Combined Heart and Kidney Transplantation: Clinical Experience in 100 Consecutive Patients

Abstract

Background Combined heart and kidney transplantation ( HKT x) is performed in patients with severe heart failure and advanced renal insufficiency. We analyzed the long-term survival after HKT x, the influence of age and dialysis status, the rates of cardiac rejection, and the influence of sensitization. Methods and Results From June 1992 to December 2016, we performed 100 HKT x procedures. We compared older (≥60 years, n=53) with younger (<60 years, n=47) recipients, and recipients on preoperative dialysis (n=49) and not on dialysis (n=51). We analyzed actuarial freedom from any cardiac rejection, acute cellular rejection, and antibody-mediated rejection, and survival rates by sensitized status with panel-reactive antibody levels <10%, 10% to 50%, and >50%, and compared these survival rates with those from the United Network for Organ Sharing database. There was no difference in 15-year survival between the 2 age groups (35±12.4% and 49±17.3%, ≥60 versus <60 years; P=0.45). There was no difference in 15-year survival between the dialysis and nondialysis groups (44±13.4% and 37±15.2%, P=0.95). Actuarial freedom from any cardiac rejection ( acute cellular rejection >0 or antibody-mediated rejection >0) was 92±2.8% and 84±3.8%, acute cellular rejection (≥2R/3A) 98±1.5% and 94±2.5%, and antibody-mediated rejection (≥1) 96±2.1% and 93±2.6% at 30 days and 1 year after HKT x. There was no difference in the 5-year survival among recipients by sensitization status with panel-reactive antibody levels <10%, 10% to 50%, and >50% (82±5.9%, 83±10.8%, and 92±8.0%; P=0.55). There was no difference in 15-year survival after HKT x between the United Network for Organ Sharing database and our center (38±3.2% and 40±10.1%, respectively; P=0.45). Conclusions HKT x is safe to perform in patients 60 years and older or younger than 60 years and with or without dialysis dependence, with excellent outcomes. The degree of panel-reactive antibody sensitization did not appear to affect survival after HKT x.

Keywords: heart failure; heart transplantation; hemodialysis; kidney transplantation; mortality; renal disease.

Figure 1

Kaplan–Meier survival rates after heart and kidney transplantation in recipients younger (<) and older than (≥) 60 years. Survival rates were similar between the groups up to 15 years after transplant (P=0.45). SE indicates standard error.

Figure 2

Kaplan–Meier survival rates after heart and kidney transplantation in recipients with and without pretransplant dialysis. Survival rates were similar between the groups up to 15 years after transplant (P=0.95). SE indicates standard error.

Figure 3

Kaplan–Meier actuarial freedom from rejection after heart and kidney transplantation. A, free from any cardiac rejection (grade of acute cellular rejection [ACR] >0 or antibody‐mediated rejection [AMR] >0), (B) free from significant or treated cellular rejection (ACR ≥2R/3A), (C) free from AMR (AMR ≥1). SE indicates standard error.

Figure 4

Kaplan–Meier survival rates after heart and kidney transplantation in recipients with panel‐reactive antibody sensitizations <10%, 10% to 50%, and >50%. Survival rates were similar between the groups up to 5 years after transplant (P=0.55). SE indicates standard error.

Figure 5

Kaplan–Meier survival rates comparing the United Network for Organ Sharing (UNOS) heart transplantation (HTx) experience, the UNOS heart and kidney transplantation (HKTx) experience, and our HKTx experience. Our data are from June 1992 to December 2016. The UNOS data are from February 1992 to December 2014. Survival rates were similar among all groups up to 15 years after transplant (P=0.16). Survival rates were also similar between UNOS HKTx and our own HKTx recipients up to 15 years after transplant (P=0.45 when separately analyzed). SE indicates standard error.