Simultaneous Heart-kidney Transplantation Research Articles

To kidney or not to kidney: Applying lessons learned from the simultaneous liver-kidney transplant policy to simultaneous heart-kidney transplantation.

As the medical community is increasingly offering transplantation to patients with increasing comorbidity burdens, the number of simultaneous heart-kidney (SHK) transplants is rising in the United States. How to determine eligibility for SHK transplant versus heart transplant alone is unknown. In this review, we situate this problem in the broader picture of organ shortage. We critically appraise available literature on outcomes in SHK versus heart transplant alone. We posit staged kidney-after-heart transplantation as a plausible alternative to SHK transplantation and review the pros and cons. Drawing lessons from the field of simultaneous liver-kidney transplant, we argue for an analogous policy for SHK transplant with standardized minimal eligibility criteria and a modified Safety Net provision. The new policy will serve as a starting point for comparing simultaneous versus staged approaches and refining the medical eligibility criteria for SHK.

A Half-Century 3000 Cases of Kidney Transplant Experiences in a Single Hospital: the Longest Registry in Korea

BackgroundThis study aims to analyze the entire registry of kidney transplant over the past 50 years and understand the clinical significance. MethodsFrom the data on 3012 kidney transplants performed at our center between March 1969 and September 2018, we analyzed retrospectively clinical variables. ResultsUntil September 2018, there have been 3012 kidney transplants performed. The number of primary transplant cases was 2755 (91.8%), which included 16 cases of simultaneous liver-kidney transplant, and the number of repeated transplants was 245 (225 second transplants [7.5%] and 20 third transplants [0.7%]). There were 3 simultaneous pancreas kidney transplants, and 3 small bowel–kidney transplants, one of them being transplanted at the same time. There was a single simultaneous heart-kidney transplant. The viability rates of a transplanted kidney for 1, 5, 10, 20, and 30 years were 97%, 92%, 90%, 51%, and 36%, respectively, and the patient survival rates were 96%, 89%, 82%, 64%, and 52%, respectively. Five-year graft survival rate of the first 1000 cases was 64.6%; those of the 1001st to 2000th cases and 2001st to 3012th cases were 87.6% and 88.8%, respectively. There are statistically significant differences among the groups. ConclusionThis study has identified the appropriate selection or control of immunotherapy, based on the risk level of kidney transplant recipient, is needed to minimize chronic rejection, which is the key cause of transplanted kidney failure.

Pre-emptive pangenotypic direct acting antiviral therapy in donor HCV-positive to recipient HCV-negative heart transplantation: an open-label study

Low donor heart availability underscores the need to identify all potentially transplantable organs. We sought to determine whether pre-emptive administration of pangenotypic direct-acting antiviral therapy can safely prevent the development of chronic hepatitis C virus (HCV) infection in uninfected recipients of HCV-infected donor hearts. Patients were recruited for this an open-label, single-centre, proof-of-concept study from Nov 1, 2017, to Nov 30, 2018. Following enrolment, the recipient's status on the heart transplantation waiting list was updated to reflect a willingness to accept either an HCV-positive or HCV-negative heart donor. Patients who underwent transplantation with a viraemic donor heart, as determined by nucleic acid testing (NAT), received pre-emptive oral glecaprevir-pibrentasvir before transport to the operating room followed by an 8-week course of glecaprevir-pibrentasvir after transplantation. Patients receiving HCV antibody-positive donor hearts without detectable circulating HCV RNA were followed using a reactive approach and started glecaprevir-pibrentasvir only if they developed viraemia. The primary outcome was achievement of sustained virological response 12 weeks after completion of glecaprevir-pibrentasvir therapy (SVR12). Patients were followed from study enrolment to 1 year after transplantation. This is an interim analysis, initiated after all enrolled patients reached the primary outcome. Results reflect data from Nov 1, 2017, to May 30, 2019. This trial is registered with ClinicalTrials.gov, number NCT03208244. 55 patients were assessed for eligibility and 52 consented to enrolment. 25 patients underwent heart transplantation with HCV-positive donor hearts (20 NAT-positive, five NAT-negative), three of whom underwent simultaneous heart-kidney transplantation. All 20 recipients of NAT-positive hearts tolerated glecaprevir-pibrentasvir and showed rapid viral suppression (median time to clearance 3·5 days, IQR 0·0-8·3), with the subsequent achievement of SVR12 by all 20. The five recipients of NAT-negative grafts did not become viraemic. Median pre-transplant waiting time for patients following enrolment in the HCV protocol was 20 days (IQR 8-57). Patient and allograft survival were 100% at a median follow-up of 10·7 months (range 6·5-18·0). Pre-emptive administration of glecaprevir-pibrentasvir therapy results in expedited organ transplantation, rapid HCV suppression, prevention of chronic HCV infection, and excellent early allograft function in patients receiving HCV-infected donor hearts. Long-term outcomes are not yet known. American Association for the Study of Liver Diseases, National Institutes of Health, and the Massachusetts General Hospital.

