Simultaneous Heart Kidney Research Articles

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.

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.

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.

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.

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.

(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

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

&#x0D; &#x0D; &#x0D; Background&#x0D; 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.&#x0D; Methods&#x0D; 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.&#x0D; Results&#x0D; 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%).&#x0D; &#x0D; &#x0D; &#x0D; Conclusions&#x0D; 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).&#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D;

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.

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.

How Old Is Too Old for Simultaneous Heart Kidney Donation?

How Old Is Too Old for Simultaneous Heart Kidney Donation?

(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

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.

542: Simultaneous Heart-Kidney Transplantation in Children – Are the Outcomes as Bad as We Think: An Analysis of the United Network for Organ Sharing Database

542: Simultaneous Heart-Kidney Transplantation in Children – Are the Outcomes as Bad as We Think: An Analysis of the United Network for Organ Sharing Database