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Peled Y, Ducharme A, Kittleson M, Bansal N, Stehlik J, Amdani S, Saeed D, Cheng R, Clarke B, Dobbels F, Farr M, Lindenfeld J, Nikolaidis L, Patel J, Acharya D, Albert D, Aslam S, Bertolotti A, Chan M, Chih S, Colvin M, Crespo-Leiro M, D'Alessandro D, Daly K, Diez-Lopez C, Dipchand A, Ensminger S, Everitt M, Fardman A, Farrero M, Feldman D, Gjelaj C, Goodwin M, Harrison K, Hsich E, Joyce E, Kato T, Kim D, Luong ML, Lyster H, Masetti M, Matos LN, Nilsson J, Noly PE, Rao V, Rolid K, Schlendorf K, Schweiger M, Spinner J, Townsend M, Tremblay-Gravel M, Urschel S, Vachiery JL, Velleca A, Waldman G, Walsh J. International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024. J Heart Lung Transplant 2024; 43:1529-1628.e54. [PMID: 39115488 DOI: 10.1016/j.healun.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 05/14/2024] [Indexed: 08/18/2024] Open
Abstract
The "International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024" updates and replaces the "Listing Criteria for Heart Transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates-2006" and the "2016 International Society for Heart Lung Transplantation Listing Criteria for Heart Transplantation: A 10-year Update." The document aims to provide tools to help integrate the numerous variables involved in evaluating patients for transplantation, emphasizing updating the collaborative treatment while waiting for a transplant. There have been significant practice-changing developments in the care of heart transplant recipients since the publication of the International Society for Heart and Lung Transplantation (ISHLT) guidelines in 2006 and the 10-year update in 2016. The changes pertain to 3 aspects of heart transplantation: (1) patient selection criteria, (2) care of selected patient populations, and (3) durable mechanical support. To address these issues, 3 task forces were assembled. Each task force was cochaired by a pediatric heart transplant physician with the specific mandate to highlight issues unique to the pediatric heart transplant population and ensure their adequate representation. This guideline was harmonized with other ISHLT guidelines published through November 2023. The 2024 ISHLT guidelines for the evaluation and care of cardiac transplant candidates provide recommendations based on contemporary scientific evidence and patient management flow diagrams. The American College of Cardiology and American Heart Association modular knowledge chunk format has been implemented, allowing guideline information to be grouped into discrete packages (or modules) of information on a disease-specific topic or management issue. Aiming to improve the quality of care for heart transplant candidates, the recommendations present an evidence-based approach.
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Affiliation(s)
- Yael Peled
- Leviev Heart & Vascular Center, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel; Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv, Israel.
| | - Anique Ducharme
- Deparment of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
| | - Michelle Kittleson
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Neha Bansal
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Josef Stehlik
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Shahnawaz Amdani
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, Ohio, USA
| | - Diyar Saeed
- Heart Center Niederrhein, Helios Hospital Krefeld, Krefeld, Germany
| | - Richard Cheng
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Brian Clarke
- Division of Cardiology, University of British Columbia, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Fabienne Dobbels
- Academic Centre for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Maryjane Farr
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX; Parkland Health System, Dallas, TX, USA
| | - JoAnn Lindenfeld
- Division of Cardiovascular Medicine, Vanderbilt University, Nashville, TN, USA
| | | | - Jignesh Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Deepak Acharya
- Division of Cardiovascular Diseases, University of Arizona Sarver Heart Center, Tucson, Arizona, USA
| | - Dimpna Albert
- Department of Paediatric Cardiology, Paediatric Heart Failure and Cardiac Transplant, Heart Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Saima Aslam
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Alejandro Bertolotti
- Heart and Lung Transplant Service, Favaloro Foundation University Hospital, Buenos Aires, Argentina
| | - Michael Chan
- University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Sharon Chih
- Heart Failure and Transplantation, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Monica Colvin
- Department of Cardiology, University of Michigan, Ann Arbor, MI; Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Maria Crespo-Leiro
- Cardiology Department Complexo Hospitalario Universitario A Coruna (CHUAC), CIBERCV, INIBIC, UDC, La Coruna, Spain
| | - David D'Alessandro