Renal outcome after simultaneous heart and kidney transplantation.

Simultaneous heart-kidney transplant (HKTx) is a valid treatment for patients with coexisting heart and renal failure. The aim of this study was to assess renal outcome in HKTx and to identify predictive factors for renal loss. A retrospective study was conducted among 73 HKTx recipients: Donors' and recipients' records were reviewed to evaluate patients' and renal transplants' survival and their prognostic factors. The mean follow-up was 5.36years. Renal primary non-function occurred in 2.7%, and complications Clavien IIIb or higher were observed in 67.1% including 16 (22%) postoperative deaths. Five-year overall survival and renal survival were 74.5% and 69.4%. Among survivors, seven returned to dialysis during follow-up. The postoperative use of ECMO (HR=6.04, P=0.006), dialysis (HR=1.04/day, P=0.022), and occurrence of complications (HR=31.79, P=0.022) were independent predictors of postoperative mortality but not the history of previous HTx or KTx nor renal function prior to transplantation. History of KTx (HR=2.52, P=0.026) and increased delay between the two transplantations (HR=1.25/hour, P=0.018) were associated with renal transplant failure. HKTx provides good renal transplant survival and function, among survivors. Early mortality rate of 22% underlines the need to identify perioperative risk factors that would lead to more judicious and responsible allocation of a scarce resource.

Simultaneous Pediatric Heart-Kidney Transplant Outcomes in the US: A 25 Year National Cohort Study

Purpose Pediatric simultaneous heart-kidney transplantation (sHKTx) remains uncommon in the US and criteria for sHKTx are unclear. We examined outcomes of pediatric sHKTx compared to pediatric heart transplant alone (PHTx). Our objective was to identify a threshold estimated glomerular filtration rate (eGFR) that justified pediatric sHKTx. Methods Data from the Scientific Registry for Transplant Recipients heart and kidney databases were used to identify 9245 PHTx, and 63 pediatric sHKTx between 1992 and 2017 (age ≤21 years). Outcomes included patient survival, acute heart and kidney rejection . Results The median age for pediatric sHKTx was 16 (IQR: 12, 19.5) years, and included 31 males (31/63=49%). Over half of sHKTx (36/63 = 57%) were performed in cases where pre-transplant dialysis was initiated. The risk of death in sHKTx recipients was significantly lower than PHTx alone, amongst patients who required pre-transplant dialysis (sHKTx vs. PHTx: HR 0.4, 95% CI [0.2, 0.9], p=0.01) (Figure 1a). There was no improvement in survival between sHKTx and PHTx in those without pre-transplant dialysis (HR 0.5, 95% CI [0.16, 1.51], p=0.2) (Figure 1b). When stratified by eGFR, PHTx alone recipients had worse survival than sHKTx in the group with eGFR ≤35 ml/min/1.73m2 (n = 37, p=0.04). The 1, 3, and 5 year actuarial survival rates in pediatric sHKTx recipients was 87%, 84%, and 83% respectively, and was similar to isolated PHTx (p=0.5). One-year rates of treated heart (11%) and kidney (7.9%) rejection were similar in sHKTx compared to PHTx alone (p =0.7) and pediatric kidney transplant alone ( p=0.5) respectively. Conclusion Pediatric sHKTx should be considered in heart transplant candidates with kidney failure requiring dialysis, whereas the usefulness of sHKTx in cases of kidney failure not requiring dialysis warrants further study. Pediatric sHKTx may be considered for eGFR ≤35 ml/min/1.73m2.

