Impact of Pretransplant Renal Replacement Therapy on Clinical Outcome After Isolated Heart Transplantation

Abstract

End stage renal disease (ESRD) is a contraindication to isolated heart transplantation (HT). However, heart candidates with cardiogenic shock may experience acute kidney injury and require renal replacement therapy (RRT) and isolated HT as a life-saving operation. The outcomes, including survival and renal function, are rarely reported. We enrolled 569 patients undergoing isolated HT from 1989 to 2018. Among them, 66 patients required RRT before HT (34 transient and 32 persistent). The survival was worse in patients with RRT than those without (65.2% vs 84.7%; 27.3% vs 51.1% at 1- and 10-year, p < 0.001 and p = 0.012, respectively). Multivariate Cox analysis identified pre-transplant hyperbilirubinemia (Hazard ratio (HR) 2.534, 95% confidence interval (CI) 1.098–5.853, p = 0.029), post-transplant RRT (HR 5.551, 95%CI 1.280–24.068, p = 0.022) and post-transplant early bloodstream infection (HR 3.014, 95%CI 1.270–7.152, p = 0.012) as independent risk factors of 1-year mortality. The majority of operative survivors (98%) displayed renal recovery after HT. Although patients with persistent or transient RRT before HT had a similar long-term survival, patients with persistent RRT developed a high incidence (49.2%) of dialysis-dependent ESRD at 10 years. In transplant candidates with pretransplant RRT, hyperbilirubinemia should be carefully re-evaluated for the eligibility of HT whereas prevention and management of bloodstream infection after HT improve survival.

Impact of Previous Conventional Cardiac Surgery on the Clinical Outcomes After Heart Transplantation

“…Infection remained the leading cause of mortality in both groups in this study. Our previous research found that post-transplant dialysis and early bloodstream infection contributes to a 5.5-fold and 3.43-fold increase in early mortality, respectively [ 18 , 21 ]. In the present study, the PCCS group exhibited a higher incidence of certain factors, namely, post-transplant ECMO support (29%), delayed sternum closure (31%), early bloodstream infection (18%), and dialysis (41%).…”

“…After surgery, sternal closure may be delayed for 24 h if adequate hemostasis is not achieved. Furthermore, immunosuppressant and desensitization protocols were followed as usual, based on previous publications [18][19][20][21].…”