- Massachusetts General Hospital, Boston; Harvard School of Medicine, Boston, MA, USA
| | - Kevin Daly
- Boston Children's Hospital & Harvard Medical School, Boston, MA, USA
| | - Carles Diez-Lopez
- Advanced Heart Failure and Heart Transplant Unit, Department of Cardiology, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Anne Dipchand
- Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Melanie Everitt
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alexander Fardman
- Leviev Heart & Vascular Center, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel; Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Marta Farrero
- Department of Cardiology, Hospital Clínic, Barcelona, Spain
| | - David Feldman
- Newark Beth Israel Hospital & Rutgers University, Newark, NJ, USA
| | - Christiana Gjelaj
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Matthew Goodwin
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Kimberly Harrison
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eileen Hsich
- Cleveland Clinic Foundation, Division of Cardiovascular Medicine, Cleveland, OH, USA
| | - Emer Joyce
- Department of Cardiology, Mater University Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Dublin, Ireland
| | - Tomoko Kato
- Department of Cardiology, International University of Health and Welfare School of Medicine, Narita, Chiba, Japan
| | - Daniel Kim
- University of Alberta & Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Me-Linh Luong
- Division of Infectious Disease, Department of Medicine, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Haifa Lyster
- Department of Heart and Lung Transplantation, The Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, UK
| | - Marco Masetti
- Heart Failure and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Johan Nilsson
- Department of Cardiothoracic and Vascular Surgery, Skane University Hospital, Lund, Sweden
| | | | - Vivek Rao
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Katrine Rolid
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Kelly Schlendorf
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Joseph Spinner
- Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Madeleine Townsend
- Division of Pediatric Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Maxime Tremblay-Gravel
- Deparment of Medicine, Montreal Heart Institute, Université?de Montréal, Montreal, Quebec, Canada
| | - Simon Urschel
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Jean-Luc Vachiery
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Angela Velleca
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Georgina Waldman
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - James Walsh
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane; Heart Lung Institute, The Prince Charles Hospital, Brisbane, Australia
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Wu L, Rodriguez M, Hachem KE, Tang WHW, Krittanawong C. Management of patients with heart failure and chronic kidney disease. Heart Fail Rev 2024; 29:989-1023. [PMID: 39073666 DOI: 10.1007/s10741-024-10415-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2024] [Indexed: 07/30/2024]
Abstract
Chronic kidney disease (CKD) and heart failure are often co-existing conditions due to a shared pathophysiological process involving neurohormonal activation and hemodynamic maladaptation. A wide range of pharmaceutical and interventional tools are available to patients with CKD, consisting of traditional ones with decades of experience and newer emerging therapies that are rapidly reshaping the landscape of medical care for this population. Management of patients with heart failure and CKD requires a stepwise approach based on renal function and the clinical phenotype of heart failure. This is often challenging due to altered drug pharmacokinetics interactions with various degrees of kidney function and frequent adverse effects from the therapy that lead to poor patient tolerance. Despite a great body of clinical evidence and guidelines that have offered various treatment options for patients with heart failure and CKD, respectively, patients with CKD are still underrepresented in heart failure clinical trials, especially for those with advanced CKD and end-stage renal disease (ESRD). Future studies are needed to better understand the generalizability of these therapeutic options among heart failures with different stages of CKD.
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Affiliation(s)
- Lingling Wu
- Cardiovascular Division, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mario Rodriguez
- John T Milliken Department of Medicine, Division of Cardiovascular disease, Section of Advanced Heart Failure and Transplant, Barnes-Jewish Hospital, Washington University in St. Louis School of Medicine, St. Louis, USA
| | - Karim El Hachem
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland, Clinic, Cleveland, OH, USA
| | - Chayakrit Krittanawong
- Cardiology Division, Section of Cardiology, NYU Langone Health and NYU School of Medicine, 550 First Avenue, New York, NY, 10016, USA.