Preemptive Pan-Genotypic Direct Acting Antiviral Therapy in Donor HCV-Positive to Recipient HCV-Negative Cardiac Transplantation Produces Viral Clearance and is Associated with Favorable Outcomes

Summary of Objectives Limited donor heart availability highlights the importance of identifying all potentially transplantable organs. We sought to determine if preemptive administration of pan-genotypic direct-acting antiviral therapy could prevent the development of chronic hepatitis C virus (HCV) infection while expediting access to donor hearts. Methods We developed a novel non-industry funded protocol supporting HCV donor-positive to recipient-negative heart transplantation (HT). In this single center proof-of-concept trial, patients receiving a NAT-positive HT received preemptive oral glecaprevir-pibrentasvir (GP) on call to the operating room followed by an 8-week course of GP post-transplant. Patient's receiving HCV-antibody positive donors without detectable circulating HCV by nucleic acid testing (NAT) were followed with a reactive approach, and started on GP therapy only if they developed viremia. HCV RNA monitoring was performed to ensure viral suppression and sustained virologic response (SVR). Endpoints Between Nov 2017 and Oct 2018, 23 patients underwent HT with HCV-positive donor hearts, 3 of whom underwent simultaneous heart-kidney transplantation. Median pre-transplant waiting time for patients following enrollment in the HCV protocol (20, IQR 5-59 days) has been lower than that for the 99 patients who have undergone HT outside of the HCV protocol in the last 3 years (113, IQR 40-366 days, p=0.0001). Average peak recipient HCV viral loads were

Clinical Outcome after Simultaneous Heart and Kidney Transplantation

Background Simultaneous heart kidney transplantation (SHKT) is an acceptable treatment for patients with end stage heart disease associated with severely impaired kidney function. Methods We reviewed medical record of our registered patients from September 1990 and July 2017. 5 patients underwent SHKT in our center. All the patients were treated with basiliximab induction and maintained with tacrolimus, steroid and mycophenolate. Results 4 patients were male (80.0%). Mean age at transplant was 49.6 ± 12.4 years (range, 33~66). All patients were on dialysis at transplant. The indications for heart transplantation included dilated cardiomyopathy (n=4), ischemic cardiomyopathy (n=1). Surgical procedures were uneventful in all patients. Median follow-up after transplantation was 53 months (range, 5~152). 2 patients had delayed graft function (DGF) after transplant (defined as the need for dialysis during the first 7 days after transplant). 1 patient had coronary artery disease, but no cardiac allograft rejection was noted. Acute cellular kidney rejection occurred in 2 patients. There was no cardiac or kidney graft failure during follow-up. Conclusion SHKT is a good choice for long-term survival in patients with end stage heart and kidney failure.

Use of durable mechanical circulatory support on outcomes of heart-kidney transplantation.

Previous studies have demonstrated that preheart transplant mechanical circulatory support (MCS) can lead to a small but significant increase in mortality. However, data on outcomes of patients with MCS who require simultaneous heart-kidney transplant are limited. A retrospective review of simultaneous heart-kidney transplantations (HKTxs) performed at a single institution over a 5-year period was performed. Patients were divided based on the preoperative use of durable MCS. Renal graft-related end points were evaluated, including glomerular filtration rate following transplantation, prevalence of delayed renal graft function and freedom from antibody and cellular-mediated graft rejection. Patient-specific outcomes, including survival and frequency of non-fatal major adverse cardiac events at 1 year, were additionally assessed. During the study period, 50 HKTxs were performed, 14 of which had preoperative MCS. HKTx patients with and without MCS implantations had a similar prevalence of delayed graft function (57.1% vs 50.0%; P = 0.757). A numerical trend was observed towards a reduced glomerular filtration rate 1-month post-transplant in patients without an MCS device (81.2 ± 32.8 vs 64.4 ± 27.5; P = 0.072), but no significant difference was observed at 6 and 12 months. No significant difference was observed on the need for post-transplant renal replacement therapy, non-fatal major adverse cardiac events, freedom from graft rejection and overall survival at 1 year. The use of preoperative MCS in patients undergoing combined HKTx was not found to affect renal graft function post-transplantation and does not seem to be associated with increase in morbidity or mortality.

