Use of Ventricular Assist Device as Bridge to Simultaneous Heart and Kidney Transplantation in Patients with Cardiac and Renal Failure

Outcomes of Patients Undergoing Combined Heart-Kidney Transplantation With or Without Prior Ventricular Assist Device

BACKGROUND

Both combined heart-kidney transplantation and ventricular assist devices (VADs) pose significant challenges, including sensitization, immunosuppressive treatment, and infrastructure demands. Despite these challenges, we hypothesized that the recipients of combined heart-kidney transplants with and without VADs would have equivalent survival. We aimed to compare the survival of heart-kidney transplant recipients with and without prior VAD placement.

METHODS

We retrospectively analyzed all patients enrolled in the United Network for Organ Sharing database who underwent heart-kidney transplants. We created a matched cohort of patients undergoing heart-kidney transplantation with or without prior VAD using 1:1 nearest propensity-score matching with preoperative variables.

RESULTS

In the propensity-matched cohort, 399 patients underwent heart-kidney transplantation with prior VAD, and 399 underwent heart-kidney transplantation without prior VAD. The estimated survival of heart--kidney recipients with prior VAD was 84.8% at one year, 81.2% at 3 years, and 75.3% at 5 years. The estimated survival of heart-kidney recipients without prior VAD was 86.8.7% at one year, 84.0% at 3 years, and 78.8% at 5 years. There was no statistically significant difference in the survival of heart-kidney transplant recipients with or without prior VAD at one year (P = .42; Figure 2), 3 years (P = .34), or 5 years (P = .30).

CONCLUSION

Despite the increased challenge of heart-kidney transplantation in recipients with prior VAD, we demonstrated that these patients have similar survival to those who underwent heart-kidney transplantation without previous VAD placement.

Outcomes in LVAD Patients Undergoing Simultaneous Heart-Kidney Transplantation

BACKGROUND

Multiple studies have shown better outcomes for simultaneous heart kidney transplant (sHKT) compared with isolated orthotopic heart transplant (iOHT) in recipients with chronic kidney disease (CKD). However, outcomes in patients supported by durable LVAD have not been well studied.

METHODS

Patients with durable LVADs and stage 3 or greater CKD (eGFR <60ml/min/1.73m2) undergoing iOHT or sHKT between 2008-2020 were identified from the United Network for Organ Sharing (UNOS) registry. Kaplan Meier survival analysis with associated log-rank test was conducted to compare post-transplant survival. Multivariable modeling was used in order to identify risk adjusted predictors of one-year posttransplant mortality.

RESULTS

4375 patients were identified, 366 underwent sHKT and 4009 iOHT. The frequency of sHKT increased over the study period. One-year post-transplant survival was worse in sHKT compared with iOHT (80.3% vs 88.3%, p<0.001), and persisted up to 5 years post-transplant (p=0.001). sHKT recipients were more likely to require dialysis after transplant and had longer hospital length of stay (p<0.001). Multivariable analysis showed sHKT remained an independent risk factor for mortality at 1 year (OR 1.58, p=0.002).

CONCLUSIONS

HKT is becoming more common in patients with durable LVADs. Compared with iOHT, sHKT have worse short and long-term survival are more likely to require posttransplant dialysis.

Use of durable mechanical circulatory support on outcomes of heart-kidney transplantation

OBJECTIVES

Previous studies have demonstrated that preheart transplant mechanical circulatory support (MCS) can lead to a small but significant increase in mortality. However, data on outcomes of patients with MCS who require simultaneous heart-kidney transplant are limited.

METHODS

A retrospective review of simultaneous heart-kidney transplantations (HKTxs) performed at a single institution over a 5-year period was performed. Patients were divided based on the preoperative use of durable MCS. Renal graft-related end points were evaluated, including glomerular filtration rate following transplantation, prevalence of delayed renal graft function and freedom from antibody and cellular-mediated graft rejection. Patient-specific outcomes, including survival and frequency of non-fatal major adverse cardiac events at 1 year, were additionally assessed.

RESULTS

During the study period, 50 HKTxs were performed, 14 of which had preoperative MCS. HKTx patients with and without MCS implantations had a similar prevalence of delayed graft function (57.1% vs 50.0%; P = 0.757). A numerical trend was observed towards a reduced glomerular filtration rate 1-month post-transplant in patients without an MCS device (81.2 ± 32.8 vs 64.4 ± 27.5; P = 0.072), but no significant difference was observed at 6 and 12 months. No significant difference was observed on the need for post-transplant renal replacement therapy, non-fatal major adverse cardiac events, freedom from graft rejection and overall survival at 1 year.

