1
|
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.
Collapse
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.
| |
Collapse
|
2
|
Nuqali A, Bellumkonda L. Dual organ transplantation: when heart alone is not enough. Curr Opin Organ Transplant 2023; 28:370-375. [PMID: 37582057 DOI: 10.1097/mot.0000000000001093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
PURPOSE OF REVIEW The number of dual organ transplantations (DOT) are steadily increasing over the past few years. This is both a reflection of increasing complexity and advanced disease process in the patients and greater transplant center experience with performing dual organ transplants. Due to lack of standardization of the process, there remains significant center-based variability in patient selection, perioperative and long-term management of these patients. RECENT FINDINGS Overall posttransplant outcomes for DOT have been acceptable with some immunological advantages because of partial tolerance offered by the second organ. These achievements should, however, be balanced with the ethical implications of bypassing the patients who are listed for single organ transplantation because of the preferential allocation of organs for DOT. SUMMARY The field of DOT is expanding rapidly, with good long-term outcomes. There is an urgent need for guidelines to standardize the process of patient selection and listing dual organ transplantation.
Collapse
Affiliation(s)
- Abdulelah Nuqali
- Division of Cardiology, Department of Medicine Yale University School of Medicine, New Haven, Connecticut, USA
| | | |
Collapse
|
3
|
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.
Collapse
|
4
|
Mete M, Ayvaci MU, Ariyamuthu VK, Amin A, Peltz M, Thibodeau JT, Grodin JL, Mammen PP, Garg S, Araj F, Morlend R, Drazner MH, AbdulRahim N, Kim Y, Salam Y, Gungor AB, Delibasi B, Kotla SK, MacConmara MP, Mohan P, Gupta G, Tanriover B. Predicting Post-Heart Transplant Composite Renal Outcome Risk in Adults: A Machine Learning Decision Tool. Kidney Int Rep 2022; 7:1410-1415. [PMID: 35685329 PMCID: PMC9171705 DOI: 10.1016/j.ekir.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 03/29/2022] [Accepted: 04/04/2022] [Indexed: 12/02/2022] Open
|
5
|
Donor selection for multiorgan transplantation. Curr Opin Organ Transplant 2022; 27:52-56. [PMID: 34939964 DOI: 10.1097/mot.0000000000000940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW There is limited data and guidance on donor selection for multiorgan transplantation. In this article, we review the current Organ Procurement and Transplantation Network policy on multiorgan allocation and the ideal donor criteria for each specific organ, in order to provide a framework to guide donor selection for various scenarios of multiorgan transplantation, including heart-kidney, heart-lung, heart-liver and heart-kidney-liver transplant procedures. RECENT FINDINGS Combined heart-kidney transplantation is the most common multiorgan transplant procedure and requires the most stringent HLA matching to ensure optimal graft survival. Using the virtual crossmatch and desensitization therapies can shorten waitlist times without increasing posttransplant rejection or mortality rates. The ideal heart-lung donor tends to be younger than other multiorgan transplants, and more tolerant to HLA mismatch, but ideally requires donors with no prior history of smoking, a short period of time on mechanical ventilation, adequate oxygenation and absence of pulmonary infection. The ideal heart-liver donor is often driven by criteria specific to the donor heart. Finally, several observational studies suggest that livers are more tolerant to HLA mismatch than other organs, and offer some degree of immune protection in combined organ transplants. SUMMARY Multiorgan transplantation is a steadily growing field. The required short ischemic time for the donor heart is often the limiting factor, as well as the scarcity of appropriate donors available within geographical confines. In general, as with single organ transplantation, younger age, size matching, few medical comorbidities and HLA compatibility confer the best posttransplant outcomes.
Collapse
|
6
|
Optimal Immunosuppression Strategy in the Sensitized Kidney Transplant Recipient. J Clin Med 2021; 10:jcm10163656. [PMID: 34441950 PMCID: PMC8396983 DOI: 10.3390/jcm10163656] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/09/2021] [Accepted: 08/15/2021] [Indexed: 01/10/2023] Open
Abstract
Patients with previous sensitization events against anti-human leukocyte antigens (HLA) often have circulating anti-HLA antibodies. Following organ transplantation, sensitized patients have higher rates of antibody-mediated rejection (AMR) compared to those who are non-sensitized. More stringent donor matching is required for these patients, which results in a reduced donor pool and increased time on the waitlist. Current approaches for sensitized patients focus on reducing preformed antibodies that preclude transplantation; however, this type of desensitization does not modulate the primed immune response in sensitized patients. Thus, an optimized maintenance immunosuppressive regimen is necessary for highly sensitized patients, which may be distinct from non-sensitized patients. In this review, we will discuss the currently available therapeutic options for induction, maintenance, and adjuvant immunosuppression for sensitized patients.
