SIMULTANEOUS TRANSPLANTATION OF THE HEART AND KIDNEY

Background: Multiple organ transplants have become frequent. Combined heart-and-kidney grafting has been reported recently and we have pursu ed this in selected cases. Aims: To devise a protocol for simultaneous heart-and-kidney transplantation, review our clinical experience with the procedure and the causes of cardiac and renal disease in this gro up. Methods: Seven patients with advanced cardiac failure (LV ejection fraction < 0.29 units; five with IDCM), and chronic renal failure (se rum creatinine > 375 mu mol/L) due to a variety of causes, were accept ed for combined heart-and-kidney transplantation. Four males, of mean age 33 years, underwent the procedure. Each received his organs from a single cadaveric donor with ABO blood group compatibility and a negat ive 'current' lymphocytotoxic cross-match, but without regard to HLA-a ntigen matching. Cardiac ischaemic time averaged 3 hours 40 minutes, t he renal first warm time was 0 minutes in all cases, and renal cold an d second warm ischaemic times averaged 5 hours 17 minutes and 52 minut es respectively. The heart was grafted first and the kidney second in a procedure which averaged seven hours. Immunosuppression was achieved by induction with antithymocyte globulin, thence steroids, azathiopri ne and cyclosporin A. Results: No patient required post-operative dial ysis. One patient had early urological complications requiring operati ve correction, but no serious opportunistic infections were observed. Early cardiac rejection on biopsy (ISHT grade 3a) was seen in three pa tients at four-ten weeks and responded promptly to increased steroids, but severe steroid-resistant rejection of both heart and kidney conte mporaneously occurred in one of these three at 19 months and required a course of muromonab-CD3. All four patients developed hypertension. M ean creatinine clearance was 1.23 +/- 0.22 ml/second (74 +/- 13 mL/min ute) at last follow-up. All four recipients were alive, well and rehab ilitated 5, 20, 28 and 35 months after grafting. Two patients died whi le waiting for the double procedure and another patient eventually die d after being taken off the dual waiting list and receiving a renal tr ansplant only. Conclusions: In experienced hands, combined heart-and-k idney transplantation is feasible and offers a compelling therapeutic solution in the treatment of advanced cardiac and renal failure. IDCM is a frequent cause of the heart failure in this group.