Purpose: To describe a unique sequential surgical strategy for heart-kidney transplantation.

Methods: We reviewed all 6 patients who received combined heart-kidney transplants at our institution between 2013-2016. We waited 16-39 hours after the cardiac transplant before transplanting the kidney. The donor kidney was preserved with pulsatile perfusion. This allowed us to stabilize the hemodynamics, and control any coagulopathy and bleeding from the thorax.

Demographics: The 6 recipients were males, ages 54-67 years (62.7 ± 5.7). Their HLA mismatches were 5-6. Heart failure was ischemic in 3 patients. 5 patients had one or more LVAD's pre-transplant. 2 patients were on dialysis. The kidney failure was associated with diabetes in 3 patients, hypertension in 6 patients, and hepatitis C in 1. The donors were all males, ages 26-32 years (29 ± 2.5). All donors but 1 died of a CVA. Their initial serum creatinine was 1.00-1.23 mg/dl, and terminal serum creatinine was 0.6-1.68 mg/dl. Only 1 donor had hypertension. The cold ischemic time was 16-39 hours (26.3 ± 8.7) for the kidney transplant.

Results: We had excellent outcomes with immediate renal allograft function, with 100% patient and allograft survival. This is in contrast to previous reports with higher mortality in simultaneous heart-kidney transplant patients. The immunosuppression included Thymoglobulin induction and Tacrolimus, MMF, Prednisone maintenance. 5 of the 6 patients had no acute cellular rejection at anytime. 1 patient had 5 episodes of 1 R rejection, 2 of which were treated with IV Methylprednisolone followed by an oral Prednisone taper. There was no hemodynamic compromise or antibody mediated rejection.

Conclusions: Our unique strategy allows us to transplant the donor kidney once the patient is stable. This avoids exposing the kidney to nephrotoxic byproducts of cardiopulmonary bypass like plasma-free hemoglobin, as well as acute tubular necrosis from hypotension and pressors in the immediate post-cardiac transplant period. We feel this technique will result in better patient and renal allograft survival in the long-term. Randomized clinical trials are warranted to further examine this surgical strategy.

CITATION INFORMATION: Mital D, Petruccione M, Brown J, Vasquez S, Wheaton S, Johnson W, Desai C, Chhabra D, Kinzler G, Sankary H, Lawrecki T, Pappas P, Tatooles A, Bresticker M, Cotts W, Bhat G. Sequential Surgical Strategy for Heart-Kidney Transplantation. Am J Transplant. 2017;17 (suppl 3).

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