Kidney Transplantation in Patients with Severe Pulmonary Hypertension: Not an Absolute Contraindication?
B. Prajapati1, D. Gumber2, I. Moinuddin1, C. Bhati1, G. Gupta1, D. Grinnan3, D. Kumar1
1Nephrology, Virginia Commonwealth University, Richmond, VA, 2Cardiology, Virginia Commonwealth University, Richmond, VA, 3Pulmonology, Virginia Commonwealth University, Richmond, VA
Meeting: 2021 American Transplant Congress
Abstract number: 904
Keywords: Echocardiography, Hemodynamics, Outcome, Pulmonary hypertension
Topic: Clinical Science » Kidney » Kidney: Cardiovascular and Metabolic Complications
Session Information
Session Name: Kidney: Cardiovascular and Metabolic Complications
Session Type: Poster Abstract
Session Date & Time: None. Available on demand.
Location: Virtual
*Purpose: Severe pulmonary arterial hypertension (PAH) as defined by a pulmonary artery systolic pressure (PASP) >50mmHg is associated with high peri-operative mortality and thus is usually considered a contraindication to kidney transplantation. In this preliminary study, we describe the pre-kidney transplant management and post-transplant outcomes in patients with severe PAH using a multidisciplinary care team approach.
*Methods: Between November 2013 and August 2020 we identified all patients with severe PAH on initial pre-transplant workup who underwent ultrafiltration (UF) and/or medical therapy for PAH prior to kidney transplant. After transplant we evaluated their peri-operative course, renal function, graft and patient survival.
*Results: Fourteen patients (mean age=56±12years, AA race: 8/14; 57%) were diagnosed with severe PAH on pre transplant screening echocardiogram. These findings were confirmed by right heart catheterization (RHC) (mean PASP 63.4±15mmHg). These patients were also noted to have an elevated pulmonary capillary wedge pressure (mean PCWP 23.4±6.4mmHg) and right atrial pressure (mean RA 12.1±3.6mmHg). Based upon a diagnosis of mixed PAH with a post-capillary component, patients were subjected to aggressive mechanical ultrafiltration (UF; mean 4.6±1.6 sessions) with an average weight loss of 5.5±2.1kg at the end of the UF sessions. Twelve (out of 14; 86%) patients underwent repeat RHC and were noted to have a marked decline in PASP from an average of 65±16 to 33±12 mmHg, in PCWP from 23.5±7 to 7.4±3.4 mmHg and in RA pressure from 12.1±3.6 to 3.17±2.0 mmHg. Four (29%) patients were on vasodilator (phosphodiesterase type 5; PDE5 inhibitor therapy) prior to UF and remained on those after UF and through transplant. Majority of these patients received a deceased donor kidney transplant (12/14; 86%). Two (14%) of the patients had a planned one-day ICU stay after surgery, six (42%) had a 30-day readmission and nine (64%) of the patients had delayed graft function. The mean eGFR at 3, 6, 9 and 12 months was 70.69±27, 70.23±27, 74.92±30 and 73.09±32 ml/min/1.73m2. At a mean follow-up of 28±21 months post-transplant both graft and patient survival are 100%.
*Conclusions: In this small single center study, we report that severe PAH should not be considered an absolute contra-indication to kidney transplantation. A better elucidation of the etiology of PAH with a RHC should be considered. Post-capillary PAH can be a significant and common contributor to elevations in PASP and mean PAP especially in the dialysis population. Using a multidisciplinary approach, PAH could be improved with optimal volume removal and PDE5 inhibitor therapy leading to a complication free peri-operative period and a successful post-transplant outcome.
To cite this abstract in AMA style:
Prajapati B, Gumber D, Moinuddin I, Bhati C, Gupta G, Grinnan D, Kumar D. Kidney Transplantation in Patients with Severe Pulmonary Hypertension: Not an Absolute Contraindication? [abstract]. Am J Transplant. 2021; 21 (suppl 3). https://atcmeetingabstracts.com/abstract/kidney-transplantation-in-patients-with-severe-pulmonary-hypertension-not-an-absolute-contraindication/. Accessed October 15, 2024.« Back to 2021 American Transplant Congress