*Purpose: Pre transplant renal function has been shown to be a strong predictor of long term renal as well as patient survival in heart transplant patients. We undertook this study to determine if worsening renal function (decline in eGFR of >1%) while waiting for heart transplant was associated with poor patient survival or increased risk of end stage kidney disease (ESRD) post heart transplantation.

*Methods: We analyzed 2000-2017 UNOS heart transplant data. Adults receiving their first isolated heart transplant who were not on dialysis were included in the study. Cox regression was used to assess the effect of worsening renal function between listing and transplant on post heart transplant outcomes and to adjust for the effects of independent variables.

*Results: 28,411 patients met the inclusion criteria. 15,818 patients did not have any worsening of renal function while on the waitlist (Group 0), 6565 had ≤25% reduction in eGFR (Group 1), 3635 patients had 26%-50% reduction in eGFR (Group 2), 739 patients had 51% to 75% reduction of eGFR (Group 3) and 87 patients had >75% reduction of eGFR (group 4). On multivariate Cox regression modeling there was no difference in mortality among the five groups. Risk of ESRD progressively increased for group 1 through 4: Group 1 (adjusted hazard ratio (aHR) of 1.02 (0.92-1.13, p value 0.61), Group 2 aHR 1.17 (1.04-1.32, p value 0.009), Group 3 aHR 1.92 (1.56-2.36 p value <0.001) and Group 4 aHR 3.46 (2.16-5.5, p value <0.001).

*Conclusions: In this UNOS database analysis of adult patients who received their first heart transplant, we found that worsening renal function during the waitlist period was not associated with increased mortality post heart transplant but a decline in eGFR of 25% or more (15.7% of patients) was associated with a progressively higher risk of ESRD. Other significant predictors for ESRD were recipient age, black race, diabetes, VAD use, CNI use, post transplant ejection fraction and post transplant diabetes. This has important implication for wait list management and once declining trajectory in renal function is noted, multidisciplinary approach to stabilize renal function should be considered.

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