Anesthetic and Perioperative Considerations for Combined Heart-Kidney Transplantation

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

“…From the perspective of the patient, staged transplants confer distinct advantages and disadvantages 26 . Advantages include the avoidance of peri‐ and immediate postoperative hemodynamic instability, 27 which is a major contributor to primary kidney non‐function; improved chance of heart transplant in a highly sensitized and difficult‐to‐match patient; and the avoidance of unnecessary kidney transplants and their complications. Disadvantages include potential immunologic risk from receiving organs from two donors 24 ; two surgeries, induction therapies, and recoveries; and possibly a greater need for dialysis after HTx (although available studies have not established this).…”

“…The staged approach, where it to be adopted for heart transplant candidates, also confers distinct advantages and disadvantages to the allocation system as a whole. Advantages include the avoidance of the “futile transplant,” considering patients who die within one year despite multi‐organ transplantation or who experience primary kidney non‐function, 36 and potentially improved kidney allograft survival by avoiding peri‐ and early postoperative insults common to SHK transplants, that is, high‐dose vasopressor support, right ventricular dysfunction, and use of temporary mechanical circulatory support 27 . As hypotension prior to kidney transplant is strongly associated with early kidney allograft failure, 37,38 and as alternative therapies to kidney transplant exist, a judicious approach to kidney allocation would be to address the non‐kidney organ first and to tackle kidney transplant later.…”

Machine perfusion use for combined staged kidney transplantation after heart re‐transplantation: keep calm and stabilize the recipient!

“…Even the development of hyperdynamic states and the massive use of inotropic drugs have been shown to have a detrimental effect on kidney graft [2]. Under this perspective, the management of combined heart-kidney transplant (HKT) recipients must face significant complexities [2,3] which are reflected by an increased risk of kidney graft loss compared to KT alone (hazard ratio 1.43 [4]). Moreover, kidney graft loss has been identified as a negative prognostic factor for HKT recipient survival [3].…”

Combined Thoracic and Abdominal Organ Transplantation: Special Considerations

“…Because tranexamic acid is associated with seizures in patients with impaired renal clearance, ε-aminocaproic acid is the preferred antifibrinolytic agent. 15 Uremia associated with renal failure can also lead to impaired platelet adhesion and aggregation and result in increased perioperative bleeding. Desmopressin is an effective way of treating bleeding in these patients and works by increasing the expression of endothelial von Willebrand Factor (vWF) multimers.…”