Incidence, risk factor, and prognosis of end-stage renal disease after heart transplantation in Chinese recipients

Impact of Pretransplant Renal Replacement Therapy on Clinical Outcome After Isolated Heart Transplantation

End stage renal disease (ESRD) is a contraindication to isolated heart transplantation (HT). However, heart candidates with cardiogenic shock may experience acute kidney injury and require renal replacement therapy (RRT) and isolated HT as a life-saving operation. The outcomes, including survival and renal function, are rarely reported. We enrolled 569 patients undergoing isolated HT from 1989 to 2018. Among them, 66 patients required RRT before HT (34 transient and 32 persistent). The survival was worse in patients with RRT than those without (65.2% vs 84.7%; 27.3% vs 51.1% at 1- and 10-year, p < 0.001 and p = 0.012, respectively). Multivariate Cox analysis identified pre-transplant hyperbilirubinemia (Hazard ratio (HR) 2.534, 95% confidence interval (CI) 1.098–5.853, p = 0.029), post-transplant RRT (HR 5.551, 95%CI 1.280–24.068, p = 0.022) and post-transplant early bloodstream infection (HR 3.014, 95%CI 1.270–7.152, p = 0.012) as independent risk factors of 1-year mortality. The majority of operative survivors (98%) displayed renal recovery after HT. Although patients with persistent or transient RRT before HT had a similar long-term survival, patients with persistent RRT developed a high incidence (49.2%) of dialysis-dependent ESRD at 10 years. In transplant candidates with pretransplant RRT, hyperbilirubinemia should be carefully re-evaluated for the eligibility of HT whereas prevention and management of bloodstream infection after HT improve survival.

Long-Term Outcomes and Risk Factors of Renal Failure Requiring Dialysis after Heart Transplantation: A Nationwide Cohort Study

Acute kidney injury and renal failure are common after heart transplantation. We retrospectively reviewed a national cohort and identified 1129 heart transplant patients. Patients receiving renal replacement therapy after heart transplantation were grouped into the dialysis cohort. The long-term survival and risk factors of dialysis were investigated. Patients who had undergone dialysis were stratified to early or late dialysis for subgroup analysis. The mean follow-up was five years, the incidence of dialysis was 28.4% (21% early dialysis and 7.4% late dialysis). The dialysis cohort had higher overall mortality compared with the non-dialysis cohort. The hazard ratios of mortality in patients with dialysis were 3.44 (95% confidence interval (CI), 2.73–4.33) for all dialysis patients, 3.58 (95% CI, 2.74–4.67) for early dialysis patients, and 3.27 (95% CI, 2.44–4.36; all p < 0.001) for late dialysis patients. Patients with diabetes mellitus, chronic kidney disease, acute kidney injury, and coronary artery disease were at higher risk of renal failure requiring dialysis. Cardiomyopathy, hepatitis B virus infection, and hyperlipidemia treated with statins were associated with a lower risk of renal dysfunction requiring early dialysis. The use of Sirolimus and Mycophenolate mofetil was associated with a lower incidence of late dialysis. Renal dysfunction requiring dialysis after heart transplantation is common in Taiwan. Early and late dialysis were both associated with an increased risk of mortality in heart transplant recipients.

Changes in Renal Function After Heart Transplantation

Renal function after heart transplantation (HTx) typically follows a biphasic pattern and an initial decay within 1 to 2 years. Trajectory of renal function after HTx is less reported, especially in Asia. The aims of this cohort study were to describe the changes in HTx recipients' serum creatinine and estimated glomerular filtration rate (eGFR) levels 5 years following HTx in Taiwan.

METHODS

We retrospectively reviewed 5 years of 440 consecutive adult patients (≥ 18 years) who underwent first HTx from June 1987 to December 2014 at the National Taiwan University Hospital.

RESULTS

Among 422 participants, they received induction therapy consisting of intravenous rabbit antithymocyte globulin. Here, we illustrated the trends over the years by dividing the subjects into 2 groups based on their immunosuppressive regimen of transplantation (1987-2002 and 2003-2014) The pretransplantation median serum creatinine concentration level was 1.2 mg/dL, rose to 1.4 mg/dL at 3 months after surgery, and remained steady over 5 years after HTx. Pretransplant median eGFR was 67 mL/min/1.73 m².The median serum creatinine concentration level and eGFR at baseline were all significantly difference than pretransplantation (P > .05). This result has showed that an initial steep decline within 3 months after transplant remained stable 5 years after HTx.

CONCLUSION

As renal function deteriorates after HTx, we observed a steep decline in serum creatinine level and glomerular filtration rate within the 3 months after HTx, followed by a slow rate of deterioration over the following months. We found a time-related progressive deterioration in renal function during the 5 years after HTx.