Striking a Balance in Simultaneous Heart Kidney Transplant: Optimizing Outcomes for All Wait-Listed Patients

Abstract

donor and kidney transplant recipient evaluations. This could lead to worsening of existing racial disparities. Overcoming these fears will require that we examine our own implicit biases to ensure that we are providing equitable care worthy of our patients' trust. We should also engage trusted community leaders and organizations as partners in communicating the benefits of timely and appropriate care, even during these tumultuous times. This foundation of trust 14 will become increasingly important as a vaccine and effective treatments for COVID-19 are developed, which we will want to equitably provide to our patients. In all of these efforts, we should be mindful that many of our Black colleagues are also experiencing similar grief and other direct and indirect consequences as are our patients during these dual crises. It is important that they be provided emotional as well as instrumental support to mitigate negative effects on their personal and professional lives, as well as bolstered kidney community support to advance health equity. The COVID-19 pandemic and recent high-profile acts of racism have unleashed new adversity for Black individuals to "weather." Our actions as a kidney community can influence the effect that these crises have on racial disparities and prepare us to better address challenges to come.

Need for improvements in simultaneous heart-kidney allocation: The limitation of pretransplant glomerular filtration rate

“…That is, kidneys allocated to multiorgan transplant generally and SHK specifically may not generate the maximum utility. As we have previously written, though concerns of beneficence, or ensuring that the sickest patients who would most immediately derive value from an organ, are important, long‐term claims on utility must also be considered given that kidneys are truly scarce resources 13 …”

And Then There Were Three: Effects of Pretransplant Dialysis on Multiorgan Transplantation

“…These patients experience diminished access to transplant each time a prophylactic kidney transplant is performed, in which a heart or liver transplant candidate, who is not dialysis-dependent and likely won’t be dialysis-dependent even without a kidney transplant, receives a kidney ahead of kidney-alone candidates . 1 , 2 , 17 …”

“…3) a Safety Net option to enable liver/heart transplant recipients to obtain allocation priority for deceased donor kidneys. 14 , 17 …”

Impact of changing renal function, while waiting for a heart transplant, on post‐transplant mortality and development of end stage kidney disease

“…Several studies have now shown better outcomes with combined heart kidney transplantation as compared to heart transplantation alone in recipients with reduced eGFR [3][4][5]22]. These emerging data could be prompting an increase in the number of simultaneous heart kidney transplantation (nearly fivefold increase from 2004 to 2018) [23]. Moreover, because of the current allocation algorithm recipients undergoing simultaneous heart kidney transplant likely receive a higher quality deceased donor kidney compared to a subsequent isolated deceased donor kidney transplant [24].…”

“…Moreover, because of the current allocation algorithm recipients undergoing simultaneous heart kidney transplant likely receive a higher quality deceased donor kidney compared to a subsequent isolated deceased donor kidney transplant [24]. This creates an imbalance between beneficence and utility and can place patients in need of a kidney transplant alone at a relative disadvantage [23]. Furthermore, some patients who receive a simultaneous heart/kidney transplant may recover native kidney function making that kidney transplant unnecessary and consequential to those remaining on the kidney transplant waitlist.…”