Renal outcome after simultaneous heart and kidney transplantation

Abstract

Simultaneous heart‐kidney transplant (HKTx) is a valid treatment for patients with coexisting heart and renal failure. The aim of this study was to assess renal outcome in HKTx and to identify predictive factors for renal loss. A retrospective study was conducted among 73 HKTx recipients: Donors’ and recipients' records were reviewed to evaluate patients’ and renal transplants’ survival and their prognostic factors. The mean follow‐up was 5.36 years. Renal primary non‐function occurred in 2.7%, and complications Clavien IIIb or higher were observed in 67.1% including 16 (22%) postoperative deaths. Five‐year overall survival and renal survival were 74.5% and 69.4%. Among survivors, seven returned to dialysis during follow‐up. The postoperative use of ECMO (HR = 6.04, P = 0.006), dialysis (HR = 1.04/day, P = 0.022), and occurrence of complications (HR = 31.79, P = 0.022) were independent predictors of postoperative mortality but not the history of previous HTx or KTx nor renal function prior to transplantation. History of KTx (HR = 2.52, P = 0.026) and increased delay between the two transplantations (HR = 1.25/hour, P = 0.018) were associated with renal transplant failure. HKTx provides good renal transplant survival and function, among survivors. Early mortality rate of 22% underlines the need to identify perioperative risk factors that would lead to more judicious and responsible allocation of a scarce resource.

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

“…Previous studies of patients receiving HKTx reported considerably impaired renal graft and patient survival after the first year of transplantation. After five years, patient survival was reported between 53 to 80% versus 84 to 86% in case of solitary KTx, whereas differences in renal graft survival were slightly less pronounced (69% versus 76%) [1,[4][5][6][7]. Our study demonstrates similar results after one and five years, however; significant differences in graft and patient survival diminished over time, which is mainly explained by a lower rate of DWFG following the first year after HKTx.…”

“…In our study we therefore investigated the outcome of patients undergoing HKTx in comparison to patients undergoing solitary KTx, focusing on renal graft performance and survival. Previous investigations on the matter demonstrated that graft damage due to the necessity of complex and prolonged ICU treatment as well as early renal graft loss due to increased in-hospital mortality following HKTx are major limitations for the success of this combined approach [1,5,6,14]. Significantly lengthened ICU treatment, frequent necessity of subsequent dialysis and a considerable rate of primary nonfunction (18.5%; 5 of 27 patients) and in-hospital mortality (22%, 6 of 27 patients) in our patients undergoing HKTx corroborate these previous findings.…”

“…To avoid hemodynamic instability and negative influence of its treatment during kidney implantation and the early post-transplant period or even graft loss due to early mortality some authors suggest a staged procedure [5,20,21], implying that the renal engraftment is delayed for several hours. However, a staged procedure increases ischemic allograft time and is therefore associated with impaired renal function and reduced long-term graft survival [22][23][24] and thus others recommend implantation immediately following thoracic closure [25].…”

“…Data obtained from the Organ Procurement and Transplantation Network revealed a nearly fivefold increase of HKTx from 2004 (44) to 2018 (202), equivalent to the most significant increase in all multiorgan transplants performed over the past years [3]. However, in comparison to solitary kidney-transplants (KTx) with low in-hospital mortality (0.8 to 1.4%) and satisfying 1-year patient survival of 96% [4], HKTx is accompanied by a severely increased in-hospital mortality of up to 22% [5] and thus, reduced 1-year survival rates ranging from 62 to 84% [1,[5][6][7]. In times of ongoing organ shortage, this data is alarming as the allocation of two organs to a single patient has to be justified not only with regard to patients awaiting HTx, but also to patients on the waiting list for KTx: Since kidney injury is frequently associated with end-stage heart failure and a growing number of patients experience prolonged waiting times for an appropriate cardiac transplant [8], concomitant demand of renal grafts for these patients is predictable, which will further diminish the availability of organs in the KTx allocation system [9].…”

Renal replacement therapy in heart transplant recipients

“…До настоящего времени не существует каких-либо рекомендаций, в каких случаях надо использовать одномоментную или поэтапную методику. Несмотря на увеличение срока холодовой ишемии для почечного трансплантата, многие авторы выступают в пользу двух последовательных операций [64,66]. В этом случае наличие восстановительного периода для нового трансплантированного сердца позволяет оптимизировать статус гидратации перед пересадкой почки и уменьшить негативное влияние на почечный трансплантат таких факторов, как низкое перфузионное давление и нестабильные гемодинамические условия.…”