Induction regimen and survival in simultaneous heart-kidney transplant recipients

Induction therapy in simultaneous heart-kidney transplantation (SHKT) is not well studied in the setting of contemporary maintenance immunosuppression consisting of tacrolimus (TAC), mycophenolic acid (MPA), and prednisone (PRED). We analyzed the Organ Procurement and Transplant Network registry from January 1, 2000, to March 3, 2015, for recipients of SHKT (N = 623) maintained on TAC/MPA/PRED at hospital discharge. The study cohort was further stratified into 3 groups by induction choice: induction (n = 232), rabbit anti-thymoglobulin (r-ATG; n = 204), and interleukin-2 receptor-α (n = 187) antagonists. Survival rates were estimated using the Kaplan-Meier estimator. Multivariable inverse probability weighted Cox proportional hazard regression models were used to assess hazard ratios associated with post-transplant mortality as the primary outcome. The study cohort was censored on March 4, 2016, to allow at least 1-year of follow-up. During the study period, the number of SHKTs increased nearly 5-fold. The Kaplan-Meier survival curve showed superior outcomes with r-ATG compared with no induction or interleukin-2 receptor-α induction. Compared with the no-induction group, an inverse probability weighted Cox proportional hazard model showed no independent association of induction therapy with the primary outcome. In sub-group analysis, r-ATG appeared to lower mortality in sensitized patients with panel reactive antibody of 10% or higher (hazard ratio, 0.19; 95% confidence interval, 0.05-0.71). r-ATG may provide a survival benefit in SHKT, especially in sensitized patients maintained on TAC/MPA/PRED at hospital discharge.

(320) - Trends in Simultaneous Heart-Kidney Transplantation: An Analysis of UNOS/OPTN Data from 2000 to 2015

(320) - Trends in Simultaneous Heart-Kidney Transplantation: An Analysis of UNOS/OPTN Data from 2000 to 2015

(928) - Survival with Induction Therapy for Simultaneous Heart-Kidney Transplant Recipients on Tacrolimus/Mycophenolate

(928) - Survival with Induction Therapy for Simultaneous Heart-Kidney Transplant Recipients on Tacrolimus/Mycophenolate

Favorable Outcomes of LVAD as Bridge to Simultaneous Heart-Kidney Transplantation


 
 
 Background
 Chronic kidney disease (CKD) is an established risk factor for incident cardiovascular disease and progression of heart failure disease state, and is associated with decreased survival after left ventricular assist device (LVAD) therapy or heart transplantation (HT). Combined heart-kidney transplantation (HKT) compared with isolated HT recently has been shown to have survival advantage among patients whose estimated glomerular filtration rate is less than 37 ml/min/m2. Data on LVAD to HKT are limited.
 Methods
 At our center, a total of 803 patients have received HT, 594 patients LVAD therapy, and 23 patients HKT from single donors; of those 23, 15 were without the use of LVAD and 8 were after support with LVAD.
 Results
 Kaplan-Meier survival analysis found LVAD-supported patients with CKD stages 4 or 5 had statistically worse 24-month survival after HT as compared with those with CKD stage 1, 2, and 3 (58% versus 88%, p=0.01). Patients who received combined HKT after LVAD had comparable 24-month survival with those who received HKT without LVAD (87% and 85%, p=NS); both groups had numerically better survival compared with those who had CKD (stage 4-5) with isolated HT (58%).
 
 
 
 Conclusions
 Patients supported with LVAD who demonstrate advanced CKD (stage 4-5) have worse 24-month post-HT survival compared with those with less advanced CKD (stage 1-3). Combined HKT after LVAD support is feasible and confers comparable 24-month survival compared with HKT without prior LVAD therapy. Our study supports combined HKT for select LVAD patients with advanced CKD (stage 4-5).
 
