Heart retransplant recipients with renal dysfunction benefit from simultaneous heart-kidney transplantation

https://doi.org/10.1016/j.healun.2023.04.010Get rights and content

Background

Given ongoing donor shortages, appropriate patient selection for dual-organ transplantation is critical. We evaluated outcomes of heart retransplant with simultaneous kidney transplant (HRT-KT) vs isolated heart retransplant (HRT) across varying levels of renal dysfunction.

Methods

The United Network for Organ Sharing database identified 1189 adult patients undergoing heart retransplantation between 2005 and 2020. Recipients undergoing HRT-KT (n = 251) were compared to those undergoing HRT (n = 938). The primary outcome was 5-year survival; subgroup analyses and multivariable adjustment were performed utilizing the following 3 estimated glomerular filtration (eGFR) groups: <30 ml/min/1.73m2, 30-45 ml/min/1.73m2, and >45 ml/min/1.73m2.

Results

HRT-KT recipients were older and had longer waitlist times, longer inter-transplant periods, and lower eGFR levels. HRT-KT recipients were less likely to require pretransplant ventilator (1.2% vs 9.0%, p < 0.001) or ECMO (2.0% vs 8.3%, p < 0.001) support but were more likely to have severe functional limitation (63.4% vs 52.6%, p = 0.001). After retransplantation, HRT-KT recipients had less treated acute rejection (5.2% vs 9.3%, p = 0.02) and more dialysis requirement (29.1% vs 20.2%, p < 0.001) before discharge. Survival at 5-years was 69.1% after HRT and 80.5% after HRT-KT (p < 0.001). After adjustment, HRT-KT was associated with improved 5-year survival among recipients with eGFR <30 ml/min/1.73m2 (HR:0.42, 95% CI: 0.26-0.67) and 30 to 45 ml/min/1.73m2 (HR:0.29, 95% CI 0.13-0.65), but not among those with eGFR>45 ml/min/1.73sm2 (HR 0.68, 95% CI 0.30-1.54).

Conclusion

Simultaneous kidney transplantation is associated with improved survival following heart retransplantation in patients with eGFR <45 ml/min/1.73m2 and should be strongly considered to optimize organ allocation stewardship.

Section snippets

Data source

A retrospective analysis was performed utilizing the United Network for Organ Sharing (UNOS) Standard Transplant Analysis and Research files, updated as of June 30, 2022. From the thoracic transplant recipient file, we identified all adult patients undergoing cardiac retransplantation between January 1, 2005005 and December 31, 20202020, after excluding patients undergoing simultaneous solid-organ transplantation other than kidney. Patients were stratified according to those who underwent

Patient cohort and characteristics

Of the 1,189 patients undergoing heart retransplantation, 251 (21.1%) underwent simultaneous heart-kidney retransplant and 938 (78.9%) underwent isolated heart retransplant. Across the study period, there was increased utilization of simultaneous heart-kidney retransplant (Figure 1): in 2005, simultaneous heart-kidney retransplant accounted for 11.8% (8/68) of all cardiac retransplants compared to 37.0% (37/100) of all cardiac retransplants in 2020 (p < 0.001).

Baseline recipient and donor

Discussion

Heart retransplant recipients remain a high-risk cohort of patients, and thus efforts to enhance outcomes are paramount to optimize organ stewardship. Furthermore, patient selection for simultaneous heart-kidney transplantation requires further study to identify groups deriving true benefit from dual organ transplantation to inform practice policies. As such, our analysis of the UNOS database highlights several important findings. First, simultaneous heart-kidney transplantation has been

Limitations

This analysis of outcomes following simultaneous heart-kidney vs isolated heart retransplantation utilizing the UNOS database has several limitations. Most importantly, baseline renal function was calculated utilizing a single creatinine value prior to transplant, as this was the most reliable marker available within the registry. Therefore, we were unable to quantify the chronicity of renal dysfunction and identify potential markers used clinically to determine potential recoverability of

Conclusion

The utilization of simultaneous heart-kidney transplantation in the setting of cardiac retransplantation has increased dramatically in the United States, accounting for over 33% of all cases in 2020. Significant renal disease in patients requiring heart retransplantation should not be a contraindication to retransplantation, and selected patients with chronic kidney disease and eGFR <45 ml/min/1.73m2 derive a survival benefit from simultaneous kidney transplantation. These findings are

Author contributions

JM, QC, MB, and FE were involved in the study conceptualization and design. JM, QC, and MB conducted the data analysis and drafted the manuscript. All authors were involved in data interpretation, manuscript review, and critical revisions and final approval of the manuscript.

Disclosure statement

Jad Malas and Qiudong Chen are both supported by grants from the National Institutes of Health for advanced heart disease research (T32HL116273). The remaining authors have no relevant financial disclosures.

This work was supported in part by Health Resources and Services Administration contract HHSH250-2019-00001C. The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of

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