Collapse
|
7
|
Kobashigawa J, Dadhania DM, Farr M, Tang WHW, Bhimaraj A, Czer L, Hall S, Haririan A, Formica RN, Patel J, Skorka R, Fedson S, Srinivas T, Testani J, Yabu JM, Cheng XS. Consensus conference on heart-kidney transplantation. Am J Transplant 2021; 21:2459-2467. [PMID: 33527725 DOI: 10.1111/ajt.16512] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 01/13/2021] [Accepted: 01/24/2021] [Indexed: 01/25/2023]
Abstract
Simultaneous heart-kidney transplant (sHK) has enabled the successful transplantation of patients with end-stage heart disease and concomitant kidney disease, with non-inferior outcomes to heart transplant (HT) alone. The decision for sHK is challenged by difficulties in differentiating those patients with a significant component of reversible kidney injury due to cardiorenal syndrome who may recover kidney function after HT, from those with intrinsic advanced kidney disease who would benefit most from sHK. A consensus conference on sHK took place on June 1, 2019 in Boston, Massachusetts. The conference represented a collaborative effort by experts in cardiothoracic and kidney transplantation from centers across the United States to explore the development of guidelines for the interdisciplinary criteria for kidney transplantation in the sHK candidate, to evaluate the current allocation of kidneys to follow the heart for sHK, and to recommend standardized care for the management of sHK recipients. The conference served as a forum to unify criteria between the different specialties and to forge a pathway for patients who may need dual organ transplantation. Due to the continuing shortage of available donor organs, ethical problems related to multi-organ transplantation were also debated. The findings and consensus statements are presented.
Collapse
Affiliation(s)
- Jon Kobashigawa
- Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | | | | | | | | | - Lawrence Czer
- Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Shelley Hall
- Baylor University Medical Center, Dallas, Texas, USA
| | | | | | - Jignesh Patel
- Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Rafael Skorka
- Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | | | | | | | - Julie M Yabu
- University of California at Los Angeles, Los Angeles, California, USA
| | | | | |
Collapse
|
8
|
Kovac D, Choe J, Liu E, Scheffert J, Hedvat J, Anamisis A, Salerno D, Lange N, Jennings DL. Immunosuppression considerations in simultaneous organ transplant. Pharmacotherapy 2021; 41:59-76. [PMID: 33325558 DOI: 10.1002/phar.2495] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/21/2020] [Accepted: 12/01/2020] [Indexed: 12/12/2022]
Abstract
Solid organ transplantation is a life-saving procedure for patients in the end stage of heart, lung, kidney, and liver failure. For patients with more than one failing organ, simultaneous organ transplantation has emerged as a viable treatment option. Immunosuppression strategies and outcomes for simultaneous organ transplant recipients have been reported, but often involve limited populations. Transplanting dual organs poses challenges in terms of balancing immunosuppression with immunologic risk and allograft damage from surgical complications. Furthermore, transplanting certain organs can impose considerations on the management of immunosuppression. For example, liver allografts may confer immunologic privilege and lower rates of rejection of other allografts. This review article evaluates immunosuppression strategies for simultaneous kidney-pancreas, liver-kidney, heart-kidney, heart-liver, heart-lung, lung-liver, and lung-kidney transplants. To date, no comprehensive review exists to address immunosuppressive strategies in simultaneous organ transplant populations. Our review summarizes the available literature and provides evidence-based recommendations regarding immunosuppression strategies in simultaneous organ transplant recipients.
