Asian Cardiovasc Thorac Ann 2000;8:164-166
© 2000 Asia Publishing EXchange Pte Ltd
Cardiac and Delayed Renal Transplantation With Same-Donor Allografts
Glen S McKay, MB, ChB,
David A Haydock, FRACS,
Russell Bourchier, FRACS,2,
Peter N Ruygrok, FRACP,1,
Trevor M Agnew, FRACP,1,
H Arthur Coverdale, FRACP,1,
Mayanna Lund, FRACP,1,
John Collins, FRACP,3
Department of Cardiothoracic Surgery
1 Department of Cardiology
Green Lane Hospital
Auckland, New Zealand
2 Department of Vascular Surgery
3 Department of Renal Medicine
Auckland Hospital
Auckland, New Zealand
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For reprint information contact: David A Haydock, FRACS Tel: 64 9 638 9909 Fax: 64 9 630 9906 email: davidhay{at}ahsl.co.nz Department of Cardiothoracic Surgery, Green Lane Hospital, Green Lane West, Epsom, Auckland 3, New Zealand.
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Abstract
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Three combined heart and delayed kidney transplantations were carried out between 1992 and 1998. The patients received induction therapy with antithymocyte immunoglobulin and were maintained on triple immunosuppressive therapy (cyclosporin, azathioprine, and prednisone). All are currently alive with satisfactory transplanted organ function. The medical histories, clinical course, and outcomes are described. Heart and delayed kidney transplantation with allografts from the same donor appears to be effective treatment for selected patients with end-stage cardiac and renal disease.
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Introduction
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Advanced renal and cardiac failure is associated with a poor prognosis and substantial cost. Combined organ transplantation carries a significant operative risk in these very sick surgical candidates, but when successful, it provides the best long-term outlook in terms of improved prognosis, quality of life, and cost effectiveness. Heart transplantation can be combined with immediate or delayed kidney transplantation when using organs from the same donor.
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Case Reports
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Since 1987, 93 heart transplants have been performed at Green Lane Hospital (one-year actuarial survival, 88%). Three of these patients underwent combined heart and kidney transplantation.
Case 1
A 16-year-old male with end-stage chronic renal failure secondary to biopsy-proven crescentic glomerulonephritis required the institution of continuous ambulatory peri-toneal dialysis. He developed dilated cardiomyopathy and a 2-dimensional echocardiogram performed prior to transplantation revealed a left ventricular end-diastolic dimension (LVEDD) and left ventricular end-systolic dimension (LVESD) of 7.3 and 6.8 cm, respectively, giving a fractional shortening (FS) of 7%. His pretransplant serum creatinine was 0.99 mmol•L–1 and serum urea was 32.7 mmol•L–1. Additional comorbidities included seronegative chronic juvenile arthritis diagnosed at the age of 8 years and a pulmonary embolism (documented by pulmonary angiography) one month after the institution of dialysis. This embolic episode followed minor surgery and led to a left lower lobectomy and decortication 1 year later for chronic empyema and bronchopleural fistula. Prior to transplantation, he was cachectic with a weight of 39 kg and he was severely restricted in his daily activities. Five months after the lobectomy procedure, the patient underwent orthotopic cardiac transplantation (cardiac allograft ischemic time, 180 minutes) and renal transplantation 4 hours later (total renal ischemic time, 7 hours). During his intensive care stay of 10 days, he required minimal inotropic support and diuretic therapy. While an inpatient (25 days), he had a mild exacerbation of arthritis, controlled with sulindac 100 mg daily. Subsequent right ventricular biopsies showed evidence of only mild rejection (International Society for Heart and Lung Transplantation grade 1A). He had one episode of renal rejection treated with methylprednisolone. Six and a half years after combined transplantation, he remains well, plays golf with a 14-stroke handicap, and works part time. His weight is now 71 kg, serum creatinine 0.15 mmol•L–1, and urea 18.1 mmol•L–1. Echocardiographically, he has normal left ventricular function with LVEDD of 4.5 cm and LVESD of 3.1 cm (FS 31%).
Case 2
A 44-year-old woman underwent a right mastectomy and radiotherapy for a ductal breast carcinoma (stage-I disease) and was subsequently treated for hypothyroidism. Ten years later, polycystic kidneys led to end-stage renal failure (urea, 24.4 mmol•L–1; creatinine, 1.05 mmol•L–1). Continuous ambulatory peritoneal dialysis was commenced. The following year, she underwent a left nephrectomy for abdominal discomfort due to a massive polycystic kidney. An idiopathic dilated cardiomyopathy with progressive symptoms became apparent 3 years later, initially presenting with cardiac arrest. Echocardiography showed LVEDD 6.5 cm, LVESD 6 cm, and FS 7%. Orthotopic cardiac transplantation was performed semiurgently 31 months later, following admission to the coronary care unit for observation of ventricular arrhythmias. The cardiac allograft ischemic time was 240 minutes. Renal transplantation occurred 8 hours later with a total renal ischemic time of 12 hours. Postoperative problems included pseudomembranous colitis (treated with oral metronidazole 400 mg x 3 for 10 days), neutropenia (resolved rapidly following cessation of azathioprine therapy), and a low grade systemic cytomegalovirus infection (treated with intravenous ganciclovir). However, these were relatively minor problems and both allografts functioned well from the beginning, with minimal support. Six days were spent in the intensive care unit and a further 16 days in hospital. Fourteen months posttransplantation, she remains well with normal cardiac function documented echocardiographically and no evidence of cardiac rejection on multiple right ventricular biopsies. Her current renal function is normal with serum urea of 8.1 mmol•L–1 and creatinine 0.10 mmol•L–1. She is no longer anemic.
