Decreased survival of simultaneous heart-kidney transplant recipients in the new heart allocation era

Max Shin; Amit Iyengar; Mark R Helmers; Noah Weingarten; William L Patrick; David Rekhtman; Cindy Song; John J Kelly; Marisa Cevasco

doi:10.1016/j.healun.2023.08.006

Decreased survival of simultaneous heart-kidney transplant recipients in the new heart allocation era

J Heart Lung Transplant. 2023 Dec;42(12):1725-1734. doi: 10.1016/j.healun.2023.08.006. Epub 2023 Aug 12.

Authors

Max Shin¹, Amit Iyengar², Mark R Helmers², Noah Weingarten², William L Patrick², David Rekhtman¹, Cindy Song¹, John J Kelly³, Marisa Cevasco⁴

Affiliations

¹ Perelman School of Medicine, Philadelphia, PA, USA.
² Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.
³ Perelman School of Medicine, Philadelphia, PA, USA; Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.
⁴ Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA. Electronic address: Marisa.cevasco@pennmedicine.upenn.edu.

PMID: 37579829
DOI: 10.1016/j.healun.2023.08.006

Abstract

Background: In 2018, the United Network for Organ Sharing (UNOS) modified their heart allocation policy to reduce waitlist mortality. The rates of simultaneous heart-kidney transplant (SHKT) have dramatically increased in recent years, despite increased rates of posttransplant renal failure in the new policy era. This study sought to investigate the impact of the new allocation system on waitlist and posttransplant outcomes of simultaneous heart-kidney transplantation.

Methods: Adult patients listed for SHKT between 2012 and 2021 were included. Patients were cross-validated across both Thoracic and Kidney UNOS databases to confirm accurate listing and transplant data. Patients were stratified according to listing era. The Fine and Gray model was used to assess waitlist outcomes and posttransplant renal graft function. Kaplan-Meier analysis and Cox regression were used to compare posttransplant survival.

Results: A total of 2,588 patients were included, of whom 1,406 (54.1%) were listed between 2012 and 2018 (era 1) and 1,182 (45.9%) between 2019 and 2021 (era 2). Era 2 was associated with increased likelihood of transplant (adjusted Sub-hazard ratios (aSHR): 1.52; p < 0.01) and decreased waitlist mortality (aSHR: 0.63; p < 0.01). Posttransplant survival at 2 years was decreased in era 2 (78.8% vs 86.9%; p < 0.01). Undersized hearts (hazard ratio [HR]: 2.02; p < 0.01), use of extracorporeal membrane oxygenation (HR: 2.67; p < 0.1), and transplants performed following the policy change (HR: 1.45; p = 0.03) were associated with increased mortality. Actuarial survival (combined waitlist and posttransplant) was significantly lower in the modern era (71.6% vs 62.2%; p = 0.02).

Conclusions: The allocation policy change has improved waitlist outcomes in patients listed for SHKT but potentially at the cost of worsened posttransplant outcomes.

Keywords: Heart transplantation; Heart-lung transplant; New allocation policy; VA-ECMO.

MeSH terms

Adult
Heart Transplantation* / adverse effects
Humans
Kidney
Kidney Transplantation*
Proportional Hazards Models
Retrospective Studies
Survival Rate
Waiting Lists