Pub Date: Thursday, Jul 13, 2023
Author: Shelley Hall MD FACC, FHFSA, FAST
Affiliation: Baylor University Medical Center, Dallas TX part of Baylor Scott and White Healthcare
Heart transplantation is the gold standard therapy for Stage D heart failure since the advent of immunosuppressive agents and improved understanding of the immune system. With growing expertise and experience, more patients are listed - always outstripping the supply of usable donor organs. As a result, allocation systems were created to organize the waitlist with specific prioritizations elucidated by the Final rule in 2000 by the US Department of Health and Human Services including preserving the ability for transplant programs to accept or deny an organ, avoid wasting organs, to promote patient access to organs, not be based on a candidate's place of residence or listing, improve waitlist survival, and be reviewed periodically. The heart allocation system has prioritized getting organs to the sickest patients on the waitlist to reduce waitlist death while not adversely impacting post-transplant outcomes. As a result, our heart candidates are sicker than ever and as a result, concomitant advanced end organ dysfunction is more likely as the disease pathways are often shared, especially with heart and kidney disease and the aging congenital population for heart and liver disease. It is well known that isolated heart transplant in the setting of kidney or liver disfunction has worse outcomes, both in morbidity and mortality. This, combined with growing pressures for maintaining high post-transplant outcomes, has resulted in a rise in heart-kidney and heart-liver listings and transplants, especially over the past decade. While some of the second organs will recover after isolated heart transplant, there are no clear mechanisms to accurately predict such in an individual patient and to be wrong could be devastating for the patient and the program. Until now, there have been no guiding principles of how these patients qualify for the second organ (beyond society guidelines recommending CrCl < 30 mL/min or active clinical cirrhosis) until recently. Prompted by the growing volume of multi-organ transplantation, a new allocation policy has been created to standardize listing criteria for the heart-kidney candidate, going into effect spring 2023 and the criteria for the heart-liver candidate is under development.
This scientific statement summarizes the current implications of advanced kidney or liver disease on heart transplant only outcomes and acknowledges the limitations to pre-transplant evaluations for predicting reversibility of organ dysfunction after cardiac transplant. It must be understood that any guidelines for clinical practice or allocation systems which are based on numbers such as creatine clearance, glomerular filtration rate, cystatin or liver function tests can fluctuate based on the cardiac condition at the moment, and can be modified to promote listing or delisting in many circumstances. Consensus guidelines are the only method currently available to unite the transplant programs under similar "rules of engagement" to provide equitable access to single and multi-organ transplants across the country. Yet these qualifying criteria are just the first step in the process leading to multiorgan transplantation.
In this statement, Kittleson and colleagues acknowledge that transplant center expertise in dual organ transplantation can factor heavily into the decision to list for one heart alone or dual organ, especially the congenital patients who make up a significant portion of heart-liver candidates. Transplant centers must honestly evaluate their internal expertise and processes to tackle multiorgan transplants as the outcomes are worse than heart transplant alone with functional secondary organs. Proper surgical planning between the thoracic and abdominal teams is paramount as significant primary graft dysfunction of the heart will almost certainly prevent implantation of the abdominal organ or markedly impair its chances for successful function. Aggressive strategies to mitigate primary graft dysfunction must also be in place.
This statement also reviews immunosuppressive strategies at the time of transplant to minimize dysfunction of the second organ and ongoing therapies to promote longevity of both organs. This is especially important as there is growing concern that the kidney or liver could have been given to a kidney or liver only recipient with superior outcomes than are currently demonstrated by our heart dual transplant recipients.
As our heart transplant candidates continue to get sicker in an environment of waitlists growing faster than there are donors available, more and more of these patients will need consideration for dual organ, and in some circumstances, triple organ transplantation. As a community, it is imperative that we create universal standards for evaluation and qualification for multiorgan transplants that are based on scientific data and not institutional biases or fear of outcomes. We must understand who we can improve and convert to heart only transplant, best methods for managing the post-heart transplant recipient with compromised end organ function as the new safety net criteria go into effect and who truly requires dual organs for adequate survival. Finally, we must develop an allocation system that is equitable for all patients and acknowledge that without an increase in available donors, we continue to produce a "survival of the fittest" scenario for our patients on the waitlist.
Kittleson MM, Sharma KS, Brennan DC, Cheng XS, Chow SL, Colvin M, DeVore AD, Dunlay SM, Fraser M, Garonzik-Wang J, Khazanie P, Korenblat KM, Pham DT; on behalf of the American Heart Association Heart Failure and Transplantation Committee of the Council on Clinical Cardiology; Council on the Kidney in Cardiovascular Disease; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular and Stroke Nursing; Council on Quality of Care and Outcomes Research; and Council on Lifelong Congenital Heart Disease and Heart Health in the Young. Dual-organ transplantation: indications, evaluation, andoutcomes for heart-kidney and heart-liver transplantation: a scientific statement from the AmericanHeart Association [published online ahead of print July 13, 2023]. Circulation. doi: 10.1161/CIR.0000000000001155
- Karamlou T, Welke KF, McMullan DM, Cohen GA, Gelow J, Tibayan FA, Mudd JM, Slater MS and Song HK. Combined heart-kidney transplant improves post-transplant survival compared with isolated heart transplant in recipients with reduced glomerular filtration rate: Analysis of 593 combined heart-kidney transplants from the United Network Organ Sharing Database. J Thorac Cardiovasc Surg. 2014;147:456-461
- Khush K, Cherish W, Chambers D, et al. The International thoracic organ Registry of the In- ternational Society for heart and lung trans- plantation: thirty-fifth adult heart transplantation report - 2018: focus theme: multiorgan trans- plantation. J Heart Lung Transplant. 2018;37:1155– 1168.
