Simultaneous Heart-kidney Transplantation Research Articles

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.

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.

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.

Renal Outcomes Following Simultaneous Heart-Kidney Transplant Compared with Heart Transplant Alone

<h3>Purpose</h3> Acute renal dysfunction and chronic kidney disease (CKD) are frequent complications of advanced heart failure. Post-heart transplant (HT) renal injury is common and is precipitated by intra-operative volume shifts and prolonged exposure to calcineurin inhibitors, impacting patient survival and quality of life. Our aim was to compare renal outcomes among simultaneous heart-kidney transplant (HKT) and HT recipients. <h3>Methods</h3> This is a single-center, retrospective cohort study of HKT and HT recipients between 01/2012 and 06/2020 who had pre-transplant CKD3 or worse. The primary endpoint was change in estimated glomerular filtration rate (eGFR) from baseline to 12 months post-transplant, using the Modification of Diet in Renal Disease (MDRD) equation. Secondary endpoints included biopsy-proven acute rejection (BPAR), patient survival, and cytomegalovirus (CMV) infection. <h3>Results</h3> 12 HKT and 51 HT recipients were included. Baseline demographics and clinical outcomes are included in Table 1. There were significant differences between groups in heart failure etiology, induction therapy, and baseline renal function. There were no differences in maintenance immunosuppression. The change in eGFR from baseline to 12 months post-transplant was +24.2 mL/min/1.73m² for the HKT group and -3 mL/min/1.73m² for the HT group (p=0.002). There was no difference in BPAR, CMV viremia or patient survival. <h3>Conclusion</h3> HKT appears to offer improved renal function for patients with baseline CKD3, with similar patient and graft outcomes compared to HT alone. HT alone does not appear to facilitate renal recovery in CKD3 patients.

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.

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.

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.

Abstract 12624: Optimal Patient Selection for Simultaneous Heart-Kidney Transplant: A Modified Cost-Effectiveness Analysis

Introduction: Increasing rates of simultaneous heart-kidney (SHK) transplant in the United States exacerbate the shortage of deceased donor kidneys (DDK) for kidney-only transplant (KT-only) candidates. Current allocation policy imposes no constraints on eligibility for SHK, and how best to do so remains unknown. Methods: We apply a decision analytic model to evaluate options for heart transplant (HT) candidates with comorbid kidney dysfunction, comparing 1) upfront SHK transplant (using a DDK) and 2) a “Safety Net” strategy, in which HT-only is performed first and DDK transplant is performed six months later if native kidneys do not recover. We measure “cost” in expected number of DDKs allocated to HT recipients, effectiveness in quality-adjusted life years (QALYs), and cost-effectiveness in terms of QALYs gained per kidney. We evaluate each outcome for patients of varying “reversibility”, defined as their probability of native kidney recovery after HT-only. We identify those for whom SHK (compared to Safety Net) is efficient from a societal standpoint, producing more QALYs per kidney than each additional kidney used for KT-only. Results: For a candidate with 50% reversibility, SHK (compared to Safety Net) produces 0.54 - 0.77 more QALYs (varying by age) at a cost of 0.58 more kidneys used. SHK is inefficient in this scenario, producing fewer QALYs per DDK (0.92 - 1.31) than an additional DDK allocated for KT-only (2.2 QALYs per kidney, derived from published estimates). SHK confers more benefit and is more cost-effective with decreasing age and reversibility, and is preferred to Safety Net for patients with reversibility under 24 - 38%. Conclusions: A Safety Net strategy produces greater societal benefit than SHK for HT candidates with concurrent kidney dysfunction, excepting only those with a low probability of native kidney recovery. This finding favors implementation of a Safety Net provision and should inform the use of objective criteria to limit SHK eligibility.