Collapse
Affiliation(s)
- Danielle Kovac
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - Jason Choe
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - Esther Liu
- Department of Pharmacy, NewYork-Presbyterian Weill Cornell Medical Center, New York, New York, USA
| | - Jenna Scheffert
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - Jessica Hedvat
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - Anastasia Anamisis
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - David Salerno
- Department of Pharmacy, NewYork-Presbyterian Weill Cornell Medical Center, New York, New York, USA
| | - Nicholas Lange
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - Douglas L Jennings
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA.,Division of Pharmacy Practice, Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, New York, New York, USA
| |
Collapse
|
9
|
Awad MA, Czer LSC, Emerson D, Jordan S, De Robertis MA, Mirocha J, Kransdorf E, Chang DH, Patel J, Kittleson M, Ramzy D, Chung JS, Cohen JL, Esmailian F, Trento A, Kobashigawa JA. Combined Heart and Kidney Transplantation: Clinical Experience in 100 Consecutive Patients. J Am Heart Assoc 2020; 8:e010570. [PMID: 30741603 PMCID: PMC6405671 DOI: 10.1161/jaha.118.010570] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Combined heart and kidney transplantation (HKTx) is performed in patients with severe heart failure and advanced renal insufficiency. We analyzed the long‐term survival after HKTx, the influence of age and dialysis status, the rates of cardiac rejection, and the influence of sensitization. Methods and Results From June 1992 to December 2016, we performed 100 HKTx procedures. We compared older (≥60 years, n=53) with younger (<60 years, n=47) recipients, and recipients on preoperative dialysis (n=49) and not on dialysis (n=51). We analyzed actuarial freedom from any cardiac rejection, acute cellular rejection, and antibody‐mediated rejection, and survival rates by sensitized status with panel‐reactive antibody levels <10%, 10% to 50%, and >50%, and compared these survival rates with those from the United Network for Organ Sharing database. There was no difference in 15‐year survival between the 2 age groups (35±12.4% and 49±17.3%, ≥60 versus <60 years; P=0.45). There was no difference in 15‐year survival between the dialysis and nondialysis groups (44±13.4% and 37±15.2%, P=0.95). Actuarial freedom from any cardiac rejection (acute cellular rejection>0 or antibody‐mediated rejection>0) was 92±2.8% and 84±3.8%, acute cellular rejection (≥2R/3A) 98±1.5% and 94±2.5%, and antibody‐mediated rejection (≥1) 96±2.1% and 93±2.6% at 30 days and 1 year after HKTx. There was no difference in the 5‐year survival among recipients by sensitization status with panel‐reactive antibody levels <10%, 10% to 50%, and >50% (82±5.9%, 83±10.8%, and 92±8.0%; P=0.55). There was no difference in 15‐year survival after HKTx between the United Network for Organ Sharing database and our center (38±3.2% and 40±10.1%, respectively; P=0.45). Conclusions HKTx is safe to perform in patients 60 years and older or younger than 60 years and with or without dialysis dependence, with excellent outcomes. The degree of panel‐reactive antibody sensitization did not appear to affect survival after HKTx.
Collapse
Affiliation(s)
- Morcos Atef Awad
- 1 Division of Cardiology Cedars-Sinai Smidt Heart Institute the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA
| | - Lawrence S C Czer
- 1 Division of Cardiology Cedars-Sinai Smidt Heart Institute the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA
| | - Dominic Emerson
- 2 Division of Cardiothoracic Surgery Department of Surgery Cedars-Sinai Smidt Heart Institute the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA
| | - Stanley Jordan
- 3 Division of Pediatric Nephrology the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA
| | - Michele A De Robertis
- 2 Division of Cardiothoracic Surgery Department of Surgery Cedars-Sinai Smidt Heart Institute the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA
| | - James Mirocha
- 4 Section of Biostatistics Cedars-Sinai Medical Center Los Angeles CA
| | - Evan Kransdorf
- 1 Division of Cardiology Cedars-Sinai Smidt Heart Institute the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA
| | - David H Chang
- 1 Division of Cardiology Cedars-Sinai Smidt Heart Institute the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA
| | - Jignesh Patel
- 1 Division of Cardiology Cedars-Sinai Smidt Heart Institute the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA
| | - Michelle Kittleson
- 1 Division of Cardiology Cedars-Sinai Smidt Heart Institute the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA
| | - Danny Ramzy
- 2 Division of Cardiothoracic Surgery Department of Surgery Cedars-Sinai Smidt Heart Institute the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA
| | - Joshua S Chung
- 2 Division of Cardiothoracic Surgery Department of Surgery Cedars-Sinai Smidt Heart Institute the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA
| | - J Louis Cohen
- 5 Department of Surgery Cedars-Sinai Medical Center Los Angeles CA
| | - Fardad Esmailian
- 2 Division of Cardiothoracic Surgery Department of Surgery Cedars-Sinai Smidt Heart Institute the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA
| | - Alfredo Trento
- 2 Division of Cardiothoracic Surgery Department of Surgery Cedars-Sinai Smidt Heart Institute the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA
| | - Jon A Kobashigawa
- 1 Division of Cardiology Cedars-Sinai Smidt Heart Institute the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA
| |
Collapse
|
10
|
Grupper A. The first step of a long journey: Effect of induction regimen on prognosis among simultaneous heart-kidney transplant recipients. J Heart Lung Transplant 2018; 37:570-571. [PMID: 29426715 DOI: 10.1016/j.healun.2018.01.1292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 01/18/2018] [Indexed: 10/18/2022] Open
Affiliation(s)
- Avishay Grupper
- Heart Failure Institute, Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel.
| |
Collapse
|