Mechanical Circulatory Support

<h3>Purpose</h3> The United Network for Organ Sharing (UNOS) changed the donor heart allocation system in October 2018 aiming to prioritize organ availability to candidates with the highest mortality risk. Following this change, the use of temporary mechanical circulatory support devices (tMCS) increased dramatically in transplant centers across the United States. However, the potential effect of this change remains unknown in patients undergoing simultaneous heart-kidney (SHK) transplantation. The aim of this study was to compare outcomes in SHK recipients before and after the allocation change. <h3>Methods</h3> We identified all SHK recipients from the Scientific Registry of Transplant Recipients who underwent transplantation between January 2016 and November 2019. Patients were stratified into pre- and post-heart allocation change groups based on the date of surgery. Kaplan-Meier curves were generated to compare 1-year outcomes by era. Subsequently, patients with the following tMCS devices were identified within each group: Intra-aortic balloon pump (IABP); Impella 2.5, CP, 5.0; Centrimag and VA-ECMO. Separate 1-year survival analyses were performed and compared between pre- and post-heart allocation change. <h3>Results</h3> We identified 400 and 138 patients who underwent SHK transplant pre- and post-heart allocation change, respectively. The overall 1-year survival rate of SHK recipients was lower after October 2018 (p=0.002; Figure 1A). 56 patients (14.1%) were transplanted with a tMCS device before and 65 (47.1%) after the allocation change. There was no significant difference in 1-year survival between the two groups (p=0.319; Figure 1B). <h3>Conclusion</h3> tMCS device use increased following the heart allocation change. Our results indicate that the one-year survival of SHK recipients has declined after the change, but it was independent of the increased tMCS device use. Further studies are needed to evaluate long-term outcomes.

Use of SherpaPak™ CTS for Organ Transportation During Heart Transplantation: National Outcomes from United Kingdom

<h3>Purpose</h3> SherpaPak™ CTS is CE marked and FDA approved device for organ transportation during heart transplantation. This device maintains organ temperature between 4-8°C which is the recommended temperature range by ISHLT 2020 consensus statement¹ to prevent potential freezing damage. The aim of study was to analyse the clinical outcomes since its introduction in United Kingdom. <h3>Methods</h3> Donor hearts where SherpaPak™ was used for transportation between December 2019 to September 2021 were identified and data on donor and recipient demographics, transport parameters and short-term clinical outcomes were extracted from the UK Transplant Registry held by NHS Blood and Transplant. <h3>Results</h3> A total of 30 patients had heart transplantation using SherpaPak™ across the United Kingdom, including one heart-kidney transplant. The Manchester team did 16 implants, Harefield did 11 and Papworth did 3 implants using SherpaPak™ during the 22 month period. Donor median age was 31 years (range 17-53 years). Recipients median age was 50 years (range 19 - 61 years). 6 Recipients were on super-urgent, 20 on urgent and 4 on non-urgent waiting list for heart transplantation. Median ischemic time was 3.1 hours (range 1.8 - 7 hours). Post operative ECMO support was required in 4/30 (13%) patients. Median stay in intensive care was 9 days (range 3-59 days) and in hospital was 30 days (range 15-104 days). Two patients died within 30 days resulting in 30-day survival rate of 93% (95% CI: 75-98%), which is similar to published national 30-day survival of 91.5%.² <h3>Conclusion</h3> UK national results demonstrate that SherpaPak™ is a safe device for organ transportation during heart transplantation. Further experience is needed to understand potential benefits and costs effectiveness.

