Evolving indications and management patterns in heart - kidney transplantation

Dual heart - kidney transplantation (HKT) is an increasingly utilized option for patients with end-stage heart failure and impaired renal function. In 2023, the United Network for Organ Sharing (UNOS) formalized indications for simultaneous heart - kidney transplantation (SHKT) and kidney-after-heart transplantation (KAHT). In light of this landmark effort, we review the evolution in HKT indications, outcomes after SHKT and KAHT in various patient populations, novel considerations in pre and posttransplant management, and areas for future research.

The UNOS policy was borne out of retrospective outcome studies suggesting that SHKT is superior to single-organ heart transplantation (HT) in select patients with sufficiently severe renal impairment. KAHT utilization continues to evolve, providing a helpful safety net for HT recipients with irreversible worsening of renal function. Time-limited pretransplant device trials are useful for identifying optimal candidates for HKT, and calcineurin inhibitor-sparing regimens can preserve posttransplant renal function. Explorations into artificial intelligence algorithms and biomarker technology represent interesting future opportunities.

Recent studies have refined selection and management of dual HKT recipients. The new UNOS policies now provide helpful standardization to the field. Rapid innovation to date has made dual HKT an exciting therapeutic strategy for patients with few options left.