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Sampaio NZ, Faleiro MD, Vieira LVDS, Lech GE, Viana SW, Tavares CPO, Mattiazzi AD, Burke GW. Simultaneous Heart and Kidney Transplantation: A Systematic Review and Proportional Meta-Analysis of Its Characteristics and Long-Term Variables. Transpl Int 2024; 37:12750. [PMID: 38881801 PMCID: PMC11176494 DOI: 10.3389/ti.2024.12750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 05/13/2024] [Indexed: 06/18/2024]
Abstract
Patients with end-stage heart disease who undergo a heart transplant frequently have simultaneous kidney insufficiency, therefore simultaneous heart and kidney transplantation is an option and it is necessary to understand its characteristics and long-term variables. The recipient characteristics and operative and long-term variables were assessed in a meta-analysis. A total of 781 studies were screened, and 33 were thoroughly reviewed. 15 retrospective cohort studies and 376 patients were included. The recipient's mean age was 51.1 years (95% CI 48.52-53.67) and 84% (95% CI 80-87) were male. 71% (95% CI 59-83) of the recipients were dialysis dependent. The most common indication was ischemic cardiomyopathy [47% (95% CI 41-53)] and cardiorenal syndrome [22% (95% CI 9-35)]. Also, 33% (95% CI 20-46) of the patients presented with delayed graft function. During the mean follow-up period of 67.49 months (95% CI 45.64-89.33), simultaneous rejection episodes of both organ allografts were described in 5 cases only. Overall survival was 95% (95% CI 88-100) at 30 days, 81% (95% CI 76-86) at 1 year, 79% (95% CI 71-87) at 3, and 71% (95% CI 59-83) at 5 years. Simultaneous heart and kidney transplantation is an important option for concurrent cardiac and renal dysfunction and has acceptable rejection and survival rates.
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Affiliation(s)
| | | | | | - Gabriele Eckerdt Lech
- Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | | | | | - Adela D. Mattiazzi
- Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - George W. Burke
- Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
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Jain R, Kittleson MM. Evolutions in Combined Heart-Kidney Transplant. Curr Heart Fail Rep 2024; 21:139-146. [PMID: 38231443 PMCID: PMC10923997 DOI: 10.1007/s11897-024-00646-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2024] [Indexed: 01/18/2024]
Abstract
PURPOSE OF REVIEW This review describes management practices, outcomes, and allocation policies in candidates for simultaneous heart-kidney transplantation (SHKT). RECENT FINDINGS In patients with heart failure and concomitant kidney disease, SHKT confers a survival advantage over heart transplantation (HT) alone in patients with dialysis dependence or an estimated glomerular filtration rate (eGFR) < 40 mL/min/1.73 m2. However, when compared to kidney transplantation (KT) alone, SHKT is associated with worse patient and kidney allograft survival. In September 2023, the United Network of Organ Sharing adopted a new organ allocation policy, with strict eligibility criteria for SHKT and a safety net for patients requiring KT after HT alone. While the impact of the policy change on SHKT outcomes remains to be seen, strategies to prevent and slow development of kidney disease in patients with heart failure and to prevent kidney dysfunction after HT and SHKT are necessary.
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Affiliation(s)
- Rashmi Jain
- Department of Cardiology, Cedars-Sinai Medical Center, Smidt Heart Institute, 2nd floor, 8670 Wilshire Boulevard, Los Angeles, CA, 90211, USA
| | - Michelle M Kittleson
- Department of Cardiology, Cedars-Sinai Medical Center, Smidt Heart Institute, 2nd floor, 8670 Wilshire Boulevard, Los Angeles, CA, 90211, USA.