Abstract 13850: Proteomic Profiling to Identify Pre-Transplant Biomarkers of Renal Failure After Heart Transplantation

Introduction: In patients being considered for heart transplantation (HT), differentiating reversible kidney injury due to cardiorenal syndrome from irreversible renal disease that will necessitate simultaneous heart-kidney transplant (sHK) remains a clinical challenge. Hypothesis: We hypothesized that pre-transplant proteomic profiling could identify novel biomarkers of post-transplant renal failure in HT recipients and, in so doing, identify those patients who may derive benefit from sHK evaluation. Methods: We performed targeted proteomic profiling of serum samples collected within the 24 hours prior to HT or sHK. Using a multivariable logistic regression including relative protein expression, age, and sex with adjustment for batch effect, we identified those pre-transplant proteins that were differentially expressed between patients who received HT and sHK. Proteins that met FDR significance in this multivariable model were then tested for association with post-transplant RRT in isolated HT recipients. Patients with known intraoperative hemodynamic insult as a result of primary graft dysfunction were excluded from this analysis. This model was adjusted for age, sex, and MDRD eGFR. ROC analysis was performed to test the performance of the final protein model. Results: Pre-transplant expression of 97 proteins was noted to be significantly different at the FDR p &lt;0.05 level in sHK recipients (n=12) when compared to HT (n=231) recipients in the multivariable model. We identified 205 isolated HT recipients, among whom 33 required post-HT RRT. Among these 97 candidate We identified a total of 15 proteins, many of which have previously been associated with acute and chronic kidney injury, including KIM1, FABP4, PAR-1, VSIG2, and GDF-15, that were significantly associated with post-HT RRT after adjustment for age, sex, and pre-transplant eGFR. In ROC analysis in our cohort, the AUC of the 15-protein model was 0.82. Conclusions: Proteomic profiling of pre-transplant serum of HT recipients may identify HT candidates at high risk for post-transplant RRT. Individually and in aggregate, these 17 proteins warrant additional investigation as novel biomarkers that may identify patients who would benefit from sHK evaluation.

Multiorgan Transplant From a Donor With Solid Renal Masses: An Initial Experience and Clinical Considerations

Patients with early-stage renal cell carcinoma (RCC) are considered to be eligible donors. Although preliminary experience in using kidneys of specific pathologic types, mainly those with small renal masses (SRMs), have been established, multiorgan utilization of the same donor with SRMs is limited. One deceased donor whose left-side kidney was diagnosed with Fuhrman grade I RCC was included. The tumor mass in the kidney was removed through partial nephrectomy according to the gold standard. Then, 3 transplant surgeries were performed, in which 1 recipient accepted kidney transplant after tumor exeresis, 1 simultaneous heart-kidney (the contralateral one) transplant, and 1 liver transplant. Recipients were followed up according to our standard protocol for renal cancers. (All allografts were allocated in compliance with the Declaration of Helsinki and the Declaration of Istanbul.) RESULTS: After 32 months, no radiographic findings showed any morphologic changes of the lesion, and all patients were in good condition, with neither tumor recurrence nor allograft rejection or infection. No complaints such as pain, oliguria, dyspnea, nausea, or fatigue were recorded. To the best of knowledge, this initial work takes the lead in elaborating the organ utilization of multiorgan donors with SRMs. We hope the experience will provide support for cross discussion concerned with multiorgan transplant from tumor-affected donors in clinical practices, further expand the donor pool and address the donor shortage problem.

Simultaneous heart-kidney transplantation results in respectable long-term outcome but a high rate of early kidney graft loss in high-risk recipients \u2013 a European single center analysis

