Early Renal Outcomes Following Heart Transplantation Using Organs Procured After Circulatory Death

Abstract

Background: Transplantation using hearts obtained through donation after circulatory death (DCD) is increasing, but data on recipient renal outcomes are limited.

Methods and results: Patients at a single institution who underwent heart transplantation using organs procured through DCD or donation after brain death (DBD) from April 2016 to August 2022 were included in this retrospective cohort study. Hemodynamic measures were collected via right heart catheterization performed 1 week after transplantation. Posttransplantation renal outcomes included estimated glomerular filtration rate at 1 week, 4 weeks, and 16 weeks, and the incidence of acute kidney injury (AKI) and renal replacement therapy within 1 week. The analysis included 225 patients (55 recipients of DCD). Baseline characteristics were comparable between recipients of DCD and DBD. Renal outcomes within 1 week posttransplantation in recipients of DCD were similar to recipients of DBD, including percent change in estimated glomerular filtration rate (-37.9% [-58.6 to -6.2] versus -31.9% [-52.4 to -9.9]; P=0.91), incidence of AKI (47.3% versus 46.5%; P>0.99) and incidence of renal replacement therapy (3.6% versus 4.7%; P>0.99). Recipients of DCD with AKI within 1 week ("early AKI") did not recover to baseline estimated glomerular filtration rate (75.8 [60.2-91.3] mL/min per 1.73 m²) by week 16 (59.3 [46.9-73.6] mL/min per 1.73 m²; P=0.002), whereas recipients without early AKI exhibited comparable estimated glomerular filtration rate to baseline by week 4 (84.5 [70.8-98.5] mL/min per 1.73 m²; P=0.084). Similar trends were observed in recipients of DBD.

Conclusions: Recipients of DCD demonstrated similar renal outcomes compared with recipients of DBD, supporting the ongoing use of DCD transplantation. Early AKI was associated with persistent renal dysfunction for recipients of both DCD and DBD.

Keywords: acute kidney injury; donation after circulatory death; heart transplantation.

Figure 1. Renal function through 16 weeks after heart transplantation.

Shown are the median values (nodes) and interquartile ranges (error bars) among patients receiving DCD with (n=26) and without (n=29) early AKI (A) and among recipients of DBD hearts with (n=79) and without (n=91) early AKI (B). P values reflect indicated comparisons using the Wilcoxon signed‐rank test. No corrections for multiple testing were applied. AKI indicates acute kidney injury; DCD, donation after circulatory death; DBD, donation after brain death; and eGFR, estimated glomerular filtration rate.

Figure 2. Relationships between early AKI status and 1 week hemodynamic measurements and early inotrope requirements among recipients of DCD.

Hemodynamic measurements included RA pressure, PCWP, PAPi, and CI. Inotrope requirements were assessed at 0 hours and 24 hours after transplantation. Lines within boxes indicate median values, distribution of boxes denote the interquartile range, and box whiskers denote 5th–95th percentiles. P values reflect comparisons using the Mann Whitney U test. No corrections for multiple testing were applied. AKI indicates acute kidney injury; CI, cardiac index; DCD, donation after circulatory death; PAPi, pulmonary artery pulsatility index; PCWP, pulmonary capillary wedge pressure; and RA, right atrium. Inotrope score =dopamine (×1) + dobutamine (×1) + amrinone (×1) + milrinone (×15) + epinephrine (×100) + norepinephrine (×100). Doses are in μg/kg/min.

Figure 3. Rejection rates among recipients of DCD hearts.

Shown are the number of patients with ≥2R acute cellular rejection within the first year after transplantation in patients with (n=26) and without (n=29) early AKI. Percentiles reflect the proportion with at least 1 episode of rejection. P value reflects comparison of proportions using the Fisher's exact test. AKI indicates acute kidney injury; and DCD, donation after circulatory death.