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Brocklebank P, Shorbaji K, Welch BA, Achurch MM, Kilic A. Trends and Outcomes of Combined Heart-Kidney and Heart-Lung Transplantation Over the Past Two Decades. J Surg Res 2024; 295:574-586. [PMID: 38091867 DOI: 10.1016/j.jss.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 09/26/2023] [Accepted: 11/09/2023] [Indexed: 02/25/2024]
Abstract
INTRODUCTION Combined heart-kidney transplantation (HKTx) and combined heart-lung transplantation (HLTx) remain the definitive therapy for patients with end-stage heart failure with concomitant end-stage renal or lung failure. We sought to study trends and outcomes of HKTx and HLTx over the last two decades. METHODS The United Network for Organ Sharing registry was used to identify all adult patients (aged >18 y) who underwent HKTx and HLTx between 2001 and 2021. Patients were divided into 5-y groups by the year of transplantation (2001-2006, 2007-2011, 2012-2016, and 2017-2021). Primary outcome was 1-y posttransplantation mortality. Kaplan-Meier and multivariable Cox proportional hazards models were used for unadjusted and risk-adjusted survival analyses, respectively. RESULTS A total of 2301 HKTx and 567 HLTx patients were included. Between 2001 and 2021, HKTx volume increased from 25 to 344 patients (P < 0.001) and centers performing HKTx increased from 19 to 76 (P < 0.001). On unadjusted analysis, 1-y survival after HKTx improved from 86.7% in 2001-2006 to 89.0% in 2017-2021 (log-rank, P = 0.005). On risk-adjusted analysis, the hazard ratio of 1-y mortality for 2017-2021 was 0.62 (0.39-1.00, P = 0.048) compared with that for 2001-2006. Between 2001 and 2021, HLTx volume increased from 21 to 43 patients (P < 0.001) and centers performing HLTx increased from 12 to 20 (P = 0.047). On unadjusted analysis, 1-y survival after HLTx improved from 68.9% in 2001-2006 to 83.9% in 2017-2021 (log-rank, P = 0.600). On risk-adjusted analysis, the hazard ratio of 1-y mortality for 2017-2021 was 0.37 (0.21-0.67, P = 0.001) compared with that for 2001-2006. CONCLUSIONS Over the last two decades, HKTx volume substantially increased and HLTx experienced resurgent growth. One-year survival persistently improved for both procedures, especially over the past 5 y.
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Affiliation(s)
- Paul Brocklebank
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Khaled Shorbaji
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Brett A Welch
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Mary Margaret Achurch
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina.
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Barua S, Hayward CS, Macdonald PS. Simultaneous Heart and Kidney Transplantation for LVAD-supported Patients With Chronic Kidney Disease? Transplantation 2024; 108:331-332. [PMID: 37677940 DOI: 10.1097/tp.0000000000004782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Affiliation(s)
- Sumita Barua
- Heart Lung Transplant Unit, St. Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
- School of Medicine, St. Vincent's Clinical School, University of New South Wales, Kensington, NSW, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia
| | - Christopher S Hayward
- Heart Lung Transplant Unit, St. Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
- School of Medicine, St. Vincent's Clinical School, University of New South Wales, Kensington, NSW, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Peter S Macdonald
- Heart Lung Transplant Unit, St. Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
- School of Medicine, St. Vincent's Clinical School, University of New South Wales, Kensington, NSW, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia
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Okumura K, Ohira S, Kai M, Misawa R, Wolfe K, Sogawa H, Veillette G, Nishida S, Spielvogel D, Lansman S, Dhand A. High Rate of Kidney Graft Failure after Simultaneous Heart-Kidney Transplantation. KIDNEY360 2024; 5:252-261. [PMID: 38268085 PMCID: PMC10914208 DOI: 10.34067/kid.0000000000000365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 01/11/2024] [Indexed: 01/26/2024]
Abstract