CONCLUSIONS

The use of preoperative MCS in patients undergoing combined HKTx was not found to affect renal graft function post-transplantation and does not seem to be associated with increase in morbidity or mortality.

Combined Heart and Kidney Transplantation: A 23-Year Experience

BACKGROUND

We report clinical experience with combined heart and kidney transplantation (HKTx) over a 23-year time period.

METHODS

From June 1992 to August 2015, we performed 83 combined HKTx procedures at our institution. We compared the more recent cohort of 53 HKTx recipients (group 2, March 2009 to August 2015) with the initial 30 previously reported HKTx recipients (group 1, June 1992 to February 2009). Pre-operative patient characteristics, peri-operative factors, and post-operative outcomes including survival were examined.

RESULTS

The baseline characteristics of the two groups were similar, except for a lower incidence of ethanol use and higher pre-operative left-ventricular ejection fraction, cardiac output, and cardiac index in group 2 when compared with group 1 (P = .007, .046, .037, respectively). The pump time was longer in group 2 compared with group 1 (153.30 ± 38.68 vs 129.60 ± 37.60 minutes; P = .007), whereas the graft ischemic time was not significantly different between the groups, with a trend to a longer graft ischemic time in group 2 versus group 1 (195.17 ± 45.06 vs 178.07 ± 52.77 minutes; P = .056, respectively). The lengths of intensive care unit (ICU) and hospital stay were similar between the groups (P = .083 and .39, respectively). In addition, pre-operative and post-operative creatinine levels at peak, discharge, 1 year, and 5 years and the number of people on post-operative dialysis were similar between the groups (P = .37, .75, .54, .87, .56, and P = .139, respectively). Overall survival was not significantly different between groups 2 and 1 for the first 5 years after transplant, with a trend toward higher survival in group 2 (P = .054).

CONCLUSIONS

The most recent cohort of combined heart and kidney transplant recipients had similar ICU and hospital lengths of stay and post-operative creatinine levels at peak, discharge, and 1 and 5 years and a similar number of patients on post-operative dialysis when compared with the initial cohort. Overall survival was not significantly different between the later and earlier groups, with a trend toward higher overall survival at 5 years in the more recent cohort of patients. In selected patients with co-existing heart and kidney failure, combined heart and kidney transplantation is safe to perform and has excellent outcomes.

Bridge with a left ventricular assist device to a simultaneous heart and kidney transplant: Review of the United Network for Organ Sharing database

BACKGROUND

Left ventricular assist device (LVAD) implantation as a bridge to cardiac transplantation (BTT) is an effective treatment for end-stage heart failure patients. Currently, there is an increasing number of patients with a LVAD who need a heart and kidney transplant (HKT). Little is known of the prognostic outcomes in these patients. This study was undertaken to determine whether an equivalent outcome would be present in HKTs as compared to a non-LVAD primary HKT cohort.

METHODS

We reviewed the United Network for Organ Sharing database from 2004 to 2013. Orthotropic heart transplant recipients (n = 49 799) were subcategorized as dual organ HKT (n = 1 921) and then divided into cohorts of HKT following continuous flow left ventricular assist device placement (CF-VAD-HKT, n = 113) or no LVAD placement (HKT, n = 1 808). Survival after transplantation was analyzed.

RESULTS

For CF-LVAD-HKT and HKT cohorts, preoperative characteristics were similar regarding age (50.8 ± 13.7, 50.1 ± 13.7, p = 0.75) and panel reactive antibody (12.3 ± 18.4 vs 7.1 ± 18.4, p = 0.06). Donors were similar in age, gender, creatinine, and ejection fraction. Post-transplant, there was no difference in complications. Survival for CF-LVAD-HKT and HKT were similar at 1 year (77% vs 82%) and 3 years (75% vs 77%, log rank p = 0.2814).

CONCLUSIONS

For patients with advanced heart failure and persistent renal dysfunction, simultaneous HKT is a safe option. Survival after CF-LVAD-HKT is equivalent to conventional HKT.

Combined heart-kidney transplantation after total artificial heart insertion

We present the first single-center report of 2 consecutive cases of combined heart and kidney transplantation after insertion of a total artificial heart (TAH). Both patients had advanced heart failure and developed dialysis-dependent renal failure after implantation of the TAH. The 2 patients underwent successful heart and kidney transplantation, with restoration of normal heart and kidney function. On the basis of this limited experience, we consider TAH a safe and feasible option for bridging carefully selected patients with heart and kidney failure to combined heart and kidney transplantation. Recent FDA approval of the Freedom driver may allow outpatient management at substantial cost savings. The TAH, by virtue of its capability of providing pulsatile flow at 6 to 10 L/min, may be the mechanical circulatory support device most likely to recover patients with marginal renal function and advanced heart failure.