 
 
 
 

351 - Contemporary Era of Simultaneous Heart Kidney Transplantation: A Single Center Experience

Background: Despite increasingly sicker patients and changes in perioperative techniques, the contemporary era of simultaneous heart kidney transplantation (HKT) has not been well described. We report intraoperative characteristics, postoperative medical management and causes of death in patients undergoing HKT at a single center. Methods: Patients undergoing HKT between 2009 and 2015 at Temple University Hospital were identified through review of the electronic medical record and the UNOS registry. Demographics, cause of cardiomyopathy and renal failure, comorbidities and need for preoperative dialysis, mechanical circulatory support (MCS) and inotropes were identified. Cardiac allograft ischemic time and type of immunosuppression therapy were collected. Incidence of treated rejection and death was measured. Results: Six patients underwent HKT, with average age of 61.7 ± 9.1 years. Four were male. Causes of cardiomyopathy included transplant vasculopathy (n = 3), ischemic cardiomyopathy (n = 2) and non ischemic cardiomyopathy (n = 1). Overlapping causes of renal failure were identified, including the cardiorenal syndrome (n = 3), diabetic nephropathy (n = 1), drug toxicity (one calcineurin, one vancomycin), and acute tubular necrosis (n = 2). Prior to HKT, two patients required inotropes, two MCS and two dialysis. All patients received induction immunosuppression (two basiliximab and four alemtuzumab). Average cardiac allograft ischemic and pump times were 157.6 ± 35.5 min and 185.6 ± 58.5 min respectively. One patient was treated for cardiac rejection and one for kidney rejection within the first year. One was initiated on dialysis more than 5 years after HKT. Two patients died within the first year due to sepsis and multiorgan failure. The remaining four were alive at the last clinic visit, median 801 days after HKT. Conclusions: At our center, most patients undergoing HKT required advanced hemodynamic support, with either MCS or inotropes. Causes of cardiomyopathy and renal failure were varied. One year mortality remains high in the first year after transplant and appears related to infectious complications in this sick population. Further research is required to delineate the ideal perioperative strategy regarding immunosuppression and Intraoperative management.

COMBINED HEART-KIDNEY TRANSPLANTATION

Combined heart-kidney transplantation may be performed in carefully selected patients with end-stage heart disease and renal failure. There are two types of combined transplantation of heart and kidney: 1) simultaneous heart-kidney transplantation (SHKT) from the same donor; 2) staged transplantation of heart and kidneys from two genetically different donors. The ISHLT registry in 2014 reported an increase in the number of SHKT over the years: from 22 in 1994 to 97 in 2012. World experience demonstrated excellent results of SHKT. Recipients of SHKT had superior survival, lower rates of acute cardiac and renal rejection compared to heart recipients. This article discusses the indications for simultaneous or staged heart-kidney transplantation in patients with dialysis-independent or dialysis-dependent renal failure, results and posttransplant survival of SHKT recipients. The author describes his own experience of 2 staged combined heart-kidney transplantations.

Outcomes of simultaneous heart-kidney and lung-kidney transplantations: the Australian and New Zealand experience.

Heart or lung transplantation alone in individuals with significant pre-existing renal impairment results in high mortality and morbidity. Simultaneous heart-kidney (SHK) or simultaneous lung-kidney (SLK) transplantation may be considered in patients with dual organ failure not suitable for single organ transplantation. We aimed to outline the Australian and New Zealand experience of SHK and SLK transplantations, focussing on patient characteristics and survival. We analysed all SHK and SLK transplants performed in four centres across Australia and New Zealand between 1990 and 2014. Over the study period, 35 SHK and 3 SLK transplants were performed across 4 transplant centres. Mean age at transplantation for SHK transplants was 45 years, and for SLK transplant was 27 years. The most common aetiology of renal failure was glomerulonephritis. Most SHK transplant patients (77%) required renal replacement therapy prior to transplantation, with only one of the three patients undergoing SLK transplant, dialysis dependent. One-year survival for the cohort was 79%, which is lower than reported for single organ transplantation. However, 5- and 10-year survivals of 76% and 68%, respectively, were comparable. Isolated renal graft loss was seen in five patients, with only one patient successfully re-transplanted and the rest commencing dialysis. The Australian and New Zealand experience of SHK and SLK includes 38 patients with a high 1-year mortality, but excellent 5- and 10-year survivals. Based on this, it seems reasonable to continue to offer combined organ transplantation to select patients with dual organ failure.