Cross-Organ Survival in Patients Undergoing Multi-Organ Cardiac Transplantation

<h3>Purpose</h3> Multi-organ cardiac (i.e., heart-X) transplantation indications have increased as analyses suggest comparable outcomes to patients undergoing single-organ procedures. Here, we present a comparison between survival outcomes in three of the most prevalent multi-organ procedures: heart-lung, heart-kidney, and heart-liver transplantation. <h3>Methods</h3> Using the United Network for Organ Sharing (UNOS) Standard Transplant Analysis and Research Database, we retrospectively reviewed heart transplants performed from January 1988 to September 2020. Heart-pancreas and triple-organ transplants were excluded due to insufficient sample size. Survival was assessed with Kaplan-Meier method and compared by log-rank test. Univariate and multivariate cox regression analyses were performed to assess hazard ratios. <h3>Results</h3> A total of 80,058 patients were included in this study. Heart-lung transplant recipients experienced significantly worse survival compared to those receiving heart-kidney, heart-liver, or heart-only transplants (p <0.0001). Cox regression analyses found an increased risk for mortality in heart-lung transplants, HR 1.91 (95% CI 1.79-2.04, p <0.001). Multivariate analysis adjusting for donor age, recipient age, and ethnicity found increased risk for mortality in heart-lung transplants and reduced risk in heart-kidney transplants, HR 2.15 (95% CI 2.01-2.29, p <0.001) and HR 0.86 (95% CI 0.8-0.93, p <0.001), respectively. Higher donor or recipient age and African American ethnicity were associated with worse outcomes. <h3>Conclusion</h3> Patients undergoing heart-lung transplantation have poorer outcomes, while heart-liver and heart-kidney transplants display improved rates of survival relative to heart-only transplants. Further research should be performed to validate these findings prospectively and account for confounding.

Incidence of BK Viremia in Simultaneous Heart-Kidney Transplant Recipients: A Single-Center Experience

<h3>Purpose</h3> BK virus (BKV) after kidney transplant is associated with decreased graft survival, increased morbidity, and increased health-care costs. Management of BKV post-transplant remains difficult, especially in dual organ transplants where immunosuppression requirements are typically higher and limited evidence exists. Our aim was to describe our experience with simultaneous heart-kidney transplant (HKT) recipients who developed BKV. <h3>Methods</h3> This was a single-center case series of HKT recipients between 11/2015 and 11/2019. Data are presented as median (IQR) or percentages, as appropriate. The primary endpoint was the incidence of BK viremia within 12-months post-transplant. <h3>Results</h3> Of the 12 patients included, 5 (41.7%) developed BKV at a median time of 196 (85-258) days. Baseline demographics and clinical outcomes are included in Table 1. Patients who experienced BKV were more likely to receive rabbit anti-thymocyte globulin for induction (p=0.04). There was no statistical difference in maintenance immunosuppression; however, mycophenolate dose and tacrolimus troughs were numerically higher at 3 months post-transplant in patients with BKV. All 5 patients were treated with a reduction in maintenance immunosuppression. Additionally, three (60%) received intravenous immune globulin, three (60%) received cidofovir, and three (60%) were switched to sirolimus. Although not statistically significant, eGFR was numerically lower starting at 3-months post-transplant in patients with BKV. Only one (20%) patient developed biopsy-confirmed BK nephropathy. <h3>Conclusion</h3> BKV is an underappreciated complication post-HKT. The high incidence may be explained by lymphocyte-depleting induction and increased maintenance immunosuppression in this group. Although BKV did not impact patient or graft survival, added vigilance may be warranted. Long-term follow-up is required to help identify appropriate management strategies for this complication.

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.

Evaluation of Donor Glomerular Filtration Rate on Survival Outcomes among Simultaneous Heart and Kidney Transplant Recipients

