*Purpose: Due to the aging of the population, a growing number of patients with end-stage kidney disease (ESKD) require cardiac valve replacement. As a consequence, the number of kidney transplant candidates with prosthetic heart valves (PHVs) is increasing. Yet, outcomes of kidney transplantation in these patients are unknown. We provide the first report of post-transplant outcomes in patients with prosthetic heart valves at time of kidney transplantation.

*Methods: We conducted a matched cohort study among kidney transplant recipients from the French multicentric and prospective DIVAT cohort. We compared post-transplant outcomes in patients with left-sided PHVs at time of kidney transplantation (2000-2019) and a population of recipients without PHV matched for re-transplant dialysis time, recurrent renal disease, diabetes, cardiovascular events and pre-transplant donor-specific antibodies. Cox proportional hazards regression was used to identify independent predictors of death.

*Results: Of 23018 kidney transplant recipients in the database, 368 were included in the study, 92 (0.4%) of whom had a PHV at time of transplantation and 276 had not. Delayed graft function and post-operative bleeding occurred more frequently in patients with PHVs than in those without PHV (34.8% vs 14.1%, p<0.0001 and 47.8% vs 11.6 %, p<0.0001, respectively). Kidney graft survival was similar between groups. 5-year overall survival was 68.5 % in patients with PHV versus 87.9 % in patients without PHV (HR, 2.72 [1.57-4.70], p=0.0004 by log-rank). Deaths from infection, endocarditis and bleeding were significantly more frequent in patients with PHV (14.1% vs 4.7%, p=0.004; 3.2% vs 0.4%, p=0.049; 3.3% vs 0%, p=0.02; respectively). In contrast with a bioprosthetic valve, a mechanical valve at time of transplantation was an independent risk factor for mortality (HR, 2.89 [1.68-4.97], p=0.0001) together with recipient age, pre-transplant dialysis time, diabetes and cardiac events.

*Conclusions: ESKD patients with prosthetic heart valves have high mortality rates after kidney transplantation (more than 30% at 5 years post-transplantation). These data suggest that mechanical valves, but not biological valves, increase risks of post-transplant mortality, which has to be considered when choosing the type of prosthetic heart valve in ESKD patients eligible for kidney transplantation.

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