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Awad MA, Czer LSC, Emerson D, Jordan S, De Robertis MA, Mirocha J, Kransdorf E, Chang DH, Patel J, Kittleson M, Ramzy D, Chung JS, Cohen JL, Esmailian F, Trento A, Kobashigawa JA. Combined Heart and Kidney Transplantation: Clinical Experience in 100 Consecutive Patients. J Am Heart Assoc 2020; 8:e010570. [PMID: 30741603 PMCID: PMC6405671 DOI: 10.1161/jaha.118.010570] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Combined heart and kidney transplantation (HKTx) is performed in patients with severe heart failure and advanced renal insufficiency. We analyzed the long‐term survival after HKTx, 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 HKTx 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 HKTx. 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 HKTx between the United Network for Organ Sharing database and our center (38±3.2% and 40±10.1%, respectively; P=0.45). Conclusions HKTx 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 HKTx.
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Affiliation(s)
- Morcos Atef Awad
- 1 Division of Cardiology Cedars-Sinai Smidt Heart Institute the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA
| | - Lawrence S C Czer
- 1 Division of Cardiology Cedars-Sinai Smidt Heart Institute the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA
| | - Dominic Emerson
- 2 Division of Cardiothoracic Surgery Department of Surgery Cedars-Sinai Smidt Heart Institute the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA
| | - Stanley Jordan
- 3 Division of Pediatric Nephrology the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA
| | - Michele A De Robertis
- 2 Division of Cardiothoracic Surgery Department of Surgery Cedars-Sinai Smidt Heart Institute the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA
| | - James Mirocha
- 4 Section of Biostatistics Cedars-Sinai Medical Center Los Angeles CA
| | - Evan Kransdorf
- 1 Division of Cardiology Cedars-Sinai Smidt Heart Institute the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA
| | - David H Chang
- 1 Division of Cardiology Cedars-Sinai Smidt Heart Institute the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA
| | - Jignesh Patel
- 1 Division of Cardiology Cedars-Sinai Smidt Heart Institute the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA
| | - Michelle Kittleson
- 1 Division of Cardiology Cedars-Sinai Smidt Heart Institute the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA
| | - Danny Ramzy
- 2 Division of Cardiothoracic Surgery Department of Surgery Cedars-Sinai Smidt Heart Institute the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA
| | - Joshua S Chung
- 2 Division of Cardiothoracic Surgery Department of Surgery Cedars-Sinai Smidt Heart Institute the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA
| | - J Louis Cohen
- 5 Department of Surgery Cedars-Sinai Medical Center Los Angeles CA
| | - Fardad Esmailian
- 2 Division of Cardiothoracic Surgery Department of Surgery Cedars-Sinai Smidt Heart Institute the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA
| | - Alfredo Trento
- 2 Division of Cardiothoracic Surgery Department of Surgery Cedars-Sinai Smidt Heart Institute the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA
| | - Jon A Kobashigawa
- 1 Division of Cardiology Cedars-Sinai Smidt Heart Institute the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA
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Hanna RM, Hasnain H, Kamgar M, Hanna M, Minasian R, Wilson J. Patient with a total artificial heart maintained on outpatient dialysis while listed for combined organ transplant, a single center experience. Hemodial Int 2017; 21:E69-E72. [PMID: 28799694 DOI: 10.1111/hdi.12580] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Advanced mechanical circulatory support is increasingly being used with more sophisticated devices that can deliver pulsatile rather than continuous flow. These devices are more portable as well, allowing patients to await cardiac transplantation in an outpatient setting. It is known that patients with renal failure are at increased risk for developing worsening acute kidney injury during implantation of a ventricular assist device (VAD) or more advanced modalities like a total artificial heart (TAH). Dealing with patients who have an implanted TAH who develop renal failure has been a challenge with the majority of such patients having to await a combined cardiac and renal transplant prior to transition to outpatient care. Protocols do exist for VAD implanted patients to be transitioned to outpatient dialysis care, but there are no reported cases of TAH patients with end stage renal disease (ESRD) being successfully transitioned to outpatient dialysis care. In this report, we identify a patient with a TAH and ESRD transitioned successfully to outpatient hemodialysis and maintained for more than 2 years, though he did not survive to transplant. It is hoped that this report will raise awareness of this possibility, and assist in the development of protocols for similar patients to be successfully transitioned to outpatient dialysis care.