Key Points Simultaneous heart–kidney transplant is associated with high rates of kidney graft failure which are worse when compared with kidney transplant alone. The major causes of kidney graft failure in simultaneous heart–kidney transplant recipients were patient death and primary nonfunction of kidney graft. Background The indications and outcomes of simultaneous heart–kidney transplantation (SHKT) remain suboptimally defined. Risk factors for renal graft failure after SHKT also remain poorly defined. Methods We analyzed the renal graft outcomes among SHKT recipients using United Network for Organ Sharing database from 2015 to 2020. To evaluate for factors associated with poor renal outcomes, we compared SHKT and kidney transplantation alone recipients using propensity score matching. Results Among SHKT recipients, the rate of primary nonfunction (PNF) of kidney graft was 3%, the 30-day kidney graft failure rate was 7.0%, and the 30-day post-transplant mortality rate was 4.1%. The incidence of kidney delayed graft function was 27.5%. Kidney graft failure was seen early post-SHKT with most common causes of patient death (43.9%) and PNF of kidney graft (41.5%). One- and 2-year patient survival was 89.2% and 86.5%, and 1- and 2-year freedom from kidney graft failure was 85.4% and 82.7%, respectively. In subgroup analysis of SHKT recipients, use of pretransplant mechanical cardiac support (adjusted odds ratio [aOR], 2.57; P = 0.017), higher calculated panel reactive antibody (aOR, 1.76; P = 0.016), and older donor age per 10 years (aOR, 1.94; P = 0.001) were associated with PNF. Pretransplant extracorporeal membrane oxygenation support was associated with the increased risk of 30-day recipient mortality (aOR, 5.55; P = 0.002). Increased 30-day graft failure was seen in SHKT recipients with pretransplant mechanical cardiac support (aOR, 1.77; P = 0.038) and dialysis at the time of transplant (aOR, 1.72; P = 0.044). Multivariable Cox hazard analysis demonstrated that SHKT, when compared with kidney transplantation alone, is associated with increased kidney graft failure (hazard ratio, 2.56; P < 0.001) and recipient mortality (hazard ratio, 2.65; P < 0.001). Conclusions SHKT is associated with high rates of kidney graft failure. Identification of risk factors of renal graft failure can help optimize recipient selection for SHKT versus kidney after heart transplantation, especially after introduction of the new safety-net policy.
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Affiliation(s)
- Kenji Okumura
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Suguru Ohira
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York
| | - Masashi Kai
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York
| | - Ryosuke Misawa
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Kevin Wolfe
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Hiroshi Sogawa
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Gregory Veillette
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Seigo Nishida
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - David Spielvogel
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York
| | - Steven Lansman
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York
| | - Abhay Dhand
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
- Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, New York
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Kittleson MM, Sharma K, Brennan DC, Cheng XS, Chow SL, Colvin M, DeVore AD, Dunlay SM, Fraser M, Garonzik-Wang J, Khazanie P, Korenblat KM, Pham DT. Dual-Organ Transplantation: Indications, Evaluation, and Outcomes for Heart-Kidney and Heart-Liver Transplantation: A Scientific Statement From the American Heart Association. Circulation 2023; 148:622-636. [PMID: 37439224 DOI: 10.1161/cir.0000000000001155] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
Although heart transplantation is the preferred therapy for appropriate patients with advanced heart failure, the presence of concomitant renal or hepatic dysfunction can pose a barrier to isolated heart transplantation. Because donor organ supply limits the availability of organ transplantation, appropriate allocation of this scarce resource is essential; thus, clear guidance for simultaneous heart-kidney transplantation and simultaneous heart-liver transplantation is urgently required. The purposes of this scientific statement are (1) to describe the impact of pretransplantation renal and hepatic dysfunction on posttransplantation outcomes; (2) to discuss the assessment of pretransplantation renal and hepatic dysfunction; (3) to provide an approach to patient selection for simultaneous heart-kidney transplantation and simultaneous heart-liver transplantation and posttransplantation management; and (4) to explore the ethics of multiorgan transplantation.
