Heart-kidney listing is better than isolated heart listing for pediatric heart transplant candidates with significant renal insufficiency

Published:February 28, 2022DOI:



      Significant renal insufficiency is identified as a risk factor for post-transplantation mortality in pediatric heart transplant recipients. This study evaluates simultaneous heart-kidney transplantation listing outcomes compared with heart transplant for pediatric candidates with significant renal insufficiency.


      The United Network for Organ Sharing registry was searched for patients (January 1987 to March 2020) who were simultaneously listed for a heart-kidney transplantation or for heart transplant with significant renal insufficiency at the time of listing. Significant renal insufficiency was defined as needing dialysis or having a low estimated glomerular filtration rate (<40 mL/min). Survival was calculated using Kaplan–Meier analysis.


      A total of 427 cases were identified; 109 were listed for heart-kidney transplantation, and 318 were listed for heart transplant alone. Median time on the waitlist was 101 days (interquartile range, 28-238) for heart-kidney transplantation listings compared with 39 days (14-86) and 23.5 days (6-51) for heart transplant recipients with a low estimated glomerular filtration rate (P = .002) or on dialysis (P < .001), respectively. Of all heart-kidney transplantation listings, 66% (n = 71) received a transplant compared with 54% (n = 173) of heart transplantation with significant renal insufficiency (P = .005) with a mean survival of 14.6 years (12.7-16.4 years) for heart transplant without significant renal insufficiency at transplantation and 7.6 years (5.4-9.9 years) for heart transplant with significant renal insufficiency at transplantation. At 1 year after listing, 69% of heart-kidney transplantation listed recipients were alive, compared with 51% of heart transplant listed recipients (P = .029). Heart-kidney transplantation recipients had better 1-year post-transplantation survival (86%) than heart transplantation with significant renal insufficiency at transplant (66%) (P = .001). There was no significant difference in the 1- and 5-year survivals of those undergoing heart transplantation listed with significant renal insufficiency but no significant renal insufficiency at the time of transplant (89% and 78%) and heart-kidney transplantation recipients (86% and 81%; P = .436).


      Pediatric candidates with significant renal insufficiency listed for heart-kidney transplantation have superior waitlist and post-transplantation outcomes compared with those listed for heart transplant alone. Patients with significant renal insufficiency should be listed for heart-kidney transplantation, however; if their renal function improves significantly, heart transplant alone appears judicious.

      Graphical abstract

      Key Words

      Abbreviations and Acronyms:

      CI (confidence interval), ECMO (extracorporeal membrane oxygenation), eGFR (estimated glomerular filtration rate), HKTx (simultaneous heart-kidney transplant), HR (hazard ratio), HTx (heart transplant), IQR (interquartile range), IRB (Institutional Review Board), OPTN (Organ Procurement and Transplantation Network), SRI (significant renal insufficiency), UNOS (United Network for Organ Sharing), VAD (ventricular assist device)
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      Linked Article

      • Commentary: Heart transplantation listing for children with significant renal insufficiency: The need for a paradigm shift
        The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 6
        • Preview
          Dani and colleagues1 from Cincinnati review the Organ Procurement and Transplantation Network/United Network for Organ Sharing Registry with focus on pediatric patients (younger than age 18 years) with significant renal insufficiency (defined as having a estimated glomerular filtration rate <40 mL/min/1.73 m2 and/or being on dialysis) at time of listing for heart transplantation (HTx) (n = 318) or combined heart–kidney transplantation (HKTx) (n = 109). They found that those listed for HKTx were more likely to undergo transplantation than those listed for HTx (66% vs 54%; P = .005) and more likely to be alive at 1 year after listing (69% vs 51%; P = .029).
        • Full-Text
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      • Commentary: Kidney at the heart of the matter
        The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 6
        • Preview
          Significant renal insufficiency (SRI) in pediatric patients with progressive heart failure is common, and may affect transplant candidacy and potentially compromise early and late outcomes after heart transplant. Simultaneous heart–kidney transplant (HKTx) has been shown to be an effective treatment strategy for selected patients with end-stage heart failure and SRI, but it has rarely been done in pediatric populations.1,2 Dani and colleagues3 conducted a large-scale study using United Network for Organ Sharing Registry data spanning more than 3 decades to determine whether or not listing for HKTx is superior to listing for heart transplantation (HTx) alone in patients with SRI.
        • Full-Text
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