Advertisement
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:https://doi.org/10.1016/j.healun.2023.01.004

      Abstract

      Background

      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.

      Methods

      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.

      Results

      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.

      Conclusions

      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)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The Journal of Heart and Lung Transplantation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Benjamin EJ
        • Blaha MJ
        • Chiuve SE
        • et al.
        Heart Disease and Stroke Statistics-2017 Update: A Report From the American Heart Association [published correction appears in Circulation. 2017 Mar 7;135(10):e646] [published correction appears in Circulation. 2017 Sep 5;136(10):e196].
        Circulation. 2017; 135: e146-e603https://doi.org/10.1161/CIR.0000000000000485
        • Khush KK
        • Cherikh WS
        • Chambers DC
        • et al.
        The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: Thirty-sixth adult heart transplantation report - 2019; focus theme: Donor and recipient size match [published correction appears in J Heart Lung Transplant. 2020 Jan;39(1):91].
        J Heart Lung Transplant. 2019; 38: 1056-1066https://doi.org/10.1016/j.healun.2019.08.004
        • Hunt SA
        • Haddad F.
        The changing face of heart transplantation.
        J Am Coll Cardiol. 2008; 52: 587-598https://doi.org/10.1016/j.jacc.2008.05.020
        • Organ Procurement and Transplantation Network. OPTN
        2022
        • Estep JD
        • Soltesz E
        • Cogswell R.
        The new heart transplant allocation system: Early observations and mechanical circulatory support considerations [published online ahead of print, 2020 Sep 16].
        J Thorac Cardiovasc Surg. 2020; (S0022-5223(20)32638-6)https://doi.org/10.1016/j.jtcvs.2020.08.113
        • Kilic A
        • Mathier MA
        • Hickey GW
        • et al.
        Evolving Trends in Adult Heart Transplant With the 2018 Heart Allocation Policy Change.
        JAMA Cardiol. 2021; 6: 159-167https://doi.org/10.1001/jamacardio.2020.4909
        • Awad MA
        • Shah A
        • Griffith BP.
        Current status and outcomes in heart transplantation: a narrative review.
        Rev Cardiovasc Med. 2022; 23: 11https://doi.org/10.31083/j.rcm2301011
        • Ganapathi AM
        • Lampert BC
        • Mokadam NA
        • et al.
        Allocation changes in heart transplantation: What has really changed? [published online ahead of print, 2021 Mar 16].
        J Thorac Cardiovasc Surg. 2021; (S0022-5223(21)00510-9)https://doi.org/10.1016/j.jtcvs.2021.03.031
        • Goff RR
        • Uccellini K
        • Lindblad K
        • et al.
        A change of heart: Preliminary results of the US 2018 adult heart allocation revision.
        Am J Transplant. 2020; 20: 2781-2790https://doi.org/10.1111/ajt.16010
        • Lazenby KA
        • Narang N
        • Pelzer KM
        • Ran G
        • Parker WF.
        An updated estimate of posttransplant survival after implementation of the new donor heart allocation policy.
        Am J Transplant. 2022; 22: 1683-1690https://doi.org/10.1111/ajt.16931
        • Sharma A
        • Zhao X
        • Hammill BG
        • et al.
        Trends in Noncardiovascular Comorbidities Among Patients Hospitalized for Heart Failure: Insights From the Get With The Guidelines-Heart Failure Registry.
        Circ Heart Fail. 2018; 11e004646https://doi.org/10.1161/CIRCHEARTFAILURE.117.004646
        • Heywood JT
        • Fonarow GC
        • Costanzo MR
        • et al.
        High prevalence of renal dysfunction and its impact on outcome in 118,465 patients hospitalized with acute decompensated heart failure: a report from the ADHERE database.
        J Card Fail. 2007; 13: 422-430https://doi.org/10.1016/j.cardfail.2007.03.011
        • Nadkarni GN
        • Chauhan K
        • Patel A
        • et al.
        Temporal trends of dialysis requiring acute kidney injury after orthotopic cardiac and liver transplant hospitalizations.
        BMC Nephrol. 2017; 18 (Published 2017 Jul 19): 244https://doi.org/10.1186/s12882-017-0657-8
        • Rossi AP
        • Vella JP.
        Acute Kidney Disease After Liver and Heart Transplantation.
        Transplantation. 2016; 100: 506-514https://doi.org/10.1097/TP.0000000000000916
        • Jokinen JJ
        • Tikkanen J
        • Kukkonen S
        • et al.
        Natural course and risk factors for impaired renal function during the first year after heart transplantation.
        J Heart Lung Transplant. 2010; 29: 633-640https://doi.org/10.1016/j.healun.2010.01.004
        • Escoresca Ortega AM
        • Ruíz de Azúa López Z
        • Hinojosa Pérez R
        • et al.
        Kidney failure after heart transplantation.
        Transplant Proc. 2010; 42: 3193-3195https://doi.org/10.1016/j.transproceed.2010.05.049
        • Odim J
        • Wheat J
        • Laks H
        • et al.
        Peri-operative renal function and outcome after orthotopic heart transplantation.
        J Heart Lung Transplant. 2006; 25: 162-166https://doi.org/10.1016/j.healun.2005.07.011
        • Fortrie G
        • Manintveld OC
        • Constantinescu AA
        • van de Woestijne PC
        • Betjes MGH.
        Renal function at 1 year after cardiac transplantation rather than acute kidney injury is highly associated with long-term patient survival and loss of renal function - a retrospective cohort study.
