CHAPTER 58: Combined Simultaneous Heart–Kidney Transplantation

BACKGROUND

• 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 candidates^1,2

  • 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

INDICATIONS

• 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.

TECHNIQUE

• 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.

OUTCOMES

• 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 ...