Purpose Evaluation of donor co-morbidities is critical in order to risk-stratify and optimize post-transplant survival among simultaneous heart and kidney transplant (HKT) patients. We aimed to characterize the effect of donor glomerular filtration rates (GFR) on HKT recipient survival at 60 months post-transplantation. Methods All patients registered in the UNOS database who received HKT from 1/1/2010 - 6/1/2021 were analyzed. HKT recipients with donors of GFR >30 mL/min/1.73 m2 (n =1934) and donors with GFR <=30 mL/min/1.73 m2 (n = 59) were compared. HKT recipients with donors of GFR >60 mL/min/1.73 m2 (n=1611) and <=60mL/min/1.73 m2 (n=382) were also compared. Baseline characteristics were compared using Mann-Whitney U and Chi-square analyses. Mean age among all recipients was 55.8 years (SE 10.8). Comorbidities including diabetes, smoking, pre transplant dialysis requirements, donor age, use of ventricular assist devices, life support ventilators, intra-aortic balloon pumps, and ischemic time were similar among groups. Kaplan-Meier survival analysis was performed at 60 months post-transplantation. Results At 60 months post-transplant, there were no significant differences in survival among HKT patients with donor GFR <=60mL/min/1.73 m2 and donor GFR>60mL/min/1.73 m2 groups, respectively (p=0.858). At 60 months post transplant, there was no significant survival change among those with donor GFR <=30 mL/min/1.73 m2 and >30 mL/min/1.73 m2 (p=0.400). After adjusting for variables listed above, HKT recipients with donors of GFR <=60 compared to >60 had similar survival rates (adjusted HR 1.016, 95% CI 0.776-1.332, p=0.904). A similar trend was seen for patients with donors of GFR <= 30 mL/min/1.73 m2 compared to those of GFR >30 mL/min/1.73 m2 (adjusted HR 0.650, 95% CI 0.290-1.457, p=0.295). Conclusion Donor GFR in isolation had no significant impact on survival among simultaneous heart kidney transplant recipients at 60 months post transplantation after controlling for comorbidities. Donor kidney function In isolation should also not prohibit consideration for dual organ transplantation. Evaluation of donor co-morbidities is critical in order to risk-stratify and optimize post-transplant survival among simultaneous heart and kidney transplant (HKT) patients. We aimed to characterize the effect of donor glomerular filtration rates (GFR) on HKT recipient survival at 60 months post-transplantation. All patients registered in the UNOS database who received HKT from 1/1/2010 - 6/1/2021 were analyzed. HKT recipients with donors of GFR >30 mL/min/1.73 m2 (n =1934) and donors with GFR <=30 mL/min/1.73 m2 (n = 59) were compared. HKT recipients with donors of GFR >60 mL/min/1.73 m2 (n=1611) and <=60mL/min/1.73 m2 (n=382) were also compared. Baseline characteristics were compared using Mann-Whitney U and Chi-square analyses. Mean age among all recipients was 55.8 years (SE 10.8). Comorbidities including diabetes, smoking, pre transplant dialysis requirements, donor age, use of ventricular assist devices, life support ventilators, intra-aortic balloon pumps, and ischemic time were similar among groups. Kaplan-Meier survival analysis was performed at 60 months post-transplantation. At 60 months post-transplant, there were no significant differences in survival among HKT patients with donor GFR <=60mL/min/1.73 m2 and donor GFR>60mL/min/1.73 m2 groups, respectively (p=0.858). At 60 months post transplant, there was no significant survival change among those with donor GFR <=30 mL/min/1.73 m2 and >30 mL/min/1.73 m2 (p=0.400). After adjusting for variables listed above, HKT recipients with donors of GFR <=60 compared to >60 had similar survival rates (adjusted HR 1.016, 95% CI 0.776-1.332, p=0.904). A similar trend was seen for patients with donors of GFR <= 30 mL/min/1.73 m2 compared to those of GFR >30 mL/min/1.73 m2 (adjusted HR 0.650, 95% CI 0.290-1.457, p=0.295). Donor GFR in isolation had no significant impact on survival among simultaneous heart kidney transplant recipients at 60 months post transplantation after controlling for comorbidities. Donor kidney function In isolation should also not prohibit consideration for dual organ transplantation.

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.

Is Delayed Graft Function Worse in Simultaneous Heart-Kidney Transplant vs Kidney Transplant Alone?

<h3>Purpose</h3> Simultaneous heart-kidney transplantation (HKTx) has been increasing over the past 10 years with approximately 5.5% of heart transplants (HTx) being HKTx. Due to the heart being transplanted first and then the kidneys, there is question regarding the incidence and degree of delayed graft function (DGF) in the kidney. In HKTx, it is not uncommon to have fluid shifts and labile hemodynamics perioperatively post-HTx that may require the support of inotropes and vasopressors. It is not known whether these agents can affect the donor kidney which is transplanted immediately after HTx. This may result in varying degrees of DGF and the need for dialysis. Therefore, we reviewed our experience of DGF and compared this to a cohort of patients who underwent kidney transplant (KTx) alone from the UNOS database. <h3>Methods</h3> Between 2010 and 2020, we assessed 134 HKTx patients. These patients were assessed for DGF (need for dialysis within the first 7 days post-operatively). This study group was compared to a control group of patients who received KTx alone (n=192,134 from the UNOS database) during the same period. In addition, post-transplant outcomes included 1-year survival and patients who resumed chronic dialysis for failed donor kidney. <h3>Results</h3> Patients who underwent simultaneous HKTx compared to patients who underwent KTx alone had a significant increase in the development of DGF. However, post-transplant 1-year survival and the percent of patients that resumed chronic dialysis was similar between groups. (see table) <h3>Conclusion</h3> Simultaneous HKTx has increased risk for DGF which is most likely related to intraoperative labile hemodynamics commonly requiring the use of inotropes/pressors. However, despite higher incidence for DGF, HKTx has comparable outcomes.

