Elsevier

Journal of Cardiac Failure

Volume 28, Issue 11, November 2022, Pages 1584-1592
Journal of Cardiac Failure

Outcomes in Patients With LVADs Undergoing Simultaneous Heart-Kidney Transplantation

https://doi.org/10.1016/j.cardfail.2022.04.016Get rights and content

Highlights

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    Simultaneous heart-kidney transplants are becoming more common in patients with left ventricular assist devices (LVADs) and chronic kidney disease.

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    This study shows that both short- and long-term survival is worse in patients with simultaneous heart-kidney transplants than in patients with orthotopic heart transplants when patients have chronic kidney disease and LVADs.

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    Further investigation is needed to determine whether kidney-after-heart transplant would be a better strategy for patients with LVADs needing both cardiac and renal transplants.

ABSTRACT

Background

Multiple studies have shown better outcomes for simultaneous heart-kidney transplant (sHKT) than for isolated orthotopic heart transplant (iOHT) in recipients with chronic kidney disease (CKD). However, outcomes in patients supported by durable left ventricular assist devices (LVADs) have not been well studied.

Methods

Patients with durable LVADs and stage 3 or higher CKD (eGFR < 60 mL/min/1.73 m2) undergoing iOHT or sHKT between 2008 and 2020 were identified from the United Network for Organ Sharing registry. A Kaplan-Meier survival analysis with associated log-rank test was conducted to compare post-transplant survival rates. Multivariable modeling was used to identify risk-adjusted predictors of 1 year post-transplant mortality.

Results

We identified 4375 patients; 366 underwent sHKT, and 4009 underwent iOHT. The frequency of sHKT increased during the study period. The 1-year post-transplant survival rate was worse in patients after sHKT than in patients after iOHT (80.3% vs 88.3%; P < 0.001) and persisted up to 5 years post-transplant (P = 0.001). sHKT recipients were more likely to require dialysis after transplantation and had longer hospital lengths of stay (P < 0.001). Multivariable analysis showed that sHKT remained an independent risk factor for mortality at 1 year (OR 1.58; P = 0.002).

Conclusions

sHKT is becoming more common in patients with durable LVADs. Compared with iOHT, patients with sHKTs have worse short- and long-term survival rates and are more likely to require post-transplant dialysis.

Section snippets

Data Source and Study Design

Data for this study were analyzed from the United Network for Organ Sharing (UNOS) registry database, which is a prospectively collected registry of all solid-organ transplants performed in the United States. Recipient and donor demographics as well as transplant characteristics were collected from this database, and all patients’ medical-center identifiers were removed. Institutional Review Board review was waived for this study because the UNOS contains de-identified data.

For this analysis,

Recipient and Donor Characteristics,

A total of 4375 patients who were supported by durable, continuous-flow LVADs and who had stage 3 or greater CKD (eGFR < 60mL/min/1.73m2) were studied; of them, 4009 received iOHT, and 366 received sHKT. Recipients’ characteristics are displayed in Table 1. Compared to those who underwent iOHT, those who underwent sHKT were more likely to be male, of Black race and have diabetes mellitus. After sHKT, patients had higher serum creatinine levels (2.92 vs 1.57 mL/dL) and lower eGFRs (33.13 vs

Discussion

The major findings of our study are as follows: (1) Combined sHKT is becoming more common in patients with LVADs; (2) compared with iOHT, patients with LVADs and CKD who undergo sHKT have worse short- and long-term survival rates; and (3) after sHKT, patients have higher rates of post-transplant dialysis and longer lengths of hospital stay; and (4) the benefits of sHKT in patients without LVADs who required pretransplant dialysis were not appreciated in patients with LVADs. These surprising

Conclusions

In our study, we found that sHKTs are becoming more common in patients bridged to transplant with durable LVADs. Short- and long-term survival outcomes are worse for sHKT compared with iOHT. There was also a higher incidence of post-transplant dialysis in the sHKT group. These results should give us pause with regard to routine sHKT in the population with LVADs, and future work should investigate whether KAH strategies provide survival benefit in this unique population.

Acknowledgments

None.

Funding

No grants, contracts or other financial support were received for this manuscript.

Disclosures

CI reports a consulting relationship with Abbott; ABVB reports DSMB committee work for TransMedics and research support from CareDx; AJS reports a consulting relationship with Medtronic, Abbott, Boston Scientific, and Edwards Life Sciences and is on steering committees with Medtronic, Abbott and Boston Scientific; BAH reports consulting relationships with Medtronic and Bioventrix and has received research

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These authors contributed equally to the article.

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These authors contributed equally as senior author.

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