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Chen Q, Malas J, Gianaris K, Esmailian G, Emerson D, Megna D, Catarino P, Czer L, Bowdish ME, Chikwe J, Patel J, Kobashigawa J, Esmailian F. Simultaneous heart-kidney transplant in patients with borderline estimated glomerular filtration rate without dialysis dependency. Clin Transplant 2023; 37:e14986. [PMID: 37026791 PMCID: PMC11144457 DOI: 10.1111/ctr.14986] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/07/2023] [Accepted: 03/27/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Appropriate patient selection for simultaneous heart-kidney transplantation (sHK) in patients with moderate renal dysfunction remains challenging. METHODS From the United Network for Organ Sharing database (2003-2020), we identified 5678 adults with an estimated pre-transplant glomerular filtration rate (eGFR) between 30 and 45 mL/min/1.73 m2 and no pre-transplant dialysis. Patients undergoing sHK (n = 293) were compared with those undergoing heart transplantation alone (n = 5385) using 1:3 propensity score matching. RESULTS The sHK utilization rate increased from 1.8% in 2003 to 12.2% in 2020 (p < .001). After matching, 1 and 5-year survival was 87.7% (95% confidence interval [CI] 83.3-91.0) and 80.0% (95% CI 74.2-84.6) after sHK, and 87.3% (95% CI 85.2-89.1) and 71.8% (95% CI 68.4-74.9) after heart transplant alone (p = .04). In the subgroup analysis, sHK was associated with a 5-year survival benefit only in patients with 30 < eGFR ≤ 35 mL/min/1.73 m2 (p = .05) but not in those with 35 < eGFR < 45 mL/min/1.73 m2 (p = .45). Patients who underwent heart transplants alone also had a higher incidence of becoming chronic dialysis-dependent after transplant within 5-year follow-up (10.2%, 95% CI 8.0-12.6 vs. 3.8%, 95% CI 1.7-7.1, p = .004). The 5-year incidence of subsequent kidney waitlisting and transplants after heart transplants alone was 5.6% and 1.9%, respectively. CONCLUSION Among propensity-matched patients without pre-transplant dialysis, compared to heart transplants alone, sHK had improved 5-year survival in those with 30 < eGFR ≤ 35 but not in those with 35 < eGFR < 45 mL/min/1.73 m2 . One-year survival was similar irrespective of eGFR. Receiving a kidney after a heart transplant alone is rare under the current allocation system.
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Affiliation(s)
- Qiudong Chen
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jad Malas
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Kevin Gianaris
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Gabriel Esmailian
- The George Washington School of Medicine and Health Sciences, Washington, D.C., USA
| | - Dominic Emerson
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Dominick Megna
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Pedro Catarino
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Lawrence Czer
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michael E. Bowdish
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jignesh Patel
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jon Kobashigawa
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Fardad Esmailian
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
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10
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Khan MS, Ahmed A, Greene SJ, Fiuzat M, Kittleson MM, Butler J, Bakris GL, Fonarow GC. Managing Heart Failure in Patients on Dialysis: State-of-the-Art Review. J Card Fail 2023; 29:87-107. [PMID: 36243339 DOI: 10.1016/j.cardfail.2022.09.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 08/28/2022] [Accepted: 09/20/2022] [Indexed: 11/07/2022]
Abstract
Heart failure (HF) and end-stage kidney disease (ESKD) frequently coexist; 1 comorbidity worsens the prognosis of the other. HF is responsible for almost half the deaths of patients on dialysis. Despite patients' with ESKD composing an extremely high-risk population, they have been largely excluded from landmark clinical trials of HF, and there is, thus, a paucity of data regarding the management of HF in patients on dialysis, and most of the available evidence is observational. Likewise, in clinical practice, guideline-directed medical therapy for HF is often down-titrated or discontinued in patients with ESKD who are undergoing dialysis; this is due to concerns about safety and tolerability. In this state-of-the-art review, we discuss the available evidence for each of the foundational HF therapies in ESKD, review current challenges and barriers to managing patients with HF on dialysis, and outline future directions to optimize the management of HF in these high-risk patients.