Interleukin - 2 Receptor Antagonists Induction Therapy in Simultaneous Heart - Kidney Transplantation

<h3>Purpose</h3> SRTR data currently suggests that induction therapy in simultaneous heart-kidney transplantation (SHKT) with rabbit antithymoglobulin (ATG) provides survival advantage compared to interleukin-2 receptor antagonist (IL2-RA). We are reporting the outcomes of recipients with SHKT treated with IL2-RA as induction therapy. <h3>Methods</h3> This is a single center, retrospective study of 26 patients who received SHKT at our institution from Dec 2018 to Oct 2021. A multidisciplinary team composed of heart and kidney transplant medical and surgical members determined appropriate recipient-donor SHKT candidate pairs. The majority of patients received IL2-RA induction therapy, and all patients received triple immunosuppression therapy with prednisone, mycophenolate mofetil and tacrolimus. Adjustments in long term therapy were made in collaboration between the heart and kidney transplant teams. <h3>Results</h3> From Dec 2018 to Oct 2021, 26 patients underwent SHKT. 23 patients (88%) were male, the median age was 57 years, and 5.4% were ≥ 65 years. 18 patients (69%) had non ischemic cardiomyopathy and 24 patients (92%) had CKD (mean GFR ≤ 35%). 18 patients were listed Status 2 and 2 patient Status 5. One patient received a DCD donor and 12 patients (46%) received hep C donors. 25 patients (96%) received induction therapy with IL2-RA. During the first 3 months post-transplant, the only patient who received ATG had 7 severe infections; 11 patients (44%) and 13 patients (52%) who received IL2 -RA had no infections and ≤ 4 mild infections, respectively. One patient died due to COVID 19 pneumonia complicated by multisystem organ failure. For a median follow up period of 410 (187-707) days, 8% patients in the IL2-RA induction cohort experienced a 2R/3A heart rejection, 8% patients remained on HD due to primary kidney graft non-function, and the survival rate was 96%. <h3>Conclusion</h3> Compared with present literature, our data support the use of IL2- RA as an induction strategy in SHKT with excellent patient survival.

