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

Published:November 01, 2013DOI:


      Criteria for simultaneous heart-kidney transplant (HKTx) recipients are unclear. We characterized the evolution of combined HKTx in the United States over time compared with isolated heart transplantation (HTx) and determined factors maximizing post-transplant survival. We focused on whether a threshold estimated glomerular filtration rate (eGFR) could be identified that justified combined transplantation.


      A supplemented United Network Organ Sharing Dataset identified HTx and HKTx recipients from 2000 to 2010. eGFR was calculated for HTx and recipients were grouped into eGFR quintiles. Time-related mortality was compared among recipients, with multivariable factors sought using Cox proportional hazard regression models.


      We identified 26,183 HTx recipients, of whom 593 were HKTx recipients. HTx increased modestly over time (3.6%), whereas prevalence of HKTx increased dramatically (147%). Risk-unadjusted survival was similar among HTx recipients (8.4 ± 0.04 years) and HKTx recipients (7.7 ± 0.2 years) (P = .76). Isolated HTx recipients in the lowest eGFR quintile had decreased survival (P < .001), but those in the third eGFR quintile had superior survival, suggesting a benefit in this subgroup. HTx recipients in the lowest eGFR quintile (eGFR less than mean 37 mL/minute) had worse survival than combined HKTx recipients (7.1 ± 0.07 vs 7.7 ± 0.2; P < .001). Multivariable factors for increased mortality among HTx recipients included lower eGFR, higher recent panel reactive antibody score, older age, African American race, diabetes, longer ischemic time, and certain diagnoses.


      Performance of combined HKTx is increasing out of proportion to isolated HTx. eGFR is an important determinant of improved HTx survival. Combined HKTx recovers post-transplant survival in patients with eGFR <37 mL/minute and can be recommended in this subgroup.

      CTSNet classification

      Abbreviations and Acronyms:

      eGFR (estimated glomerular filtration rate), HKTx (combined heart-kidney transplant), HTx (heart transplant), LVAD (left ventricular assist device), UNOS (United Network for Organ Sharing)
      To read this article in full you will need to make a payment


        • Norman J.C.
        • Brook M.I.
        • Cooley D.A.
        • Kilma T.
        • Kahan B.D.
        • Frazier O.H.
        • et al.
        Total support of the circulation of a patient with post-cardiotomy stone-heart syndrome by a partial artificial heart (ALVAD) for 5 days followed by heart and kidney transplantation.
        Lancet. 1978; 1: 1125-1127
        • Czer L.S.C.
        • Ruzza A.
        • Vespignani R.
        • Jordan S.
        • De Robertis M.A.
        • Mirocha J.
        • et al.
        Survival and allograft rejection rates after combined heart and kidney transplantation in comparison with heart transplantation alone.
        Transplant Proc. 2011; 43: 3869-3876
        • Laufner G.
        • Kocher A.
        • Grabenwoger M.
        • Berlakovich G.A.
        • Zuckermann A.
        • Ofner P.
        • et al.
        Simultaneous heart and kidney transplantation as treatment for end-stage heart and kidney failure.
        Transplantation. 1997; 64: 1129-1134
        • Raichlin E.
        • Kushwaha S.S.
        • Daly R.C.
        • Kremers W.K.
        • Frantz R.P.
        • Clavell A.L.
        • et al.
        Combined heart and kidney transplantation provides excellent survival and decreases risk of cardiac cellular rejection and coronary allograft vasculopathy.
        Transplant Proc. 2011; 43: 1871-1876
        • Levey A.S.
        • Bosch J.P.
        • Lewis J.B.
        • Greene T.
        • Rogers N.
        • Roth D.
        A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group.
        Ann Intern Med. 1999; 130: 461-470
        • Mathew T.H.
        • Johnson D.W.
        • Jones G.R.
        Chronic kidney disease and automatic reporting of estimated glomerular filtration rate: revised recommendations.
        Med J Aust. 2005; 187: 459-463
      1. Joint Specialty Committee on Renal Medicine of the Royal College of Physicians of London and the Renal Association. Chronic kidney disease in adults: UK guidelines for identification, management and referral. Available at: Accessed October 13, 2013.

