We read with interest the recent manuscript by Schaffer et al (1) and the accompanying editorial by Kumar and Tallaj (2) regarding combined heart-kidney transplantation (HKT) in patients with end-stage heart failure and chronic renal insufficiency. We agree that the option of HKT in patients with nondialysis-dependent renal insufficiency (NDDRI) requires further exploration. It is possible that some patients may experience an improvement in renal function with heart transplantation alone, which can be difficult to predict prior to transplantation. Both articles discuss the potential utilization of left ventricular assist devices (LVADs), which we would like to elaborate on further.Previous studies have demonstrated improvement in renal function following LVAD implantation suggesting that some patients with end-stage heart failure and NDDRI may be best served with LVAD implantation as a bridge to heart transplantation alone (3). However, it can be difficult to determine which patients with NDDRI will show benefit in renal function following LVAD placement. NDDRI is a strong predictor for adverse outcomes after LVAD implantation with those patients on hemodialysis at the time of implant having particularly poor survival (4). For this reason, many centers consider NDDRI a relative contraindication to LVAD placement (5). A key question that must be answered before LVAD placement is: is the renal failure reversible? As the authors have discussed, there is no gold standard to answer this question, although renal ultrasound to assess the kidney size and renal biopsy may be helpful. In addition, it is not clear whether there is a greater likelihood for renal recovery following LVAD as compared to heart transplantation. While transplantation has the disadvantage of immunosuppression, which can cause renal toxicity, it has the advantage of biventricular support as compared to LVAD support. At the current time, it is uncertain if heart failure patients with NDDRI are best served with LVAD implantation versus HKT. While some patients may benefit from LVAD implantation with improved renal function, others may do quite poorly, particularly if they require hemodialysis following surgery.If LVAD patients require long-term hemodialysis, it can be difficult to find an outpatient dialysis center that will accept them (5). Concerns among nephrologists stem from a lack of familiarity with LVAD technology as well as potential difficulties in measuring blood pressure for patients on continuous-flow support. However, in our experience, intermittent hemodialysis can be performed safely. Concerns about potential exorbitant length of stay in such patients further dissuade LVAD programs from considering patients with NDDRI for LVAD implantation. If these patients can be discharged to local dialysis centers and remain functional, they would be excellent candidates for HKT if renal function does not recover.Finally, for those LVAD patients who remain dialysisdependent, is renal transplantation alone an option? LVAD patients have not been con...
