Combined heart-kidney transplantation (HKTx) is a well-accepted therapy for patients with severe irreversible heart failure accompanied with renal failure. Patients are often hemodynamically unstable after heart Tx and simultaneous HKTx may increase the incidence of delayed graft function (DGF) and cause poor outcome.

Between July-2004 and May-2012 we performed 11 single-donor staged HKTx and 1 staged HK-pancreas Tx. In this study, we reviewed our single-center experience of staged HKTx, using pulsatile machine perfusion (PP) of renal allografts. The cardiac grafts were implanted as soon as possible after recovery, while the renal grafts were preserved using PP and the kidney Tx was intentionally delayed until the recipient became hemodynamically stable.

The donors’ ages ranged from 12 to 48 yrs and terminal creatinine 0.4-1.9. Cold ischemia time for the kidneys ranged from 8 to 49 hrs. Recipients’ ages were from 19 to 67 yrs. The etiology of the recipients’ end-stage renal disease included: ischemic nephropathy (n=5), hypertensive nephropathy (n=4), lupus nephritis (n=1), and bilateral renal embolization from an intracardiac clot (n=1). One recipient had type 1 diabetes mellitus and required HK-pancreas Tx (n=1). Eight recipients were on renal replacement therapy at the time of Tx and 4 recipients had a preemptive kidney Tx. Immunosuppression included Thymoglobulin and alemtuzumab for induction and mycophenolate and tacrolimus for maintenance. The patient and graft survival rates at 1, 3 and 5 yrs are both 91%, 91%, and 83%, respectively. One patient died 3 mos after Tx with massive GI bleeding with accompanied acute kidney injury, and another patient died 4 yrs after Tx from chronic heart rejection due to non-adherence to medications with good renal function. All other patients are alive with stable kidney function (creat. 0.7-1.5). Seven patients (58%) developed DGF. Biopsy-proven acute rejection occurred in one patient (8.3%).

In conclusion, our mid-term follow up of single-donor staged heart-kidney Tx with the use of PP revealed an excellent mid-term renal graft function. Although the incidence of DGF is still high, this strategy may be a valuable option for HKTx when a patient is hemodynamically unstable after heart Tx.

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