Dual Heart-kidney Transplant With Total Abdominal Hysterectomy

Introduction Dual heart and kidney transplantation (HKTx) is becoming an increasingly common surgical approach to selected patients with end-stage heart failure and end-stage renal disease. To date, there are no published reports of HKTx performed with near-concurrent total abdominal hysterectomy. Herein we present a case of a female patient who underwent successful HKTx with total abdominal hysterectomy. Case A 39 year old African American woman with a body mass index of 22 kg/m2 with significant uterine fibroids (figure 1), dilated cardiomyopathy from prior viral myocarditis, and chronic kidney disease was transferred to our institution for consideration of dual organ transplant.Upon transfer, the patient presented in SCAI shock Class D on dual inotropes. Despite the high doses of milrinone and dobutamine, her hemodynamics remained suboptimal with a blood pressure of 86/54 and heart rate of 130. Her exam was notable for elevated jugular venous pressure, cool extremities, and a loud systolic murmur with radiation to the apex. Labs revealed a sodium of 127meq/L and a worsening creatinine of 3.7mg/dL from a baseline of 2.5mg/dL. A right heart catheterization revealed elevated biventricular filling pressures and persistently low cardiac index (1.5 L/min/m2). She required the addition of epinephrine and a balloon pump for stabilization.She was then presented for an urgent heart and kidney transplantation, but given significant uterine fibroids, and relatively small BMI and waist circumference, gynecological surgery was consulted for need of total abdominal hysterectomy for the placement of the kidney. A planned surgical approach, to include orthotopic heart transplantation with concurrent total abdominal hysterectomy, followed by next-day kidney transplant, was devised. The patient was counseled regarding future inability of pregnancy. She was successfully transplanted with no intraoperative complications. On post-op day 10, the patient developed hemoperitoneum that required exploratory laparotomy with the evacuation of hemoperitoneum and re-suturing of the vaginal cuff. She was discharged 18 days after transplant. Her follow-up to date has been uneventful. Conclusion Our case demonstrates that heart and kidney transplantation with total abdominal hysterectomy is a safe and effective method in patients with a small BMI and enlarged leiomyoma that may prohibit implantation of the donor kidney. Dual heart and kidney transplantation (HKTx) is becoming an increasingly common surgical approach to selected patients with end-stage heart failure and end-stage renal disease. To date, there are no published reports of HKTx performed with near-concurrent total abdominal hysterectomy. Herein we present a case of a female patient who underwent successful HKTx with total abdominal hysterectomy. A 39 year old African American woman with a body mass index of 22 kg/m2 with significant uterine fibroids (figure 1), dilated cardiomyopathy from prior viral myocarditis, and chronic kidney disease was transferred to our institution for consideration of dual organ transplant.Upon transfer, the patient presented in SCAI shock Class D on dual inotropes. Despite the high doses of milrinone and dobutamine, her hemodynamics remained suboptimal with a blood pressure of 86/54 and heart rate of 130. Her exam was notable for elevated jugular venous pressure, cool extremities, and a loud systolic murmur with radiation to the apex. Labs revealed a sodium of 127meq/L and a worsening creatinine of 3.7mg/dL from a baseline of 2.5mg/dL. A right heart catheterization revealed elevated biventricular filling pressures and persistently low cardiac index (1.5 L/min/m2). She required the addition of epinephrine and a balloon pump for stabilization.She was then presented for an urgent heart and kidney transplantation, but given significant uterine fibroids, and relatively small BMI and waist circumference, gynecological surgery was consulted for need of total abdominal hysterectomy for the placement of the kidney. A planned surgical approach, to include orthotopic heart transplantation with concurrent total abdominal hysterectomy, followed by next-day kidney transplant, was devised. The patient was counseled regarding future inability of pregnancy. She was successfully transplanted with no intraoperative complications. On post-op day 10, the patient developed hemoperitoneum that required exploratory laparotomy with the evacuation of hemoperitoneum and re-suturing of the vaginal cuff. She was discharged 18 days after transplant. Her follow-up to date has been uneventful. Our case demonstrates that heart and kidney transplantation with total abdominal hysterectomy is a safe and effective method in patients with a small BMI and enlarged leiomyoma that may prohibit implantation of the donor kidney.

Value of Renal Histology for Predicting Cardiorenal Outcomes in Patients Listed for Cardiac Transplantation

<h3>Purpose</h3> Cardiorenal syndrome is associated with excess morbidity and mortality, particularly in patients requiring durable mechanical circulatory support or cardiac transplantation. There are minimal data regarding predictors of renal outcomes in these patients and identifying those who may benefit from dual organ-transplantation. <h3>Methods</h3> We identified 18-patients with renal histology supporting the diagnosis of cardiorenal syndrome, from 665 consecutive patients listed for cardiac transplantation between 2010-2019. These were prospectively analysed for glomerular, tubular, interstitial and arteriolar changes as shown in table 1, tallied to give a severity score. The primary outcome, major adverse kidney events (MAKE), was a composite of death, need for renal replacement therapy (RRT), drop in estimated glomerular filtration rate (eGFR) >50% or stage V chronic kidney disease occurring prior to transplantation for the baseline cohort, and following transplantation for the transplanted cohort. The secondary outcomes included the individual components of MAKE at the two different time points. <h3>Results</h3> Mean age 52.3, 22% female. 5 patients did not survive to transplant (2 of these died on ventricular assist device). 1 patient had successful heart-kidney transplant. MAKE occurred in 7/17 of baseline; this was associated with a higher severity score, mean 5 vs. 2.3, p=0.03. There was no difference in age, creatinine or eGFR at biopsy. MAKE following transplantation occurred in 8/13 patients. There were no significant associations with this outcome. MAKE in the baseline cohort was primarily driven by need for RRT (mean 5.2 vs. 2.5, p=0.04). Contrary to limited previous literature, interstitial fibrosis did not predict any outcome, whilst presence of glomerular ischaemic changes, tubular atrophy and arteriosclerosis were associated with pre-transplant MAKE. <h3>Conclusion</h3> More severe renal histology prior cardiac transplantation are associated with adverse renal endpoints.

