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Outcomes of Simultaneous Heart and Kidney Transplantation
Quick Takes
- In this retrospective cohort study of patients with end-stage heart failure undergoing heart transplantation, recipients with baseline glomerular filtration rate ≤40 mL/min/1.73 m2 had superior survival and lower risk of heart allograft failure with simultaneous kidney transplant, as compared with heart transplant alone.
- The 1-year incidence of kidney allograft loss was higher among heart-kidney recipients than among kidney failure patients who received the contralateral kidneys (14.7% vs. 4.5%; HR, 1.7; 95% CI, 1.4-2.1).
Study Questions:
In patients with end-stage heart failure undergoing heart transplantation, what are the effects and utility of simultaneous kidney transplantation at various degrees of kidney dysfunction?
Methods:
This was a retrospective cohort study based on registry data from the United Network of Organ Sharing (UNOS), which includes data on every organ transplant performed in the United States. The study period began in 2005, when use of modern left ventricular assist devices began, and ended in 2018. Adult primary heart transplant recipients with baseline concomitant kidney dysfunction (glomerular filtration rate [GFR] ≤60 mL/min/1.73 m2) were included, and contralateral kidney recipients were compared for allograft loss.
Results:
The cohort was comprised of 13,539 patients who underwent heart transplantation, including 1,124 patients (8.3%) who simultaneously received kidney allografts from the same donors. The median follow-up period was 3.9 years. In each stratum of kidney dysfunction, heart-kidney recipients were older, more likely to be Black, and more likely to have diabetes, poor functional status, and higher UNOS urgency status.
Among heart transplant recipients who were dialysis-dependent, 5-year mortality was lower in patients who received simultaneous kidney transplant (26.7% vs. 38.6%; hazard ratio [HR], 0.72; p = 0.0031). Similar risk reductions with simultaneous heart-kidney transplant were observed among nondialysis-dependent patients with GFR <30 mL/min/1.73 m2 (5-year mortality 19.3% vs. 32.4%, HR, 0.62; p = 0.0011) and GFR 30-45 mL/min/1.73 m2 (5-year mortality 16.2% vs. 24.3%, HR, 0.68; p = 0.035), but not with GFR 45-60 mL/min/1.73 m2. On graphical analysis of the interaction between GFR and the mortality benefit of simultaneous heart-kidney transplantation, benefit appeared to be present at GFR ≤40 mL/min/1.73 m2. The cumulative incidence of heart allograft failure was lower among heart-kidney recipients than heart-alone recipients (HR, 0.64; 95% confidence interval [CI], 0.54-0.75). Only 1.4% of heart-alone recipients with baseline kidney dysfunction subsequently underwent kidney transplant. After adjustment for variables including age, sex, race, dialysis status, and kidney donor profile index, the 1-year incidence of kidney allograft loss was higher among heart-kidney recipients than among contralateral kidney recipients (14.7% vs. 4.5%; HR, 1.7; 95% CI, 1.4-2.1).
Conclusions:
Heart transplant recipients with baseline GFR ≤40 mL/min/1.73 m2 had superior survival and lower risk of heart allograft failure with simultaneous kidney transplant, as compared with heart transplant alone. However, risk of kidney allograft loss in simultaneous heart-kidney recipients was higher than in contralateral kidney recipients.
Perspective:
Prediction of kidney recovery following isolated heart transplant is challenging, and listing practices for dual-organ transplant vary widely among centers. While individual clinicians seek to maximize survival and quality of life for the particular patients they serve, the organ allocation system should optimize outcomes for the recipient population as a whole. The study authors make a compelling case for a safety-net policy, through which patients may receive a subsequent kidney transplant if needed after heart transplant, similar to what currently exists for liver transplant recipients.
Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and Heart Failure, Acute Heart Failure, Heart Transplant, Mechanical Circulatory Support
Keywords: Allografts, Cardiac Surgical Procedures, Glomerular Filtration Rate, Heart-Assist Devices, Heart Failure, Heart Transplantation, Kidney Transplantation, Renal Dialysis, Renal Insufficiency, Risk, Transplant Recipients
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