- Hunt and Haddad,. The changing face of heart transplantation. JACC 2008;8:pp 587-598
- Mehra MR, Canter CE, Hannan MM, Semigran MJ, Uber PA, Baran DA, Danziger-Isakov L, Kirklin JK, Kirk R, Kushwaha SS, Lund LH, Potena L, Ross HJ, Taylor DO, Verschuuren EAM, Zuckermann A, International Society for Heart Lung Transplantation Infectious Diseases P, Heart F and Transplantation C. The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update. J Heart Lung Transplant. 2016;35:1-23.
- Shoji S, Kuno T, Kohsaka S, Amiya E, Asleh R, Alvarez P, Kampaktsis P, Staffa SJ, Zurakowski D, Doulamis I and Briasoulis A. Incidence and long-term outcome of heart transplantation patients who develop postoperative renal failure requiring dialysis. J Heart Lung Transplant. 2022;41:356-364.
- Hsu R-B, Chang C-I, Lin F-Y, Chou N-K, Chi N-H, Wang S-S and Chu S-H. Heart transplantation in patients with liver cirrhosis. European Journal of Cardio-Thoracic Surgery. 2008;34:307-312.
- Kobashigawa J, Dadhania DM, Farr M, Tang WHW, Bhimaraj A, Czer L, Hall S, Haririan A, Formica RN, Patel J, Skorka R, Fedson S, Srinivas T, Testani J, Yabu JM and Cheng XS. Consensus conference on heart-kidney transplantation. Am J Transplant. 2021;21:2459-2467.Shaw BI, Samoylova ML, Sanoff S, Barbas AS, Sudan DL, Boulware LE and McElroy LM. Need for improvements in simultaneous heart-kidney allocation: The limitation of pretransplant glomerular filtration rate. Am J Transplant. 2021;21:2468-2478.OPTN Policy
- Varshney AS, Berg DD, Katz JN, Baird-Zars VM, Bohula EA, Carnicelli AP, Chaudhry S-P, Guo J, Lawler PR, Nativi-Nicolau J, Sinha SS, Teuteberg JJ, van Diepen S, Morrow DA and Investigators ftCCCTN. Use of Temporary Mechanical Circulatory Support for Management of Cardiogenic Shock Before and After the United Network for Organ Sharing Donor Heart Allocation System Changes. JAMA Cardiology. 2020;5:703-708.
- Agarwal KA, Patel H, Agrawal N, Cardarelli F and Goyal N. Cardiac Outcomes in Isolated Heart and Simultaneous Kidney and Heart Transplants in the United States. Kidney Int Rep. 2021;6:2348-2357.
- Czer L, Kittleson M, Patel J, Kransdorf E, Levine R, Dimbil S, Sharoff R, Kearney B, Chang DH, Hamilton M, Esmailian F and Kobashigawa J. 10-Year Outcomes in Heart-Kidney Transplant Patients: Is There a Protective Effect for the Donor Heart? J Heart Lung Transplant. 2019;38:S217.
- Gallo M, Trivedi JR, Schumer EM and Slaughter MS. Combined Heart-Kidney Transplant Versus Sequential Kidney Transplant in Heart Transplant Recipients. J Card Fail. 2020;26:574-579.
- Cheng XS, Khush KK, Wiseman A, Teuteberg J and Tan JC. To kidney or not to kidney: Applying lessons learned from the simultaneous liver-kidney transplant policy to simultaneous heart-kidney transplantation. Clin Transplant. 2020;34:e13878.
- Itagaki S, Toyoda N, Moss N, et al. Outcomes of simultaneous heart and kidney transplantation. J Am Coll Cardiol. 2023;81:729–740.
- OPTN Board of Directors. Executive Summary. Establish eligibility criteria and safety net for heart-kidney and lung-kidney allocation. June 14, 2021. OPTN. Accessed August 3, 2021. https:// optn.transplant.hrsa.gov/media/4708/20210614_ board-of-directors_executive-summary.pdf
Science News Commentaries
Commentary: Cardiovascular Imaging in Cardio-Oncology: Have we made progress? 09/21/2023 | Author: Susan Dent, MD, FRCPC, FIC-OS; Juan Lopez-Mattei, MD, FACC, FASE, FSCCT, FSCMR | Cancer screening and advances in ...
Commentary: Hiding in plain sight? Optimization of organ donation opportunities at a health systems level when trust is paramount. A case for improving organ donation from out-of-hospital cardiac deaths. 08/08/2023 | Author: Blair Henry, D. Bioethics | Recent news of the death of the first ...
-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --