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  • It is postulated that heart–kidney transplantation (HKTx) can overcome the survival disadvantage of heart-alone transplant in the setting of renal dysfunction (estimated glomerular filtration rate [GFR] <60 mL/min per 1.74 m2).1

  • HKTx candidates on the wait list had a greater incidence of death and a lower incidence of transplantation than heart-alone candidates.2

  • Three-month mortality among wait list candidates1,2

    • 21% for HKTx candidates on dialysis

    • 7% for HKTx candidates with renal insufficiency not on dialysis

    • 31% for heart-alone transplant candidates on dialysis

    • 12% for heart-alone transplant candidates with renal insufficiency not on dialysis

  • HKTx constitute

    • 1.5% of all heart transplants

    • 0.4% of all deceased donor kidney transplants


  • Severe heart failure and advanced renal insufficiency1

    • Candidates with renal dysfunction who are not yet on dialysis should be evaluated for the possibility of renal recovery

      • Heart-alone recipients who are listed for a kidney transplant have almost twice the hazard of wait list death than candidates with no prior history of heart transplantation.

      • Performing a deceased donor heart transplant simultaneously with (or preceding a) live donor kidney transplant has not been fully evaluated.


  • The heart is implanted first.

    • Recipients are then hemodynamically stabilized in the operating room or intensive care unit prior to kidney transplantation.

  • The kidney is implanted:

    • Immediately after the heart (if the recipient is stable)

    • In a delayed fashion (hours after the heart if further stabilization is required)

      • The kidney is kept on a pump or on cold storage

        • A backup kidney transplant recipient should be identified in instances where the heart transplant recipient is not considered stable enough to tolerate the additional kidney transplant.


  • HKTx recipients had a better survival than heart-alone recipients with renal dysfunction.1

    • Five-year survival:2

      • 73% for HKTx recipients who were on dialysis

      • 80% for HKTx recipients who had renal insufficiency but were not on dialysis

      • 51% for heart-alone transplant recipients on dialysis

      • 69% for heart-alone transplant recipients with renal insufficiency but were not on dialysis

  • No difference in 15-year survival rates after HKTx among recipients:1

    • ≥60 or <60 years of age

      • On dialysis or preemptive (note: patients on dialysis were younger)

  • Panel Reactive Antibody (PRA) status did not seem to affect 5-year survival.1

  • Pretransplant dialysis was not reported to influence delayed kidney function after HKTx.1

  • Eighty percent incidence of freedom from rejection at 5 years.

  • Induction therapy with antithymocyte globulin may provide a survival advantage.1

  • Predictors of mortality after HKTx included2

    • Body mass index (BMI) >35 kg/m2

    • Preoperative need of mechanical life support

    • Serum bilirubin >2.0 mg/dL

  • Donor–recipient gender match was associated with improved survival.2

  • Forty-four percent lower adjusted relative risk of death with HKTx than with heart-alone transplant.3

  • Approximately 60% of HKTx performed involved recipients not yet on dialysis.3

  • Four-year ...

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