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Rejection in the setting of combined Heart and Liver Transplantation
Shuktika Nandkeolyar1, Tripti Gupta2, D Marshall Brinkley2
1Division of Cardiology, Atrium Healthcare, Charlotte, NC, USA.
Insights
Combined heart-liver transplants (HLT) carry a significant risk of rejection, particularly in patients with congenital heart disease (CHD). Close post-transplant monitoring is crucial for these individuals, similar to single-organ transplant recipients.
Area of Science:
- Cardiology
- Hepatology
- Transplant Immunology
Background:
- Combined heart-liver transplantation (HLT) is increasingly performed for distinct patient groups, including those with congenital heart disease (CHD) and liver disease.
- Historically, HLT has been associated with lower rejection rates, even in sensitized patients, leading to a perception of immunological benefit.
- However, some studies suggest that patients with CHD may be highly sensitized, potentially complicating transplantation.
Purpose of the Study:
- To investigate the actual incidence of rejection in patients undergoing combined heart-liver transplantation (HLT).
- To determine if patients with congenital heart disease (CHD) experience rejection episodes post-HLT.
- To evaluate the need for rejection treatment in HLT recipients.
Main Methods:
- Retrospective review of 15 patients who underwent combined heart-liver transplantation (HLT) between January 2017 and February 2022.
- Analysis of rejection episodes in patients with and without congenital heart disease (CHD).
- Comparison of observed rejection rates with previously reported data.
Main Results:
- Rejection episodes were identified in 4 out of 11 (36%) patients with congenital heart disease (CHD).
- One patient without CHD also experienced rejection.
- A significant proportion of CHD patients (73%) had been denied transplant at one or more centers.
Conclusions:
- Combined heart-liver transplantation (HLT) patients, particularly those with congenital heart disease (CHD), remain at risk for rejection.
- The observed rejection rate in this study was higher than previously reported.
- Close monitoring of HLT recipients is essential, similar to single-organ transplant management.
Introduction:
Each year the number of combined heart-liver transplants (HLT) increases, with two distinct patient populations proceeding down this pathway. The first are patients with congenital heart disease (CHD), most commonly single ventricle patients palliated with Fontan. The second group are those with long standing congestive hepatopathy, amyloidosis, hemochromatosis, or alcohol induced myopathies and liver disease.One argument for HLT has been the low rate of rejection even among sensitized patients, with reported rejection rates ranging from 0% to 31%. Historically, those with CHD have been highly sensitized which in some cases may prevent or at least delay transplantation. As such, a recent consensus statement by Emamaulee et al. suggest that "there may be an immunological benefit to proceed with HLT with significantly fewer acute cellular and humoral rejection episodes". The aim of this study is to demonstrate that HLT patients remain at risk for rejection and have required treatment for it.
Results:
There were 15 patients who underwent HLT from January 2017 to February 2022. Of the four patients who did not have CHD, none were considered sensitized, and all underwent induction with basiliximab per our institutional protocol. One of these had rejection. Rejection episodes were identified in four of the 11 CHD patients (36%) patients.
Conclusions:
In our study of 15 HLT, including 11 CHD patients (73% denied transplant at ≥ 1 center) demonstrated a higher rate of rejection than previously reported. While theoretically, HLT may mitigate the likelihood of rejection, the risk still exists, and patients benefit from close monitoring commensurate with single organ transplant.
