Study: Patients at higher risk for mortality after heart transplantation when placed on dialysis
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Key takeaways:
- Patients on dialysis after a heart-alone transplant had a mortality rate of 41.9%.
- Analysis supports recent Organ Procurement and Transplantation Network policy changes.
The one-year mortality rate after receiving a heart-alone transplant was highest in patients placed on dialysis compared to patients with varying levels of renal dysfunction, according to research presented at the American Transplant Congress.
“We examined the odds of mortality and renal failure at 1-year post-transplant among heart transplant recipients by the degree of renal dysfunction before heart transplant,” Rose Mary Attieh, a kidney and pancreas transplant fellow at Mayo Clinic and head author on the research, said at the meeting.
Investigators used the Scientific Registry of Transplant Recipients (SRTR) database to identify adult primary heart recipients with eGFR of less than 40 mL/min, who had at least a 1 year of follow-up, between 2000 and 2018. Recipients were categorized into four groups: dialysis group; eGFR less than 20 mL/min; eGFR 20 mL/min to 30 mL/min; and eGFR less than 30 mL/min to 40 mL/min.
Pre-transplant variables and post-transplant results were compared using chi-square or Wilcoxon tests. The 1-year outcomes were analyzed with a Cox proportional hazards model, and composite 1-year renal failure was analyzed using a generalized linear mixed model with transplant center as a random effect, according to the research. All models were adjusted for age, sex, heart transplant indication, waitlist status and time on the list. Data showed mortality rate 1 year after heart-alone transplantation (HAT) was highest in patients in the dialysis group.
“If we look at the numbers, we find that these numbers are extremely high and concerning,” Attieh said.
Post-transplant, patients on dialysis had a mortality rate of 41.9%, vs. the eGFR less than 20 mL/min group at 31.5%, the eGFR 20mL to 30 mL/min group at 19.8% and eGFR of greater than 30 mL/min to 40 mL/min group, which had the lowest mortality rate at 16.5%.
Patients on dialysis also fared poorly with renal failure risk, findings showed: Patients on dialysis had a 33.6% chance for renal failure within 1 year after HAT. Members of the eGFR of less than 20 mL/min group had a 16.5% chance; 7.4% for the eGFR 20 mL to 30 mL/min group and 3.5% in the eGFR greater than 30 mL/min 40 mL/min group.
“The severity of pre-HAT renal dysfunction is incrementally associated with mortality and renal failure after HAT,” the researchers wrote.
After an updated analysis to include all post-transplant recipients with eGFR less than 40 mL/min between January 2000 and March 2022, researchers found no significant changes in the findings.
For that reason, HAT may not be a suitable option compared with dual heart/kidney transplantation in those with moderate to severe renal dysfunction (eGFR <40 mL/min) or who require dialysis, Attieh said in her presentation.
The overall analysis supports recent Organ Procurement and Transplantation Network policy changes to be implemented in June, which may create a safety net for HAT recipients with ongoing renal dysfunction to prioritize them for a kidney transplant.
More research is warranted, Attieh said, which could address current limitations such as missing SRTR data and lack of information about the duration of pre-transplant dialysis or the chronicity of the renal dysfunction.
“In heart-alone transplant recipients with moderate to severe renal dysfunction, the 1-year mortality rates are unacceptably high and the [risk] of renal failure is remarkably elevated,” Attieh said. “Future studies have to focus on ways to develop better tools to predict the need for dialysis [with] heart transplant and define the criteria for simultaneous heart/kidney transplant.”
Editor's note: On June 7, 2023, the headline, first key takeaway and first paragraph of the article were updated to better reflect results of the study.
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Attieh RM, et al. Renal failure and mortality after heart alone transplant in recipients with eGFR <40 or on dialysis in the United States. Presented at: American Transplant Congress; June 3-7, 2023; San Diego (hybrid).
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