Ventricular Assist Devices Are a Viable Method to Support Patients to Multi-Organ Transplant

<h3>Purpose</h3> While ventricular assist devices (VADs) are known to improve survival in patients awaiting heart transplant, there are limited data describing the use of VADs in patients listed for multi-organ transplant or evaluating these patients' outcomes. <h3>Methods</h3> This retrospective cohort study identified patients from the UNOS database listed for heart transplant in combination with another solid organ from 2004-2019 and identified those with VADs at the time of listing and at transplant. Mortality was compared between patients with and without VAD using χ2 tests. Linear regression was used to assess changes in VAD use over time. <h3>Results</h3> Over 15 years, 22% (n=700) of heart-kidney (HK), 4% (n=20) of heart-liver (HLi), and 3% (n=25) of heart of heart-lung (HLu) patients were on VADs at listing. The median age of HK-VAD was 55y (IQR 47, 62), of HLi-VAD 52y (IQR 43, 55), and HLu-VAD 47y (IQR 33, 58). The majority of multi-organ VAD patients survived to transplant; 64% of HK-VAD, 70% of HLi-VAD, and 44% of HLu-VAD. Survival to transplant was higher in HK-VAD compared to HK-no VAD (72% vs 67%, p<0.05), while there was no difference between HLi-VAD and HLi-no VAD (80% vs 71%, p=0.38) or HLu-VAD and HLu-no VAD (52% vs 61%, p=0.37). One year post-transplant survival did not differ based on the presence of a VAD; HK-VAD (86.0%) vs HK-no VAD (88.9%) <i>p=0.11,</i> HLi-VAD (85.0%) vs HLi-no VAD (89.1%) <i>p=0.48</i>, and HLu-VAD (82.7%) vs HLu-no VAD (79.1%) <i>p=0.71.</i> <b>Figure</b> HK-VAD increased from 4 in 2004 to 94 in 2019 (<i>p for trend<0.001).</i> There were no changes over time in HLi-VAD or HLu-VAD <i>(p for both>0.05)</i>. <h3>Conclusion</h3> VADs are being used to support a substantial proportion of multi-organ patients, with an increase in patients waiting for heart-kidney transplant. The majority of these patients survive to transplant, and waitlist survival is higher in HK-VAD vs HK-no VAD. There is no difference in 1 year mortality when compared to patients without VADs, suggesting that this may be an effective support strategy for certain patients with multi-organ failure.