BackgroundIn spite of renal graft shortage and increasing waiting times for transplant candidates, simultaneous heart and kidney transplantation (HKTx) is an increasingly performed procedure established for patients with combined end-stage cardiac and renal failure. Although data on renal graft outcome in this setting is limited, reports on reduced graft survival in comparison to solitary kidney transplantation (KTx) have led to an ongoing discussion of adequate organ utilization.MethodsThis retrospective study was conducted to evaluate prognostic factors and outcomes of 27 patients undergoing HKTx in comparison to a matched cohort of 27 patients undergoing solitary KTx between September 1987 and October 2019 in one of Europe’s largest transplant centers.ResultsMedian follow-up was 100.33 (0.46–362.09) months. Despite lower five-year kidney graft survival (62.6% versus 92.1%; 111.73 versus 183.08 months; p = 0.189), graft function and patient survival (138.90 versus 192.71 months; p = 0.128) were not significantly inferior after HKTx in general. However, in case of prior cardiac surgery requiring sternotomy we observed significantly reduced early graft and patient survival (57.00 and 94.09 months, respectively) when compared to patients undergoing solitary KTx (183.08 and 192.71 months; p < 0.001, respectively) or HKTx without prior cardiac surgery (203.22 and 203.22 months; p = 0.016 and p = 0.019, respectively), most probably explained by the significantly increased rate of primary nonfunction (33.3%) and in-hospital mortality (25.0%).ConclusionsOur data demonstrates the increased rate of early kidney graft loss and thus significantly inferior graft survival in high-risk patients undergoing HKTx. Thus, we advocate for a “kidney-after-heart” program in such patients to ensure responsible and reasonable utilization of scarce resources in times of ongoing organ shortage crisis.

Evaluating the Role for Simultaneous Heart Kidney Transplantation in Patients with Continuous Flow Ventricular Assist Devices

<h3>Purpose</h3> Rates of simultaneous heart kidney (SHK) transplant are increasing annually. SHK confers survival benefit in recipients with pre-transplant renal failure, but its role in renal failure patients bridged to transplant with continuous-flow ventricular assist devices (VADs) is not well defined. This study evaluates the utility of SHK vs. heart transplant alone (HTA) in this population. <h3>Methods</h3> Retrospective review of the Organ Procurement and Transplantation Network database was performed for adult heart transplant recipients. Renal failure was defined as pre-transplant dialysis or glomerular filtration rate <30 mL/min. VAD patients with renal failure were divided by SHK vs. HTA. Primary outcome was patient survival. Secondary non-survival outcomes included post-operative dialysis dependence. Regression analyses assessed SHK as a predictor of post-transplant survival. <h3>Results</h3> There were 125 SHK patients and 276 HTA. Baseline characteristics were largely similar. Patient survival up to 5 years was the same between SHK and HTA (HR: 0.98, p=0.94). 45.6% of SHK patients required dialysis postoperatively compared to 40.9% in HTA (p=0.39). Renal allograft survival in the SHK population was 83.7% vs. 92.1% in kidney transplant alone (p<0.01). Multivariable regression did not identify SHK as independently predictive of post-transplant patient survival. <h3>Conclusion</h3> SHK confers no survival advantage over HTA in VAD-supported patients in renal failure. Judicious use of SHK in this population may improve renal allograft utilization without affecting outcomes for heart transplant recipients.

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

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.

Consensus conference on heart-kidney transplantation.

Simultaneous heart-kidney transplant (sHK) has enabled the successful transplantation of patients with end-stage heart disease and concomitant kidney disease, with non-inferior outcomes to heart transplant (HT) alone. The decision for sHK is challenged by difficulties in differentiating those patients with a significant component of reversible kidney injury due to cardiorenal syndrome who may recover kidney function after HT, from those with intrinsic advanced kidney disease who would benefit most from sHK. A consensus conference on sHK took place on June 1, 2019 in Boston, Massachusetts. The conference represented a collaborative effort by experts in cardiothoracic and kidney transplantation from centers across the United States to explore the development of guidelines for the interdisciplinary criteria for kidney transplantation in the sHK candidate, to evaluate the current allocation of kidneys to follow the heart for sHK, and to recommend standardized care for the management of sHK recipients. The conference served as a forum to unify criteria between the different specialties and to forge a pathway for patients who may need dual organ transplantation. Due to the continuing shortage of available donor organs, ethical problems related to multi-organ transplantation were also debated. The findings and consensus statements are presented.

Need for improvements in simultaneous heart-kidney allocation: The limitation of pretransplant glomerular filtration rate.