        • Schwartz G.J.
        • Haycock G.B.
        • Edelmann C.M.
        • Spitzer A.
        A simple estimate of glomerular filtration rate in children derived from body length and plasma creatinine.
        Pediatrics. 1976; 58: 259-263
        • Schwartz G.J.
        • Feld L.G.
        • Langford D.J.
        A simple estimate of glomerular filtration rate in full-term infants during the first year of life.
        J Pediatr. 1984; 104: 849-854
        • Karamlou T.
        • Gelow J.
        • Tibayan F.
        • Slater M.
        • Mudd J.
        • Song H.K.S.
        Mechanical circulatory support pathways that maximize survival following heart transplantation.
        Ann Thorac Surg. 2013; 145: 470-475
        • Narula J.
        • Bennett L.E.
        • Disalvo T.
        • Hosenpud J.D.
        • Semigran M.J.
        • Dec G.W.
        Outcomes in recipients of combined heart-kidney transplantation: multiorgan, same-donor study of the International Society of Heart and Lung Transplantation/United Network for Organ Sharing Scientific Registry.
        Transplantation. 1997; 63: 861-867
        • Trachiotis G.D.
        • Vega J.D.
        • Johnston T.S.
        • Berg A.
        • Whelchel J.
        • Smith A.L.
        • et al.
        Ten-year follow-up in patients with combined heart and kidney transplantation.
        J Thorac Cardiovasc Surg. 2003; 123: 2065-2071
        • Blanche C.
        • Valenza M.
        • Czer L.S.
        • Barath P.
        • Admon D.
        • Harasty D.
        • et al.
        Combined heart and kidney transplantation with allografts from the same donor.
        Ann Thorac Surg. 1994; 58: 1135
        • Kabschull L.
        • Schleicher C.
        • Palmes D.
        • Sindermann J.
        • Suwelack B.
        • Senninger N.
        • et al.
        Renal graft outcome in combined heart-kidney transplantation compared to kidney transplantation alone: a single-center, matched-control study.
        Thorac Cardiovasc Surg. 2012; 60: 57-63
        • Castillo-Luga
        • Brinker J.A.
        • Karl R.
        An overview of combined heart and kidney trabsplantation.
        Curr Opin Cardiol. 1999; 14: 121
        • Busson M.
        • Benoit G.
        • Loisance D.
        • Castaing D.
        • Martin X.
        • N’Doye P.
        • et al.
        Long-term results of simultaneous multiple-organ transplants.
        Transplant Proc. 1995; 27: 2446-2447
        • Colucci V.
        • Quaini E.
        • Colombo T.
        • Colombo T.
        • De Carlis L.
        • Grassi M.
        • et al.
        Combined heart and kidney transplantation: an effective option—report of six cases.
        Eur J Cardiothorac Surg. 1997; 12: 654-658
        • Vossler M.R.
        • Ni H.
        • Toy W.
        • Hershberger R.E.
        Pre-operative renal function predicts development of chronic renal insufficiency after orthotopic heart transplantation.
        J Heart Lung Transplant. 2002; 21: 874-881
        • Al Aly Z.
        • Abbas S.
        • Moore E.
        • Diallo O.
        • Hauptman P.J.
        • Bastani B.
        The natural history of renal function following orthotopic heart transplant.
        Clin Transplant. 2005; 19: 683-689
        • Savdie E.
        • Keogh A.
        • Macdonald P.
        • Spratt P.M.
        • Graham A.M.
        • Golovsky D.
        • et al.
        Simultaneous transplantation of the heart and kidney.
        Aust N Z J Med. 1994; 24: 554-560
        • Smith J.
        • Ribakove G.
        • Hunt S.
        • Miller J.
        • Stinson E.B.
        • Oyer P.E.
        • et al.
        Heart retransplantation: the 25-year experience at a single institution.
        J Heart Lung Transplant. 1995; 14: 832-839