Pulmonary Amyloidoma: A Rare Entity Complicating a Post-Heart Transplant Course

<h3>Introduction</h3> Heart transplantation (HT) is a viable, life-prolonging therapy for patients with severe cardiac amyloidosis. Unique amyloid-related pathology may complicate their care. We present a case of a rare manifestation of amyloidosis complicating a post-HT course. <h3>Case Report</h3> A 51-year-old female with cardiac AL amyloidosis (treated with daratumumab, cyclophosphamide, bortezomib, and dexamethasone) and chronic kidney disease was transferred for advanced options evaluation. She presented in cardiogenic shock and PEA arrest requiring escalation to venoarterial-ECMO. Admission sputum culture was positive for <i>Enterobacter cloacae</i>. CT scan revealed right lower lobe consolidation with a 5cm cavitary lesion concerning for aspiration pneumonia. Broad spectrum antibiotics were initiated. Given near-complete resolution of her light chains on chemotherapy, Oncology agreed to proceed with transplantation. She was emergently listed as status 1 and underwent heart-kidney transplantation. One-week post-HT, she developed severe leukocytosis and abdominal discomfort but remained afebrile with only mild dyspnea. Abdominal CT incidentally noted an 11cm right lower lobe cavitary lung lesion. Dedicated CT chest raised concern for aspergilloma or other necrotizing pneumonia (Figure 1). Bronchoalveolar lavage had unremarkable fungal and viral studies but did reveal <i>Acinetobacter</i>. Antibiotics were appropriately adjusted. VATS was attempted but required conversion to thoracotomy with right lower lobectomy. Pathology revealed necroinflammatory findings and Congo-red stain-positive material both inside the cavity and extensively deposited within the cavity walls. These findings were consistent with pulmonary amyloidoma. <h3>Summary</h3> Though rare, pulmonary amyloidomas may be incidentally found as large cavitating lesions amongst patients with systemic amyloidosis. In the post-HT patient, they may serve as a nidus for infections and appear similar to necrotizing pneumonias, resulting in delays in diagnosis.

Heart-kidney listing is better than isolated heart listing for pediatric heart transplant candidates with significant renal insufficiency

ObjectivesSignificant renal insufficiency is identified as a risk factor for post-transplantation mortality in pediatric heart transplant recipients. This study evaluates simultaneous heart-kidney transplantation listing outcomes compared with heart transplant for pediatric candidates with significant renal insufficiency. MethodsThe United Network for Organ Sharing registry was searched for patients (January 1987 to March 2020) who were simultaneously listed for a heart-kidney transplantation or for heart transplant with significant renal insufficiency at the time of listing. Significant renal insufficiency was defined as needing dialysis or having a low estimated glomerular filtration rate (<40 mL/min). Survival was calculated using Kaplan–Meier analysis. ResultsA total of 427 cases were identified; 109 were listed for heart-kidney transplantation, and 318 were listed for heart transplant alone. Median time on the waitlist was 101 days (interquartile range, 28-238) for heart-kidney transplantation listings compared with 39 days (14-86) and 23.5 days (6-51) for heart transplant recipients with a low estimated glomerular filtration rate (P = .002) or on dialysis (P < .001), respectively. Of all heart-kidney transplantation listings, 66% (n = 71) received a transplant compared with 54% (n = 173) of heart transplantation with significant renal insufficiency (P = .005) with a mean survival of 14.6 years (12.7-16.4 years) for heart transplant without significant renal insufficiency at transplantation and 7.6 years (5.4-9.9 years) for heart transplant with significant renal insufficiency at transplantation. At 1 year after listing, 69% of heart-kidney transplantation listed recipients were alive, compared with 51% of heart transplant listed recipients (P = .029). Heart-kidney transplantation recipients had better 1-year post-transplantation survival (86%) than heart transplantation with significant renal insufficiency at transplant (66%) (P = .001). There was no significant difference in the 1- and 5-year survivals of those undergoing heart transplantation listed with significant renal insufficiency but no significant renal insufficiency at the time of transplant (89% and 78%) and heart-kidney transplantation recipients (86% and 81%; P = .436). ConclusionsPediatric candidates with significant renal insufficiency listed for heart-kidney transplantation have superior waitlist and post-transplantation outcomes compared with those listed for heart transplant alone. Patients with significant renal insufficiency should be listed for heart-kidney transplantation, however; if their renal function improves significantly, heart transplant alone appears judicious.

Center variations in patient selection for simultaneous heart-kidney transplantation.

Using the United Network for Organ Sharing (UNOS) Standard Transplant Analysis and Research (STAR) file, we examined practice trends and variations in patient selection for SHK at the center level between January 1, 2004 and March 31, 2019. Overall, SHK is becoming more common with most centers performing heart transplants also performing SHK. Among patients who underwent heart transplant who were receiving dialysis, the rate of SHK varied from 22% to 86% at the center level. Among patients not on dialysis, the median estimated glomerular filtration rate (eGFR) of patients receiving SHK varied between 19 and 59 mL/min/1.73 m2 . When adjusting for other factors, the odds of SHK varied 57-fold between the highest and lowest SHK performing centers. Variation in SHK at the center level suggests the need for national guidelines around the selection of patients for SHK.