Mechanical circulatory support and simultaneous heart-kidney transplantation: An outcome analysis

Single-donor simultaneous heart-kidney transplantation (SHKT) can significantly improve the survival of those with advanced heart failure and advanced renal insufficiency. Data on pre-transplant use of mechanical circulatory support (MCS) devices and outcomes after SHKT are limited and conflicting. Using the United Network for Organ Sharing registry data, we evaluated 749 adults undergoing SHKT after January 1, 2000. Patients were categorized into the following groups according to their type of pre-transplant MCS device: none (n = 568), pulsatile-flow left (n = 28), continuous-flow left (n = 68), temporary (n = 12), biventricular (n = 19), total artificial heart (n = 20), and unknown (n = 34). Regression analyses were performed to assess the association between types of MCS and post-transplant outcomes. Pre-transplant MCS was not associated with in-hospital mortality (univariate odds ratio [OR], 1.57; 95% confidence interval [CI], 0.82-2.97; p = 0.170) or post-discharge mortality (univariate hazard ratio, 0.92; 95% CI, 0.58-1.47; p = 0.733). Patients supported with pre-transplant temporary MCS devices were more likely to suffer from serious complications (composite of cardiac or non-cardiac surgeries, stroke, any drug-treated infection, and permanent pacemaker; multivariable adjusted OR, 10.0; 95% CI, 2.77-36.0; p < 0.001) after SHKT. Pre-transplant MCS did not increase risk of post-transplant dialysis (multivariable adjusted OR, 1.19; 95% CI, 0.81-1.75; p = 0.375) or cardiac rejection (univariate OR, 0.71; 95% CI, 0.34-1.51; p = 0.382), and did not prolong the length of hospital stay (≥ 4 weeks; multivariable adjusted OR, 1.05; 95% CI, 0.69-1.59; p = 0.832). Post-transplant dialysis status was a major determinant of adverse in-hospital (multivariable adjusted OR, 6.17; 95% CI, 3.14-12.1; p < 0.001) and post-discharge (multivariable adjusted hazard ratio, 1.56; 95% CI, 1.02-2.39; p = 0.041) mortality after SHKT. In the current transplant era, survival after SHKT in patients with pre-transplant MCS was equivalent to that of conventional SHKT. Pre-transplant dialysis, and not MCS status, determined the need for post-SHKT dialysis, which in-turn was a major risk factor for in-hospital and long-term mortality.

The Survival Benefit of Simultaneous Heart-Kidney Transplantation Extends Beyond Dialysis-Dependent Patients

This study evaluated the effect of simultaneous heart-kidney transplantation (SHK) on survival stratified by preoperative renal function. Patients undergoing SHK or heart transplant alone (HTA) between 1992 and 2012 were identified in the United Network for Organ Sharing database. Patients were primarily stratified by the need for dialysis before transplantation. Nondialysis patients were further stratified by preoperative glomerular filtration rate (GFR) and likelihood of postoperative development of renal failure requiring new-onset dialysis (high risk defined as ≥75th percentile according to a previously derived and validated risk score). The primary outcome was 5-year survival, evaluated by Kaplan-Meier and multivariable logistic regression analyses. Included were 665 (2%) SHK and 38,488 (98%) HTA patients. SHK improved 5-year survival in dialysis-dependent patients (69% vs 54%, p < 0.001), with no survival difference in patients with a preoperative GFR ≥60 mL/min/1.73 m(2) (84% SHK vs 77% HTA, p= 0.34). In patients with a preoperative GFR of less than 60 mL/min/1.73 m(2), being high risk for postoperative new-onset dialysis discriminated those patients who would benefit from SHK (5-year survival low risk: 82% SHK vs 76% HTA, p=0.27; 5-year survival high risk: 86% SHK vs 67% HTA, p< 0.001). Risk-adjusted analysis confirmed these findings. SHK comprised only 2.6% of heart transplants in patients with a preoperative GFR of less than 60 mL/min/1.73 m(2) who were at high risk for postoperative renal failure. SHK improves long-term survival not only in dialysis-dependent patients but also in patients with reduced preoperative GFR who are at high risk for postoperative new-onset dialysis. Expansion of SHK into this subset warrants further study, especially considering its low current utilization.

