*Purpose: Mounting data shows a survival benefit of combined heart-kidney transplantation in patients with heart and renal failure. However, little has been done to understand the impact of chronic disease in this population. We therefore undertook this study to define the risk of dialysis duration and recipient diabetes on post-transplant survival in heart-kidney transplantation.

*Methods: Using the Scientific Registry of Transplant Recipients, we merged the heart and kidney datasets allowing us to perform an in depth analysis of donor and recipient factors. Ultimately, we analyzed one year survival in 1,122 recipients of combined heart-kidney transplant between 2005 and 2018. Survival analysis was performed with Cox proportional hazard models and expressed as hazard ratios (HR).

*Results: Combined heart-kidney transplant is increasingly common (Figure 1). Kidney disease due to diabetes (HR 1.56, p 0.01) and duration of dialysis (1.08, p 0.02) were associated with worse one year survival even after adjustment for donor and recipient factors. Increasing recipient age, BMI, need for ECMO and cardiac listing status were also statistically significant predictors (Table 1).

*Conclusions: As combined heart-kidney transplant becomes more common, it is important to understand the risks of transplanting patients who suffer the effects of chronic illness. Our analysis shows that recipient diabetes and increasing dialysis duration are significant predictors of survival in this population. In fact, our final multivariable model indicates a recipient with diabetes and five years of dialysis has an associated HR of 2.26 compared to a recipient with non-diabetic renal disease who is not on dialysis. This risk demonstrates that the addition of a kidney transplant does not completely mitigate the risk of diabetes and dialysis in patients undergoing heart transplant. While dialysis duration and diabetes should not exclude patients from transplant, we believe these chronically ill patients should be closely evaluated to assess for conditions such as frailty and peripheral vascular disease which result from these chronic diseases and have been shown to impact long term survival.

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