Case 3
A 32-year-old Maori male had immunoglobulin-A nephropathy leading to chronic renal failure and was managed on continuous ambulatory peritoneal dialysis. He became severely symptomatic with cardiomyopathy developing 17 months later (LVEDD, 7 cm; LVESD, 5.7 cm; FS, 19%). This was thought to have resulted from previous heavy alcohol and opiate use. Histological examination of the explanted heart revealed idiopathic cardiomyopathy with no other specific features. Additionally, he was a chronic hepatitis B carrier (positive for hepatitis B surface and core antigens). Orthotopic cardiac transplantation (cardiac allograft ischemia time, 184 minutes) was followed in 8.5 hours by renal transplantation (total renal ischemic time, 11.5 hours) 42 months after the onset of renal failure. The total intensive care stay was 5 days and total hospital stay was 47 days. Postoperatively, he had minimal inotropic requirements. An episode of mild pulmonary edema responded rapidly to intravenous frusemide. Forty days after the transplant, renal dysfunction plus a weight gain of 4 kg occurred. His urea rose to 18 mmol•L–1 and creatinine to 0.21 mmol•L–1 and a renal biopsy provided evidence of acute renal rejection. Echocardiography at that time showed vigorous ventricular function and all preceding cardiac biopsies had shown no evidence of rejection. The renal rejection was treated with OKT3 infusions (5 mg per day for 9 days). His renal function subsequently stabilized and a follow-up renal biopsy 3 weeks after completion of the OKT3 infusions was normal. When last reviewed at 10 months posttransplant, he was well. Cardiac biopsy showed mild low-grade rejection (International Society for Heart and Lung Transplantation grade 1A) with normal cardiac function echocardiographically. His creatinine was 0.18 mmol•L–1 and urea 9.8 mmol•L–1.
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Discussion
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It was found that delaying renal transplantation for an average of 6.8 hours after cardiac transplantation worked well in these patients. The rationale for delaying renal transplantation was to enable hemodynamic stabilization, rewarming, and hemostasias to provide the optimal environment for postoperative renal graft function. Because renal cold ischemic time did not exceed 12 hours in any patient, the kidneys were not placed at increased risk of initial nonfunction. As most cardiac transplants occur during the night, the renal transplant can usually be performed as an elective procedure on the next convenient surgical list.
A search of the literature search revealed 12 papers reporting results of more than 100 combined cardiac and renal transplants. It is clear that both immediate and delayed kidney transplantations are associated with satisfactory outcomes. Colucci and colleagues1 in a series of 6 cases, performed kidney transplantation immediately after closure of the chest. Their patients' renal function normalized within a few days with no signs of rejection. Savdie and colleagues2 described 4 cases of simultaneous cardiac and renal transplantation in procedures lasting 7 hours on average. None of their patients required post-operative dialysis.
Combined cardiac and renal transplantation led to good clinical outcomes in the 3 patients in this series. Blanche and colleagues3 in a review of the United Network for Organ Sharing registry of patients who had undergone heart and kidney transplant between 1987 and 1995, found survival to be similar to that of single-organ transplan-tation. In the largest series to date, Narula and colleagues4 found no significant difference in short and intermediate-term actuarial survival between simultaneous heart and kidney transplantation in 84 patients and isolated heart transplantation.
It has been suggested that combined transplantation may benefit cardiac graft survival by an immunomodulatory mechanism. Cardiac allograft rejection episodes seem less frequent in combined heart-kidney recipients when compared to isolated grafts. In agreement with a previous report, we also found that independent asynchronous rejection of either transplanted organ can occur.3 Careful observation for signs of rejection in either organ is essential for early detection and satisfactory long-term outcomes. None of our patients had cardiac rejection requiring additional immunosuppressive therapy following trans-plantation. We believe combined heart and kidney trans-plantation is effective treatment for carefully selected patients with end-stage cardiac and renal disease, and recommend a delayed renal transplantation protocol.
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References
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Colucci V, Quaini E, Magnani P, Colombo T, De Carlis L, Grassi M, et al. Combined heart and kidney transplantation: an effective therapeutic option — report of six cases. Eur J Cardio-thorac Surg 1997;12:654–8.[Abstract]
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Savdie E, Keogh AM, MacDonald PS, Spratt PM, Graham AM, Golovsky D, et al. Simultaneous transplantation of the heart and kidney. Aust NZ Med J 1994;24:554–60.
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Blanche C, Valenza M, Czer LSC, Barath P, Admon D, Harasty D, et al. Combined heart and kidney transplan-tation with allografts from the same donor. Ann Thorac Surg 1994;58:1135–8.[Abstract]
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Narula J, Bennett LE, DiSalvo T, Hosenpud JD, Semigran MJ, Dec GW. Outcomes in recipients of combined heartkidney transplantation. Transplantation 1997;63:861–7.[Medline]
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Abstract
Introduction