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Affiliation(s)
| | - Aymen Ahmed
- Division of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | - Mona Fiuzat
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute-Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA; Baylor Scott and White Research Institute, Dallas, TX, USA
| | - George L Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
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11
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Value of Renal Histology in Predicting Cardiorenal Outcomes in Heart Transplant-listed Patients. Transplant Direct 2022; 9:e1424. [PMID: 36568725 PMCID: PMC9760601 DOI: 10.1097/txd.0000000000001424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 10/28/2022] [Indexed: 12/27/2022] Open
Abstract
Cardiorenal syndrome (CRS) contributes significantly to morbidity and mortality in patients requiring mechanical circulatory support and transplantation. There are no validated markers to predict major adverse kidney events (MAKEs), for which simultaneous heart-kidney transplant (SHKT) could offer improved survival. We evaluate renal histology in predicting MAKEs in transplant-listed patients. Methods We identified 18 patients with renal histology consistent with CRS from 655 consecutive heart transplant-listed patients between 2010 and 2019. Biopsies were analyzed for glomerular, tubular, interstitial, and arteriolar changes tallied to give a biopsy chronicity score. The primary outcome, MAKE, was a composite of death, need for renal replacement therapy (RRT), or estimated glomerular filtration rate decline >50%. These were evaluated at 2 time points: before and following the transplant. Secondary outcomes included the individual components of the composite outcomes and the need for short-term RRT following the transplant. Results The mean age was 52.3 y, 22% were female. Five patients did not survive to transplant. One patient underwent successful SHKT. MAKE occurred in 8 of 18 before the transplant and in 8 of 13 following the transplant. Neither outcome was predicted by baseline biochemistry. The biopsy chronicity score was significantly higher in patients with MAKE before transplant (4.3 versus 1.7, P = 0.024) and numerically higher in patients requiring short-term RRT following transplant (3.2 versus 0.7, P = 0.075). Contrary to limited previous literature, interstitial fibrosis did not predict any outcome, whereas tubular atrophy and arteriosclerosis were associated with MAKE before transplant. Conclusions A higher biopsy chronicity score was associated with adverse kidney endpoints, raising its potential utility over standard biochemistry in considering SHKT referral.
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12
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Ahsan SA, El Nihum LI, Arunachalam P, Manian N, Al Abri Q, Guha A. Current considerations for heart-kidney transplantation. FRONTIERS IN TRANSPLANTATION 2022; 1:1022780. [PMID: 38994391 PMCID: PMC11235302 DOI: 10.3389/frtra.2022.1022780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 09/28/2022] [Indexed: 07/13/2024]
Abstract
Cardiorenal syndrome is a complex syndrome characterized by dysfunction of the heart and kidneys in an interdependent fashion and is further divided into different subtypes based on primary organ dysfunction. Simultaneous Heart-Kidney transplantation is the treatment of choice for end-stage irreversible dysfunction of both organs, however it may be avoided with determination of cardiorenal subtype and management of primary organ dysfunction. This article discusses types of cardiorenal syndrome, indications and concerns regarding the use of simultaneous heart-kidney transplantation, and outlines algorithms for determination of need for dual vs. single organ transplantation.
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Affiliation(s)
- Syed Adeel Ahsan
- DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX, United States
| | - Lamees I. El Nihum
- DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX, United States
- Texas A&M College of Medicine, Bryan, TX, United States
| | - Priya Arunachalam
- DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX, United States
- Texas A&M College of Medicine, Bryan, TX, United States
| | - Nina Manian
- DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX, United States
- Texas A&M College of Medicine, Bryan, TX, United States
| | - Qasim Al Abri
- DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX, United States
| | - Ashrith Guha
- DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX, United States
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13
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Ahsan SA, Guha A, Gonzalez J, Bhimaraj A. Combined Heart-Kidney Transplantation: Indications, Outcomes, and Controversies. Methodist Debakey Cardiovasc J 2022; 18:11-18. [PMID: 36132574 PMCID: PMC9461692 DOI: 10.14797/mdcvj.1139] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 07/08/2022] [Indexed: 11/21/2022] Open
Abstract
Renal dysfunction, a prevalent comorbidity in advanced heart failure, is associated with significant morbidity and mortality after heart transplantation. In the recent era, the field of combined heart-kidney transplantation has experienced great success in the treatment of both renal and cardiac dysfunction in end-stage disease states, and the number of transplants has increased dramatically. In this review, we discuss appropriate indications and selection criteria, overall and organ-specific outcomes, and future perspectives in the field of combined heart-kidney transplantation.
