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

Abstract

Background In 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. Methods This 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. Results Median 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%). Conclusions Our 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.

Combined Heart-Kidney Transplantation: Indications, Outcomes, and Controversies

“…While this reflects the complexity, increased comorbidities, and hemodynamic impairment associated with multiorgan transplant, particularly thoracic compared with abdominal, it remains a cause of concern when allocating renal allografts away from patients awaiting KTx. 40 UNOS data supports this, showing lower rates of graft survival both in the first year post-HKTx as opposed to KTx (84.5% compared to 89.8%, P < .001) and higher relative risk of graft loss for HKTx (HR 1.41; 95% CI, 1.13-1.76). These rates were driven by increased mortality rates in HKTx patients.…”

“…These seemed to be centered around hemodynamic instability and prolonged operating time, such as prior cardiac surgery, prior heart or kidney transplant, and requirement for extracorporeal membrane oxygenation support. 40 , 41 , 42 Overall, this suggests that utilization of kidney allografts for HKTx patients is appropriate, with care taken to identify patients at increased risk of poor outcomes.…”

Outcomes of Combined Heart and Kidney Transplantation Under the New Heart Allocation Policy: A United Organ Network for Organ Sharing Database Analysis

“…3 In addition, the process of combined HKT itself can negatively affect the chances of kidney function after HKT such as, adverse perioperative hemodynamics including heart graft dysfunction or hypotension requiring multiple vasopressors or inotropes, volume overload, bleeding, or calcineurin inhibitor use in an early postoperative period of 2 major surgeries. [1][2][3][4]6 In setting of HKT, a kidney graft is more susceptible to these insults, and it has a higher chance of graft failure compared with a heart graft, 6,10,14 and the need for dialysis following HT is associated with impaired survival. [1][2][3]28 Another important aspect of organ utilization is that KTA for patients without heart failure shows an excellent 5-year survival of ≈90%.…”

“…4,13 Conversely, HKT is a challenging procedure due to a longer overall procedure time from 2 major surgeries, 5 the use of cardiopulmonary bypass during HT, the complexity of postoperative management (eg, hemodynamics, fluid shifts, and vasopressor or inotrope use), and more coordination of care between multiple transplant teams. 8,10,11,14 Furthermore, the waiting time for HKT is generally longer than HT alone, 10 and the utilization of 2 organs for 1 recipient may be controversial given overall shortage of donors. 1,[4][5][6] In October 2018, the United Network for Organ Sharing (UNOS) heart allocation policy was modified to prioritize more acutely ill patients with higher waitlist mortality, such as those on temporary mechanical circulatory support and provide broader sharing of donor organs [15][16][17][18] Concerns have been raised about the impact of this new heart allocation system [15][16][17][18][19][20] due to an increased acuity of illness in recipients, an increase in the use of temporary circulatory support devices, and a wider regional availability of donors resulting in longer ischemic time, all of which can be associated with worse outcomes.…”

Overcoming challenges in patient selection and monitoring in combined heart and kidney transplantation

“…The core ethical conundrum lies in striking the balance between providing life-enhancing transplantation in ESRF patients and offering a chance of improved outcomes to HT candidates, the latter being at significantly higher risk of death due to their multiorgan failure state [4]. Although postoperative mortality in these patients is higher than in kidney-only transplant [15 ▪ ,24], the immediate survival benefit of HF patients with ESRF undergoing HKT is greater. [10,11 ▪▪ ] In addition, a combined strategy improves outcomes of heart allocation.…”