The incidence of simultaneous heart-kidney transplant (SHK) has increased markedly in the last 15years. There are no universally agreed upon indications for SHK vs. heart alone (HA) transplant, and center evaluation processes vary widely. We utilized Scientific Registry of Transplant Recipients data from 2003 to 2017 to quantify changes in the practice of SHK, examine the survival of SHK vs. HA, and identify patients with marginal benefit from SHK. We used Kaplan-Meier curves and Cox proportional hazards to assess differences in survival. The incidence of SHK increased more than fourfold between 2003 and 2017 from 1.6% to 6.6% of total hearts transplanted, while the proportion of dialysis-dependent patients undergoing SHK has remained constant. SHK was associated with increased survival in dialysis-dependent patients (Median Survival SHK: 12.6 vs. HA: 7.1years p<.0001) but not with nondialysis-dependent patients (Median Survival SHK: 12.5 vs. HA 12.3, p=.24). The marginal effect of SHK in decreasing the hazard of death diminished with increasing eGFR. Delayed graft function occurred in 26% of SHK recipients. Posttransplant chronic dialysis was similar for both operations (6.4% of HA and 6.0% of SHK). Further study is needed to define patients who benefit from SHK.

And Then There Were Three: Effects of Pretransplant Dialysis on Multiorgan Transplantation.

Background.Simultaneous liver-kidney (SLK) and simultaneous heart-kidney (SHK) transplantation currently utilize 6% of deceased donor kidneys in the United States. To what extent residual kidney function accounts for apparent kidney allograft survival is unknown.Methods.We examined all adult SLK and SHK transplants in the United States during 1995–2014. We considered the duration of dialysis preceding SLK or SHK (≥90 d, 1–89 d, or none) as a proxy of residual kidney function. We used multinomial logistic regression to estimate the difference in the adjusted likelihood of 6- and 12-month apparent kidney allograft failure between the no dialysis versus ≥90 days dialysis groups.Results.Of 4875 SLK and 848 SHK recipients, 1775 (36%) SLK and 449 (53%) SHK recipients received no dialysis before transplant. The likelihood of apparent kidney allograft failure was 1%–3% lower at 12 months in SLK and SHK recipients who did not require pretransplant dialysis relative to recipients who required ≥90 days of pretransplant dialysis. Among 3978 SLK recipients who survived to 1 year, no pretransplant dialysis was associated with a lower risk of apparent kidney allograft failure over a median follow-up of 5.7 years (adjusted hazard ratio 0.73 [0.55–0.96]).Conclusions.Patients with residual kidney function at the time of multiorgan transplantation are less likely to have apparent failure of the kidney allograft. Whether residual kidney function facilitates function of the allograft or whether some SLK and SHK recipients have 3 functional kidneys is unknown. Sustained kidney function after SLK and SHK transplants does not necessarily indicate successful MOT.

Abstract 14565: Simultaneous Heart-Kidney Transplant - Does Hospital Experience With Heart Transplant or Kidney Transplant Have a Greater Impact on Patient Outcomes?

Objective: High institutional transplant volume is known to be associated with improved outcomes in heart transplant and kidney transplant. However, little is known regarding the impact of institutional experience on outcomes in simultaneous heart-kidney transplant (SHKT). The aim of this study was to assess trends and outcomes of SHKT nationally, as well as the impact of institutional heart and kidney transplant volume on mortality for SHKT patients. Methods: All adult patients (age ≥18) who underwent SHKT between 2005 - 2019 were identified using the United Network for Organ Sharing (UNOS) database. Annual institutional volume in heart transplant and kidney transplant were determined. Univariate and multivariable analyses were conducted to assess the impact of patient demographics, comorbidities, and institutional transplant volumes on 1-year mortality. Results: There were 1564 SHKT identified in the sample, increasing fourfold from 54 in 2005 to 221 in 2019 (p &lt; .001). Median annual institutional heart transplant volume among centers performing SHKT was 35 (IQR 24 - 56); median annual kidney transplant volume was 166 (IQR 89 - 224). One-year mortality was 11.8%. In multivariable analysis, increasing annual institutional heart transplant volume was associated with reduced 1-year-month mortality. Contrarily, annual institutional kidney transplant volume was not associated with mortality. Increasing body mass index, dialysis, requirement for extracorporeal membrane oxygenator support (ECMO) at time of transplant, ischemic times, and total bilirubin levels were independently associated with increased 1-year mortality (Table 1). Conclusion: Increased institutional heart transplant volume is associated with reduced mortality in SHKT. A similar association was not identified between institutional kidney transplant volume and mortality. Thus, emphasis should be placed on high-volume heart transplant centers to manage SHKT patients.

