When transplanted simultaneously, the liver allograft has been thought to have an immunoprotective role on other organs. However, detailed studies on simultaneous heart-liver transplantation (SHLT) are lacking. The goal of this study was to assess the patient outcomes and the incidence of immune-mediated injury in SHLT vs. isolated heart transplantation (IHT) based on protocol heart allograft biopsies.

Methods: 22 SHLT and 223 IHT were done between 2004 and 2013. Demographic, laboratory, protocol heart biopsy and donor-specific HLA antibody (DSA) (baseline, 1-wk, 4-mo, 1-yr, yearly thereafter) data were reviewed. Survival was analyzed by Kaplan-Meier, and categorical data by Fisher's Exact tests.

Results: Indications for SHLT included familial amyloidosis (15/22; 68.2%), restrictive cardiomyopathy (4/22; 18.2%), congenital heart disease (2/22; 9.1%), and arrhythmogenic cardiac disease (1/22; 4.5%). The SHLT group had an average BMI of 24.5±2.9, biologic MELD of 12.3±4.6, LVEF of 42.8±17.7%, and NYHA III-IV. At a mean of 52.9 months, survival was similar (86.4% in SHLT and 83.9% in IHT; P=NS). Five SHLT (22.7%) and 18 IHT (18.1%) recipients had preformed DSA (MFI>2000), of which 4 and 11 had a positive cross-match, respectively. Despite identical immunosuppression, persistence of DSA post-transplant was less common in SHLT (1/5; 20%) than in IHT (9/18; 50%). A total of 3912 heart biopsies were reviewed (3606 IHT, 306 SHLT). The cumulative incidence of heart allograft rejection was lower in SHLT (8/22; 36.4%) than in IHT (191/223; 85.6%) (P<0.001). Of the 8 rejection episodes in SHLT, 7 were acute cellular (ACR) and 1 was antibody-mediated (AMR). The single AMR episode was concomitant with ACR of the liver with significant liver graft injury, which resolved after treatment with a steroid bolus. Similarly the most common type of rejection in IHT was ACR (159/223) vs. AMR (2/223) or mixed ACR-AMR (30/223). Post-transplant, de novo DSA were found in 18.2% of SHLT and 18.8% of IHT; in both groups these were predominantly anti-class II antibodies (100% in SHLT, 88.1% in IHT).

Conclusions: Compared to IHT, both ACR and AMR of the heart allograft appear to be less common in SHLT. In addition, persistence of preformed DSA in SHLT is rare. Taken together, these data suggest that in SHLT, the liver appears to provide immunoprotection for the cardiac allograft.

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