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Published on: May 7, 2019
Simultaneous heart-kidney transplant compared with heart transplant alone in patients with borderline renal function
Iris Feng1, Amy S Wang2, Koji Takeda1
1Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY.
Insights
For heart transplant candidates with declining kidney function (eGFR <45 mL/minute), simultaneous heart-kidney transplant improves survival and reduces the need for dialysis compared to heart transplant alone.
Area of Science:
- Nephrology
- Cardiology
- Transplantation Medicine
Background:
- Heart transplantation is a life-saving procedure for end-stage heart failure.
- Chronic kidney disease (CKD) is a common comorbidity in heart transplant candidates.
- The optimal management strategy for patients with both heart disease and declining kidney function who are not on dialysis is debated.
Purpose of the Study:
- To compare outcomes of simultaneous heart-kidney transplant ( સંયુક્ત transplant) versus heart transplantation alone (HTA) in patients with estimated glomerular filtration rate (eGFR) <60 mL/minute not requiring dialysis.
- To identify the optimal eGFR threshold at which a combined transplant strategy may offer superior results.
- To evaluate the impact of CKD stage on the benefits of combined versus HTA.
Main Methods:
- Retrospective analysis of 7896 adult patients from the United Network for Organ Sharing database (2005-2021).
- Exclusion of patients who received pretransplant dialysis.
- Stratification into groups based on CKD stage: Stage 3A (eGFR 45-59 mL/minute), Stage 3B (eGFR 30-44 mL/minute), and Stage 4/5 (eGFR <30 mL/minute).
- Comparison of outcomes including all-cause mortality, cardiac allograft failure, and freedom from dialysis or renal transplant.
Main Results:
- Simultaneous heart-kidney transplant recipients with eGFR <45 mL/minute demonstrated improved short- and long-term overall survival and cardiac allograft survival compared to HTA recipients.
- Patients undergoing combined transplant showed greater long-term freedom from dialysis or renal transplant.
- Propensity matched analyses and multivariable Cox regression confirmed these findings, identifying an eGFR cutoff of approximately 45 mL/minute for predicting elevated renal failure risk in HTA recipients.
Conclusions:
- Patients with eGFR between 30-44 mL/minute (CKD Stage 3B) undergoing simultaneous heart-kidney transplant experienced superior outcomes compared to HTA.
- These findings suggest that a combined transplant strategy may benefit a specific subset of heart transplant candidates with moderate to severe CKD.
- The study supports considering combined heart-kidney transplantation for patients with eGFR around 45 mL/minute or lower.
Objective:
This study assessed characteristics and outcomes of patients who are not dependent on dialysis receiving simultaneous heart kidney transplantation versus heart transplantation alone (HTA) to identify optimal eGFR threshold where combined transplant strategy may be superior.
Methods:
This study retrospectively analyzed 7896 adult patients with estimated glomerular filtration rate (eGFR) <60 mL/minute from the United Network for Organ Sharing database who received HTA or simultaneous heart kidney transplant between 2005 and 2021, excluding those who received pretransplant dialysis. Subjects were further stratified into 3 groups based on chronic kidney disease stage at time of transplant: Stage 3A (eGFR 45-59 mL/minute; n = 5044), Stage 3B (eGFR 30-44 mL/minute; n = 2193), and Stage 4 or 5 (eGFR <30 mL/minute; n = 659). Outcomes of interest were all-cause mortality, cardiac allograft failure, and freedom from chronic dialysis or renal transplant following heart transplant.
Results:
Simultaneous heart kidney transplant and HTA recipients differed in various baseline characteristics. Simultaneous heart kidney transplant recipients with eGFR <45 mL/minute had greater short- and long-term overall survival and cardiac allograft survival compared with HTA, as well as greater long-term freedom from chronic dialysis or renal transplant. These results were consistent with both propensity matched analyses and multivariable Cox regression analysis of 10 year outcomes. Optimal cutoff value for pretransplant eGFR in predicting elevated risk of renal failure in recipients of heart transplant alone was found to be eGFR ∼45 mL/minute.
Conclusions:
Similar to patients with eGFR <30 mL/minute, patients with eGFR 30 to 44 mL/minute who underwent simultaneous heart kidney transplant had superior outcomes compared with HTA, suggesting possible benefit of combined transplant strategy for this subset of heart transplant candidates.
Related Concept Videos
01:28Kidney Transplant I: Introduction
01:26Kidney Transplant II: Surgical Procedure
01:16Kidney Transplant III: Nursing Management