        Transpl Int. 2017; 30: 788-798https://doi.org/10.1111/tri.12940
        • Cogswell R
        • John R
        • Estep JD
        • et al.
        An early investigation of outcomes with the new 2018 donor heart allocation system in the United States.
        J Heart Lung Transplant. 2020; 39: 1-4https://doi.org/10.1016/j.healun.2019.11.002
        • Liu J
        • Yang BQ
        • Itoh A
        • Masood MF
        • Hartupee JC
        • Schilling JD.
        Impact of New UNOS Allocation Criteria on Heart Transplant Practices and Outcomes.
        Transplant Direct. 2020; 7 (Published 2020 Dec 15): e642https://doi.org/10.1097/TXD.0000000000001088
        • Arora S
        • Andreassen A
        • Simonsen S
        • et al.
        Prognostic importance of renal function 1 year after heart transplantation for all-cause and cardiac mortality and development of allograft vasculopathy.
        Transplantation. 2007; 84: 149-154https://doi.org/10.1097/01.tp.0000268810.61393.2c
        • Ojo AO
        • Held PJ
        • Port FK
        • et al.
        Chronic renal failure after transplantation of a nonrenal organ.
        N Engl J Med. 2003; 349: 931-940https://doi.org/10.1056/NEJMoa021744
        • Villar E
        • Boissonnat P
        • Sebbag L
        • et al.
        Poor prognosis of heart transplant patients with end-stage renal failure.
        Nephrol Dial Transplant. 2007; 22: 1383-1389https://doi.org/10.1093/ndt/gfl811
        • Roest S
        • Hesselink DA
        • Klimczak-Tomaniak D
        • et al.
        Incidence of end-stage renal disease after heart transplantation and effect of its treatment on survival.
        ESC Heart Fail. 2020; 7: 533-541https://doi.org/10.1002/ehf2.12585
        • Wang TJ
        • Lin CH
        • Wei HJ
        • Wu MJ.
        Long-Term Outcomes and Risk Factors of Renal Failure Requiring Dialysis after Heart Transplantation: A Nationwide Cohort Study.
        J Clin Med. 2020; 9 (Published 2020 Jul 31): 2455https://doi.org/10.3390/jcm9082455
        • Sarnak MJ
        • Levey AS
        • Schoolwerth AC
        • et al.
        Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention.
        Hypertension. 2003; 42: 1050-1065https://doi.org/10.1161/01.HYP.0000102971.85504.7c
        • Stenvinkel P
        • Carrero JJ
        • Axelsson J
        • Lindholm B
        • Heimbürger O
        • Massy Z.
        Emerging biomarkers for evaluating cardiovascular risk in the chronic kidney disease patient: how do new pieces fit into the uremic puzzle?.
        Clin J Am Soc Nephrol. 2008; 3: 505-521https://doi.org/10.2215/CJN.03670807
        • Costa E
        • Rocha S
        • Rocha-Pereira P
        • et al.
        Cross-talk between inflammation,coagulation/fibrinolysis and vascular access in hemodialysis patients.
        J Vasc Access. 2008; 9: 248-253
        • Kendrick J
        • Chonchol MB.
        Nontraditional risk factors for cardiovascular disease in patients with chronic kidney disease.
        Nat Clin Pract Nephrol. 2008; 4: 672-681https://doi.org/10.1038/ncpneph0954
        • Weiss ES
        • Allen JG
        • Kilic A
        • et al.
        Development of a quantitative donor risk index to predict short-term mortality in orthotopic heart transplantation.
        J Heart Lung Transplant. 2012; 31: 266-273https://doi.org/10.1016/j.healun.2011.10.004
        • Kilic A
        • Hickey G
        • Mathier MA
        • et al.
        Outcomes of the First 1300 Adult Heart Transplants in the United States After the Allocation Policy Change.
        Circulation. 2020; 141: 1662-1664https://doi.org/10.1161/CIRCULATIONAHA.119.045354
        • Singh SSA
        • Dalzell JR
        • Berry C
        • Al-Attar N
        Primary graft dysfunction after heart transplantation: a thorn amongst the roses.
        Heart Fail Rev. 2019; 24: 805-820https://doi.org/10.1007/s10741-019-09794-1
        • Habib PJ
        • Patel PC
        • Hodge D
        • et al.
        Pre-orthotopic heart transplant estimated glomerular filtration rate predicts post-transplant mortality and renal outcomes: An analysis of the UNOS database.
        J Heart Lung Transplant. 2016; 35: 1471-1479https://doi.org/10.1016/j.healun.2016.05.028
        • Gill J
        • Shah T
        • Hristea I
        • et al.
        Outcomes of simultaneous heart-kidney transplant in the US: a retrospective analysis using OPTN/UNOS data.
        Am J Transplant. 2009; 9: 844-852https://doi.org/10.1111/j.1600-6143.2009.02588.x
        • Schaffer JM
        • Chiu P
        • Singh SK
        • Oyer PE
        • Reitz BA
        • Mallidi HR
        Heart and combined heart-kidney transplantation in patients with concomitant renal insufficiency and end-stage heart failure.
        Am J Transplant. 2014; 14: 384-396https://doi.org/10.1111/ajt.12522
        • Karamlou T
        • Welke KF
        • McMullan DM
        • et al.
        Combined heart-kidney transplant improves post-transplant survival compared with isolated heart transplant in recipients with reduced glomerular filtration rate: Analysis of 593 combined heart-kidney transplants from the United Network Organ Sharing Database.
        J Thorac Cardiovasc Surg. 2014; 147 (e1): 456-461https://doi.org/10.1016/j.jtcvs.2013.09.017
        • Kilic A
        • Grimm JC
        • Whitman GJ
        • et al.
        The survival benefit of simultaneous heart-kidney transplantation extends beyond dialysis-dependent patients.
        Ann Thorac Surg. 2015; 99: 1321-1327https://doi.org/10.1016/j.athoracsur.2014.09.026