Objectives: Progressive renal failure is a frequent complication following heart transplantation (HTx), is generally attributed to calcineurin inhibitor (CNI) based immunosuppression, and may result in end stage renal disease (ESRD) prompting consideration of kidney after heart transplantation (KAH). The aim of this study was to: (a) determine the incidence and identify risk factors for the development of ESRD post HTx, (b) to assess long-term renal graft survival in KAH recipients and (c) to evaluate survival benefit of KAH.

Methods: We identified 268 (mean age 50 ± 12 years) patients who underwent HTx or KAH between the years 2000-2012. GFR was measured as corrected iothalamate clearance and ESRD defined as the need for renal replacement therapy.

Results: During a median follow up time of 76 months (42, 121) 51 patients (19%) developed ESRD. The mean time from HTx to ESRD was 83 months (40, 116). Recipients who developed ESRD had significantly lower GFR at HTx, higher incidence of dilated cardiomyopathy and diabetes mellitus post-HTx compared to patients without ESRD (p<0.05). The incidence of switching to a CNI free regimen (sirolimus as primary immunosuppression) was significantly lower among recipients with ESRD (6 vs. 57%, p=0.0001), and prolonged exposure to CNI significantly increased the risk for ESRD (HR=1.09, 1.03 to 1.15, p<0.005). Among recipients with ESRD, 39 patients (76%) underwent KAH during follow up period. The median time from HTx to KAH was 103 months (56, 144). Death censored renal graft survival post KAH was 95%, 95% and 83% at 1, 5 and 10 years, respectively. Long term survival of KAH patients was comparable to HTx recipients without ESRD (median survival time 16 years) and significantly better compared to HTx recipients with ESRD (p<0.001).

Conclusion: Prolonged exposure to CNI immunosuppression medications significantly increases the risk for ESRD among HTx recipients. KAH is a good therapeutic option with comparable survival benefit to HTx alone and good long term renal allograft function.

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