Combined Heart and Kidney Transplantation: How Hypothermic Machine Perfusion Enables Delayed Kidney Implantation

Objectives: Combined heart and kidney transplantation (HKTx) is a well-established procedure in a highly demanding patient population. Due to the growing complexity of heart recipients, the early postoperative period is crucial for the timing of the kidney. In the era of dynamic perfusion strategies, hypothermic machine perfusion (HMP) became a standard clinical procedure for kidney transplantation with favorable outcomes compared with SCS (static cold storage). We introduce a new strategy for delayed kidney implantation applying HMP in patients undergoing HKTx.

Methods: Within the last 20 years, 25 patients (median age: 57, IQR: 48–61 years) underwent HKTx at our center. In the last 12 months, five patients were transplanted using HMP for delayed kidney implantation. Hence, we are retrospectively describing this case series.

Result: Five male patients (median age: 58 years) with end-stage heart failure (two ischemic cardiomyopathy [CMP], two dilative CMP, one restrictive CMP) and cardiorenal syndrome received the transplants. Four patients had at least one previous cardial surgical procedure. Two were bridged with mechanical circulatory support (Impella for 6 days, venoarterial extracorporeal life support for 4 days) and underwent high urgency (HU) transplantation. Three patients were upgraded for HKTx due to progressive kidney failure during the waiting period (median: 21 months). Median SCS time for the heart was 197 minutes. All patients were transferred to the ICU for initial stabilization after HTx with adequate graft function but moderate catecholamine and inotropic support. Once patients started clearing lactate and entered the weaning phase, they were transferred to the OR for kidney implantation. Mean overall cold ischemic time (SCS and HMP) for the kidney was 24 hours. On average, kidney HMP was performed for 18.2 ± 10 hours. All patients had a normal cardiac function with none or minimal medical support within a week after HNTx. One patient, transplanted under HU conditions, died after 20 days due to severe sepsis. In one patient, primary nonfunction of the kidney occurred following a critical early postoperative period with major volume shifts.

Conclusion: Implementation of HMP for delayed kidney transplantation in increasingly complex HNTx recipients offers the possibility to stabilize the patients hemodynamically after HTx.

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Publikationsverlauf

Artikel online veröffentlicht:
19. Februar 2021