Heart-alone transplant recipients with pre-existing kidney impairment have “unacceptably high” risks of progressing to end-stage kidney disease (ESKD) requiring renal replacement therapy and dying, investigators warned at the 2023 American Transplant Congress in San Diego, California.
Using the 2000-2018 Scientific Registry of Transplant Recipients, Rose Mary Attieh, MD, of the Mayo Clinic in Jacksonville, Florida, and colleagues identified 3391 first-time recipients of a heart-only transplant who had a low baseline estimated glomerular filtration rate (eGFR; in mL/min/1.73m2). Of the cohort, 227 patients were receiving short-term dialysis prior to transplantation surgery; 197 had an eGFR of 20 or less; 672 had an eGFR of 21 to 30, and 2295 had an eGFR of 31 to 40.
ESKD requiring renal replacement therapy occurred within 1 year of heart transplantation in 33.6% of the short-term dialysis group, 16.5% of the eGFR less than 20 group, 7.4 % of the eGFR 21-30 group, and 3.5% of the eGFR 31-40 group.
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The risks for ESKD and death within 1 year were highest for the group receiving short-term dialysis prior to heart transplantation, the investigators reported. The likelihood of ESKD was 2.2-, 6.1-, and 15.2-fold higher for the eGFR 21-30, eGFR 20 or less, and short-term dialysis groups, respectively, compared with the eGFR 31 to 40 group (reference). The risks for all-cause mortality were 1.3-, 2.1-, and 3.1-fold higher for the eGFR 21-30, eGFR 20 or less, and dialysis groups, respectively, compared with the reference group.
The short-term dialysis group was significantly younger than the reference group (age 58 vs 60 years). A significantly greater proportion of patients in the dialysis group were male (73% vs 69%), Black race (22% vs 13%), users of a left ventricular assistive device (45% vs 29%), and ICU patients (56% vs 31%). Concomitant listing for a kidney transplant (13% vs 0.8%) and listed status1a (75% vs 49%) also were significantly more prevalent in the dialysis vs reference group.
“Heart transplant candidates on short-term dialysis are much sicker than those with an eGFR of 31-40,” co-author Hani M. Wadei, MD, pointed out in an interview with Renal & Urology News. “The severity of pre-transplantation renal dysfunction is incrementally associated with post-transplantion ESKD and death.”
“Approximately 13% of patients on dialysis at the time of heart-alone transplantation were listed for a simultaneous heart-kidney transplant but eventually ended up getting the heart only,” added co-author Samy M. Riad, MD, of Mayo Clinic Rochester in Minnesota. The investigators did not know why a kidney transplant was not received.
A change in allocation policy should facilitate an expedited simultaneous heart-kidney transplantation, according to Dr Wadei and Dr Riad. A safety net is much needed for those who survive a heart-alone transplantation and require renal replacement therapy within a year.
The safety net parameters currently in effect for liver transplant patients should be extended to heart transplant patients, according to the team. The current safety net states that patients with an eGFR less than 20 or receiving short-term dialysis from 60 to 365 days after liver transplantation should be prioritized for a kidney transplant.
Reference
Attieh R, Aljuhani M, Wadei H, et al. Renal failure and mortality after heart alone transplant in recipients with eGFR<40ml/min or on dialysis in the United States. Presented at: ATC 2023; June 3-7, San Diego, California. Abstract 215.