(138) - Favorable Outcomes of Left Ventricular Assist Device as Bridge to Simultaneous Heart Kidney Transplantation

(138) - Favorable Outcomes of Left Ventricular Assist Device as Bridge to Simultaneous Heart Kidney Transplantation

Combined heart-kidney transplant improves post-transplant survival compared with isolated heart transplant in recipients with reduced glomerular filtration rate: Analysis of 593 combined heart-kidney transplants from the United Network Organ Sharing Database

Criteria for simultaneous heart-kidney transplant (HKTx) recipients are unclear. We characterized the evolution of combined HKTx in the United States over time compared with isolated heart transplantation (HTx) and determined factors maximizing post-transplant survival. We focused on whether a threshold estimated glomerular filtration rate (eGFR) could be identified that justified combined transplantation. A supplemented United Network Organ Sharing Dataset identified HTx and HKTx recipients from 2000 to 2010. eGFR was calculated for HTx and recipients were grouped into eGFR quintiles. Time-related mortality was compared among recipients, with multivariable factors sought using Cox proportional hazard regression models. We identified 26,183 HTx recipients, of whom 593 were HKTx recipients. HTx increased modestly over time (3.6%), whereas prevalence of HKTx increased dramatically (147%). Risk-unadjusted survival was similar among HTx recipients (8.4 ± 0.04 years) and HKTx recipients (7.7 ± 0.2 years) (P=.76). IsolatedHTx recipients in the lowest eGFR quintile had decreased survival (P<.001), but those in the third eGFR quintile had superior survival, suggesting a benefit in this subgroup. HTx recipients in the lowest eGFR quintile (eGFR less than mean 37 mL/minute) had worse survival than combined HKTx recipients (7.1 ± 0.07 vs 7.7 ± 0.2; P<.001). Multivariable factors for increased mortality among HTx recipients included lower eGFR, higher recent panel reactive antibody score, older age, African American race, diabetes, longer ischemic time, and certain diagnoses. Performance of combined HKTx is increasing out of proportion to isolated HTx. eGFR is an important determinant of improved HTx survival. Combined HKTx recovers post-transplant survival in patients with eGFR <37 mL/minute and can be recommended in this subgroup.

Outcomes of Simultaneous Heart–Kidney Transplant in the US: A Retrospective Analysis Using OPTN/UNOS Data

Simultaneous heart-kidney transplantation (SHK) remains uncommon in the US. We examined outcomes of SHK compared to heart transplant alone (HTA) and deceased donor kidney transplant (DDKT). Data from OPTN/UNOS heart and kidney data bases were used to identify 16,710 HTA, 263 SHK transplants and 68,833 DDK transplants between 1998 and 2007. Outcomes included patient survival (PS), acute cardiac and renal rejection and renal graft survival (rGS). The adjusted risk of death was 44% lower with SHK compared to HTA. Over half of SHK were performed in cases where pretransplant dialysis was not initiated. In these cases, there was no significant difference in the risk of death between SHK and HTA (HR 1.01; 95% CI 0.67-1.50). Recipients of SHK had worse 1-year rGS and PS and had a higher relative risk of overall renal graft loss compared to DDKT recipients. One-year rates of cardiac (14.5%) and renal (6.5%) rejection were lower in SHK compared to HTA and DDKT, respectively. Recipients of SHK had a lower adjusted risk of death compared to HTA recipients, particularly in patients who required pretransplant dialysis. These data suggest that SHK should be considered in heart transplant candidates with renal failure requiring dialysis, whereas the utility of SHK in cases of renal failure not requiring dialysis warrants further study.