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Impact of Pre-Operative Renal Function on Outcomes in Older Recipients Undergoing Heart-Kidney Transplantation
Brandon E. Ferrell1, Albert Dweck1, Hersh Gupta1, Adam Chalek1, Stephen M. Spindel1, Snehal Patel2, Ulrich Jorde2, Shivank Madan2, Daniel Goldstein1, Stephen Forest1
1Department of Cardiothoracic Surgery, Montefiore Medical Center, New York, New York, United States, 2Division of Cardiology, Montefiore Medical Center, New York, New York, United States
Background: Despite the rate of simultaneous heart-kidney transplantation (HKTx) steadily increasing over the past decade, older recipient age remains a relative contraindication to dual-organ transplantation in many programs. Several recent studies suggest no difference in long-term survival in older HKTx recipients, however, the impact of severity of preoperative renal function has not been well explored. We aimed to evaluate the impact of preoperative glomerular filtration rate (GFR) and dialysis on long-term outcomes of patients undergoing HKTx.
Methods: The United Network for Organ Sharing registry was queried for all adults (? 18 years) undergoing primary, heart-kidney transplantation from 2010-2023. Recipients were stratified by age (< 65 vs ? 65) and renal function (GFR ? 20 or dialysis vs GFR > 20) at time of HKTx into four groups – G1: age < 65 + GFR ? 20 / dialysis; G2: age < 65 + GFR > 20; G3: age ? 65 + GFR ? 20 / dialysis; G4: age ? 65 + GFR > 20.
Results: A total of 2,523 patients were included in the analysis – G1 (1045), G2 (904), G3 (185), G4 (389), with the majority male (G1: 78.5%, G2: 81.4%, G3: 82.7%, G4: 82.8%) and a median age of 54 (G1), 57 (G2), 67 (G3), and 67 (G4) years respectively. Median pre-operative GFR of each cohort was 16.0 (G1), 30.9 (G2), 16.7 (G3), and 30.0 (G4) mL/min. Length of pre-operative dialysis was longer in G1 vs G3 (442 vs 298 days, p < 0.001). Donor age, donor creatinine, and ischemic time did not differ between groups. Early outcomes included an increased incidence of dialysis prior to discharge in patients with a GFR ? 20 or on dialysis pre-operatively (G1: 45.0%, G2: 25.9%, G3: 42.0% G4: 18.5%, P < 0.001). However, GFR at 6- and 12 months post-HKTx did not differ based on age or pre-operative renal function (Fig). Age did not impact 5-year renal graft viability in either those with a preoperative GFR ? 20 or on dialysis (log rank p = 0.63) or GFR > 20 (log rank p = 0.66).
Unadjusted Kaplan-Meier survival analysis demonstrated no difference in 5-year survival in younger recipients based on pre-operative renal dysfunction (log rank p = 0.47); however older recipients with a pre-operative GFR ? 20 or on dialysis had inferior survival to those with a GFR > 20 (log rank p = 0.03). HKTx recipients with a pre-operative GFR > 20 did not have a difference in survival based on recipient age (log rank p = 0.45). In a multivariate cox proportional hazard regression model, pre-operative ECMO (HR 2.85 [1.17-6.98], p = 0.02) and GFR ? 20 / dialysis (HR 1.59 [1.07-2.37], p = 0.02) were independent predictors of inferior survival in older recipients. A sub-analysis evaluating the length of pre-operative dialysis (< 1 vs ? 1 year) found no difference in survival for younger HKTx recipients; however, older recipients on dialysis for ? 1 year had inferior survival (log rank p = 0.02), which persisted in the multivariate cox model (HR 5.37 [1.11-25.93], p = 0.04).
Conclusion: HKTx in recipients ? 65 years old is safe, though patients with a GFR ? 20 or on dialysis at time of transplantation have an increased risk of mortality. In the era of a limited donor pool, consideration should be given to the severity of the pre-operative renal dysfunction and duration of dialysis when carefully evaluating these patients for transplantation.
Figure 1. A) 6- and 12-month GFR and B) Kaplan-Meier survival curve after heart-kidney transplantation (HKTx) stratified by recipient age and pre-operative renal dysfunction. C) Multivariate analysis of survival in recipients ? 65 years undergoing HKTx. For cause of death, reference group is anoxia.
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