The Journal of Heart and Lung Transplantation
International Society for Heart and Lung Transplantation.

Clinical Trends, Risk Factors, and Temporal Effects of Post-transplant Dialysis on Outcomes Following Orthotopic Heart Transplantation in the 2018 United States Heart Allocation System

Published:January 19, 2023DOI:



      This study evaluated the current clinical trends, risk factors, and temporal effects of post-transplant dialysis on outcomes following orthotopic heart transplantation after the 2018 United States adult heart allocation policy change.


      The UNOS registry was queried to analyze adult orthotopic heart transplant recipients after the 10/18/2018 heart allocation policy change. The cohort was stratified according to the need for post-transplant de novo dialysis. The primary outcome was survival. Propensity score-matching was performed to compare the outcomes between two similar cohorts with and without post-transplant de novo dialysis. The impact of post-transplant dialysis chronicity was evaluated. Multivariable logistic regression was performed to identify risk factors for post-transplant dialysis.


      A total of 7,223 patients were included in this study. Of these, 968 patients (13.4%) developed post-transplant renal failure requiring de novo dialysis. Both 1-year (73.2% vs 94.8%) and 2-year (66.3% vs 90.6%) survival rates were lower in the dialysis cohort (p<0.001), and the lower survival rates persisted in a propensity-matched comparison. Recipients requiring only temporary post-transplant dialysis had significantly improved 1-year (92.5% vs 71.6%) and 2-year (86.6 % vs 52.2%) survival rates compared to the chronic post-transplant dialysis group (p<0.001). Multivariable analysis demonstrated low pre-transplant eGFR and bridge with ECMO were strong predictors of post-transplant dialysis.


      This study demonstrates that post-transplant dialysis is associated with significantly increased morbidity and mortality in the new allocation system. Post-transplant survival is affected by the chronicity of post-transplant dialysis. Low pre-transplant eGFR and ECMO are strong risk factors for post-transplant dialysis.

      Key Words

      Abbreviations and Acronyms:

      AKI (acute kidney injury), ANOVA (analysis of variance), BMI (body mass index), CHK (combined heart-kidney transplantation), CI (confidence interval), CKD (chronic kidney disease), ECMO (extracorporeal membrane oxygenation), eGFR (estimated glomerular filtration), ESRD (end-stage kidney disease), HF (heart failure), HR (hazard ratio), IQR (interquartile range), MCS (mechanical circulatory support), MV (mechanical ventilation), OHT (orthotopic heart transplantation), OR (odds ratio), SMD (standardized mean difference), UNOS (United Network for Organ Sharing)
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