Striking a Balance in Simultaneous Heart Kidney Transplant: Optimizing Outcomes for All Wait-Listed Patients.

Striking a Balance in Simultaneous Heart Kidney Transplant: Optimizing Outcomes for All Wait-Listed Patients.

P1707SIMULTANEOUS HEART-KIDNEY TRANSPLANT: OUR 10 YEARS' EXPERIENCE

Abstract Background and Aims The number of patients listed and receiving simultaneous heart-kidney transplantation (SHKT) has significantly increased in the last decade. This is likely due to the increased knowledge that SHKT is associated with a significant survival benefit in patients with heart failure with chronic kidney disease (CKD), compared to isolated heart transplant and sequential heart and kidney transplantation. Recent analysis of large data bases has shown a survival benefit in SHKT even in older patients and beyond dialysis dependent patients. However, this benefit is only proven for irreversible CKD which is often difficult to prove in patients with severe heart failure. Our center has the largest experience in SHKT in Portugal, and our aim is to report our experience with a total of 8 recipients and their outcomes after 10 years of follow up. Method We performed a retrospective analysis of all the patients submitted to SHKT in Coimbra University Hospital Center from 1 January 2009 to 31 December 2019. Data was collected using the clinical and laboratorial registries from our database. Follow up at December 2019 varied between 6 months to 10 years (median 5,5 years). Results A total of 8 patients received SHKT between 1 January 2009 and 31 December 2019. Only one patient was female and the mean age at transplant was 58.88 ± 9.7 years. The etiology of heart failure was dilated cardiomyopathy (N=4, 50%), severe valvular disease (N=2, 25%), ischemic cardiomyopathy (N=1, 12,5%) and one patient had familiar amyloidosis (N=1, 12,5%). Regarding CKD, the majority of the patients had type 2 cardiorenal syndrome (N=5, 62,5%), one patient had calcineurin toxicity due to previous liver transplantation, one patient had autosomal dominant polycystic disease, and in one patient the etiology remained unknown. Half of the patients were on chronic hemodialysis program for more than 3 months, and the remaining were preemptive. Regarding post-transplant results, average hospitalization was 19 days. Seven patients (87,5%) had immediate cardiac graft function (mean LVEF 70 ± 5.8% and mean PSAP 22.25 ± 5.6 mmHg). One patient had acute cardiac and subsequent renal graft dysfunction and died during hospitalization. Regarding renal graft outcomes, besides the patient that died, another patient had primary renal graft dysfunction due to renal artery thrombosis and one patient presented late graft function. The remaining five patients had immediate graft function and presented normal kidney graft function at follow up. Regarding complications, neoplasia was reported in two patients (one with sarcoma and the other with prostatic cancer), and there were twenty-five episodes of infection, present in all patients. Mortality at follow up was 37% (N=3). One of these, described above, died during hospitalization twenty-two days after transplant, and the other two died 4 and 5 years later due to a cardiovascular event and sarcoma, respectively. At follow up in 2019 five patients present stable kidney graft, good cardiac function and no recent complications. Conclusion In selected patients with co-existing heart and kidney failure, combined heart and kidney transplantation might be the best approach and appears to be associated with better graft and patient survival. Despite having a small number of cases, our center has the biggest experience in SHKT in Portugal and our results are very satisfying. A multidisciplinary approach between Nephrology, Cardiology and Cardiothoracic Surgery is fundamental and in the next decades it is expected an increase in SHKT number.