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Incidence and Risk Factors for Stroke After Combined Heart-Kidney and Heart-Liver Transplantation
Armaan F Akbar1,2, Sorush Rokui1,3, Alice L Zhou1,2
1Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA.
Insights
Stroke is more frequent after heart-liver (HLT) and heart-kidney transplants (HKT) than isolated heart transplants, leading to poorer survival rates. Postoperative dialysis and pre-transplant percutaneous VAD are key risk factors for stroke in these complex transplant patients.
Area of Science:
- Cardiology
- Nephrology
- Hepatology
- Transplantation Medicine
Background:
- Stroke is a known complication of isolated heart transplantation.
- The incidence and risk factors for stroke following simultaneous heart-liver (HLT) and heart-kidney transplantation (HKT) remain underexplored.
- Understanding these risks is crucial for improving patient outcomes in complex multi-organ transplant scenarios.
Purpose of the Study:
- To compare the incidence of postoperative stroke in patients undergoing HLT and HKT versus isolated heart transplantation.
- To identify independent risk factors associated with stroke after HLT and HKT.
- To evaluate the impact of stroke on short-term survival following these transplant procedures.
Main Methods:
- Utilized the United Network for Organ Sharing database for adult patients from 1994-2022.
- Stratified patients based on the occurrence of in-hospital stroke post-transplant.
- Employed Kaplan-Meier analysis for 1-year survival and multivariable logistic regression to determine stroke risk factors.
Main Results:
- Stroke incidence was higher in HKT (3.7%) and HLT (4.3%) recipients compared to isolated heart transplant recipients (2.9%).
- One-year post-transplant survival was significantly lower for stroke patients in both HKT (64.5% vs. 88.7%) and HLT (43.8% vs. 87.4%) groups.
- Independent stroke risk factors included pre-transplant VAD, prior stroke, postoperative dialysis, diabetes, prior cardiac surgery, and heart cold ischemic time for HKT; postoperative dialysis was significant for HLT.
Conclusions:
- Simultaneous HLT and HKT are associated with a higher incidence of postoperative stroke compared to isolated heart transplantation.
- Stroke following HLT and HKT significantly impairs 1-year post-transplant survival.
- Pre-transplant percutaneous VAD (for HKT) and postoperative dialysis (for HKT and HLT) are critical modifiable risk factors for stroke in these patient populations.
Objective:
While stroke is a well-recognized complication of isolated heart transplantation, stroke in patients undergoing simultaneous heart-liver (HLT) and heart-kidney transplantation (HKT) has not been explored. This study assessed postoperative stroke incidence, risk factors, and outcomes in HLT and HKT compared with isolated heart transplant.
Methods:
The United Network for Organ Sharing database was queried for adult patients undergoing HLT, HKT, and isolated heart transplants between 1994 and 2022. Patients were stratified by presence of in-hospital stroke after transplant. Post-transplant survival at 1-year was assessed using Kaplan-Meier analysis and log-rank tests. Separate multivariable logistic regression models were constructed to identify risk factors for stroke after HKT and HLT.
Results:
Of 2326 HKT recipients, 85 experienced stroke, and of 442 HLT recipients, 19 experienced stroke. Stroke was more common after HKT and HLT than after an isolated heart transplant (3.7% vs. 4.3% vs. 2.9%, p = 0.01). One-year post-transplant survival was lower in those with stroke among both HKT recipients (64.5% vs. 88.7%, p(log-rank) < 0.001) and HLT recipients (43.8% vs. 87.4%, p(log-rank) < 0.001. Pre-transplant pVAD, prior stroke, postoperative dialysis, diabetes, prior cardiac surgery, and heart cold ischemic time were independent risk factors for stroke after HKT, after adjusting for age, sex, and need for blood transfusion on the waitlist. For HLT, postoperative dialysis was a significant risk factor.
Conclusions:
Stroke is more common after HKT and HLT than after isolated heart transplant, and results in poor survival. Independent risk factors for stroke include pre-transplant percutaneous VAD (HKT) and postoperative dialysis (HKT and HLT).