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Affiliation(s)
- Ramy M Hanna
- Division of Nephrology, Department of Medicine, Ronald Regan Medical Center, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Huma Hasnain
- Division of Nephrology, Department of Medicine, Ronald Regan Medical Center, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Mohammad Kamgar
- Division of Nephrology, Department of Medicine, Ronald Regan Medical Center, David Geffen School of Medicine, UCLA, Los Angeles, California, USA.,Surgical and Consultative Nephrology, Ronald Regan Medical Center, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Mina Hanna
- School of Medicine, Creighton University Medical Center, Omaha, Nebraska, USA
| | - Raffi Minasian
- Corporate medical director of home dialysis centers 1500 S Central Ave. Suite # 300, Glendale CA 91204, USA
| | - James Wilson
- Division of Nephrology, Department of Medicine, Ronald Regan Medical Center, David Geffen School of Medicine, UCLA, Los Angeles, California, USA.,Surgical and Consultative Nephrology, Ronald Regan Medical Center, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
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Awad M, Czer LSC, Esmailian F, Jordan S, De Robertis MA, Mirocha J, Patel J, Chang DH, Kittleson M, Ramzy D, Arabia F, Chung JS, Cohen JL, Trento A, Kobashigawa JA. Combined Heart and Kidney Transplantation: A 23-Year Experience. Transplant Proc 2017; 49:348-353. [PMID: 28219597 DOI: 10.1016/j.transproceed.2016.11.040] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 11/10/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND We report clinical experience with combined heart and kidney transplantation (HKTx) over a 23-year time period. METHODS From June 1992 to August 2015, we performed 83 combined HKTx procedures at our institution. We compared the more recent cohort of 53 HKTx recipients (group 2, March 2009 to August 2015) with the initial 30 previously reported HKTx recipients (group 1, June 1992 to February 2009). Pre-operative patient characteristics, peri-operative factors, and post-operative outcomes including survival were examined. RESULTS The baseline characteristics of the two groups were similar, except for a lower incidence of ethanol use and higher pre-operative left-ventricular ejection fraction, cardiac output, and cardiac index in group 2 when compared with group 1 (P = .007, .046, .037, respectively). The pump time was longer in group 2 compared with group 1 (153.30 ± 38.68 vs 129.60 ± 37.60 minutes; P = .007), whereas the graft ischemic time was not significantly different between the groups, with a trend to a longer graft ischemic time in group 2 versus group 1 (195.17 ± 45.06 vs 178.07 ± 52.77 minutes; P = .056, respectively). The lengths of intensive care unit (ICU) and hospital stay were similar between the groups (P = .083 and .39, respectively). In addition, pre-operative and post-operative creatinine levels at peak, discharge, 1 year, and 5 years and the number of people on post-operative dialysis were similar between the groups (P = .37, .75, .54, .87, .56, and P = .139, respectively). Overall survival was not significantly different between groups 2 and 1 for the first 5 years after transplant, with a trend toward higher survival in group 2 (P = .054). CONCLUSIONS The most recent cohort of combined heart and kidney transplant recipients had similar ICU and hospital lengths of stay and post-operative creatinine levels at peak, discharge, and 1 and 5 years and a similar number of patients on post-operative dialysis when compared with the initial cohort. Overall survival was not significantly different between the later and earlier groups, with a trend toward higher overall survival at 5 years in the more recent cohort of patients. In selected patients with co-existing heart and kidney failure, combined heart and kidney transplantation is safe to perform and has excellent outcomes.
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Affiliation(s)
- M Awad
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - L S C Czer
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California.
| | - F Esmailian
- Division of Cardiothoracic Surgery, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - S Jordan
- Division of Pediatric Nephrology, Cedars-Sinai Medical Center, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - M A De Robertis
- Division of Cardiothoracic Surgery, Cedars-Sinai Heart Institute, Los Angeles, California
| | - J Mirocha
- Section of Biostatistics and Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - J Patel
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - D H Chang
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - M Kittleson
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - D Ramzy
- Division of Cardiothoracic Surgery, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - F Arabia
- Division of Cardiothoracic Surgery, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - J S Chung
- Division of Cardiothoracic Surgery, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - J L Cohen
- Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - A Trento
- Division of Cardiothoracic Surgery, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - J A Kobashigawa
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
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