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Affiliation(s)
- Syed Adeel Ahsan
- Methodist DeBakey Heart & Vascular Center, Houston Methodist, Houston, Texas, US
| | - Ashrith Guha
- Methodist DeBakey Heart & Vascular Center, Houston Methodist, Houston, Texas, US
| | - Juan Gonzalez
- The Kidney Institute, Houston Methodist, Houston, Texas, US
| | - Arvind Bhimaraj
- Methodist DeBakey Heart & Vascular Center, Houston Methodist, Houston, Texas, US
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14
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Overcoming challenges in patient selection and monitoring in combined heart and kidney transplantation. Curr Opin Organ Transplant 2022; 27:363-368. [PMID: 36354263 DOI: 10.1097/mot.0000000000000989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Combined heart-kidney transplantation (HKT) is a growing therapeutic strategy in patients with advanced heart failure (HF) and concomitant chronic kidney disease (CKD). Although patients with advanced HF and need for chronic haemodialysis have a clear indication for combined HKT, challenges to current practice lie in identifying those patients with severely depressed kidney function, which will not recover kidney function after restoration of appropriate haemodynamic conditions following heart transplantation (HT) alone. Because of the paucity of available organs, maximisation of kidney graft utility whilst minimising the operative risks associated with combined transplantation is mandatory. The benefits of HKT go beyond the mere restoration of kidney function. Data from registry analysis show that HKT improves overall survival in patients with CKD, as compared to heart transplant only, and it is associated with reduced incidence of heart allograft rejection, likely through the promotion of host immune tolerance mechanisms. In patients not requiring chronic dialysis, kidney-after-heart strategy may be explored, instead of combined HKT, in particular when the aetiology of CKD is unclear. This indeed allows for monitoring and gaging of indications for combined transplantation in the postoperative period. This approach however should be matched with priority listing for kidney transplantation given the high waitlist mortality in heart transplant recipients with associated CKD. The use of kidney machine perfusion may represent an additional tool to optimise the outcome of HKT, allowing more time to stabilise the patient after HT surgery.
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15
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Patient selection for heart transplant: balancing risk. Curr Opin Organ Transplant 2022; 27:36-44. [PMID: 34939963 DOI: 10.1097/mot.0000000000000943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Heart failure incidence continues to rise despite a relatively static number of available donor hearts. Selecting an appropriate heart transplant candidate requires evaluation of numerous factors to balance patient benefit while maximizing the utility of scarce donor hearts. Recent research has provided new insights into refining recipient risk assessment, providing additional tools to further define and balance risk when considering heart transplantation. RECENT FINDINGS Recent publications have developed models to assist in risk stratifying potential heart transplant recipients based on cardiac and noncardiac factors. These studies provide additional tools to assist clinicians in balancing individual risk and benefit of heart transplantation in the context of a limited donor organ supply. SUMMARY The primary goal of heart transplantation is to improve survival and maximize quality of life. To meet this goal, a careful assessment of patient-specific risks is essential. The optimal approach to patient selection relies on integrating recent prognostication models with a multifactorial assessment of established clinical characteristics, comorbidities and psychosocial factors.
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16
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Letter Regarding "Cardiac Outcomes in Isolated Heart and Simultaneous Kidney and Heart Transplants in the United States". Kidney Int Rep 2022; 7:125. [PMID: 35005322 PMCID: PMC8720655 DOI: 10.1016/j.ekir.2021.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/11/2021] [Indexed: 11/23/2022] Open
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17
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Agarwal K, Patel H, Agrawal N, Cardarelli F, Goyal N. In Reply to "Letter Regarding 'Cardiac Outcomes in Isolated Heart and Simultaneous Kidney and Heart Transplants in the United States'". Kidney Int Rep 2022; 7:125-126. [PMID: 35005323 PMCID: PMC8720666 DOI: 10.1016/j.ekir.2021.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 11/08/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Krishna Agarwal
- Department of Nephrology, The Transplant Institute, Boston, Massachusetts, USA
| | - Het Patel
- Department of Nephrology, The Transplant Institute, Boston, Massachusetts, USA
| | - Nikhil Agrawal
- Department of Nephrology, The Transplant Institute, Boston, Massachusetts, USA
| | | | - Nitender Goyal
- Department of Nephrology, Tufts University Medical Center, Boston, MA
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