Top Things to Know: Dual Organ Transplantation: Indications, Evaluation, and Outcomes for Heart-Kidney and Heart-Liver Transplantation
Prepared by Rashmi Jain, MD; Cardiovascular Disease Fellow, Smidt Heart Institute, Cedars-Sinai
- This statement describes the impact of pre-transplant kidney and hepatic dysfunction on post-transplant outcomes, discusses the assessment of pre-transplant kidney and hepatic dysfunction, provides an approach to patient selection for simultaneous heart-kidney transplantation and simultaneous heart-liver transplantation and post-transplant management, and explores the ethics of multi-organ transplantation.
- As a result of complex, bi-directional interactions between heart failure (HF) and kidney disease, kidney dysfunction is prevalent in patients with advanced HF. The presence of acute kidney injury and chronic kidney disease (CKD) is associated with increased mortality risk both pre- and post-heart transplantation (HT).
- The goal of pre-transplant evaluation of kidney function is to differentiate CKD that will not improve post HT from kidney dysfunction that may reverse with hemodynamic optimization after HT. Serum creatinine, cystatin C levels, and kidney ultrasound can be used to evaluate kidney function as well as race-free equations to measure estimated glomerular filtration rate.
- While pre-transplant CKD disease predicts worse kidney function and lower survival post-transplant, it has not yet been established whether simultaneous heart-kidney transplantation improves these outcomes.
- Staged kidney transplant, performed after completion of HT, is preferred to a single operation for both heart and kidney transplantation with associated improved post-transplant kidney function and graft and patient survival.
- After simultaneous heart-kidney transplantation, the immunosuppression regimen should be tailored to minimize the risks of nephrotoxicity. The use of induction therapy allows delayed initiation of nephrotoxic calcineurin inhibitors. Proliferation signal inhibitors can be initiated later after transplantation in place of calcineurin inhibitors to avoid exacerbation of nephrotoxic effects of calcineurin inhibitors, although there may be an increased risk of rejection with this regimen.
- Heart failure can lead to liver injury through ischemia and/or congestion and is particularly common in patients with single-ventricle physiology palliated with a Fontan operation.
- The pre-transplant evaluation of liver disease includes liver function laboratory testing and imaging. For patients with abnormal findings on this initial screening evaluation, a transvenous liver biopsy with assessment of wedged and free hepatic vein pressures may be warranted. The MELD-XI score offers prognostic information on post-transplant outcomes in heart transplant candidates.
- Sequential transplantation of the liver after the heart, and simultaneous implantation of both organs together in one operation, have similar one-year outcomes.
- Simultaneous heart-liver transplantation has been associated with a lower risk of rejection than HT alone, and the use of induction immunosuppression is typically on a center-specific basis.
- Multi-organ transplantation policies can create inequities for patients on transplant waiting lists. Safety Net policies, which prioritize transplantation of a second organ if its function does not recover after a single-organ transplant, may maximize equitable distribution of limited organs. Patients who undergo a kidney-after-heart transplantation in this manner have similar survival to heart transplant recipients without kidney disease.
Citation
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