TREATMENT OF END-STAGE RENAL-FAILURE AFTER HEART-TRANSPLANTATION

Background. Five to 10% of heart-transplant recipients develop end-sta ge renal failure (ESRF). Little is known about the outcome of these pa tients under renal replacement therapy. Methods. We conducted a retros pective study in 16 men (mean age 52.8 +/- 7.4 years at heart transpla ntation) who developed ESRF 5.3 +/- 2.1 years later. Results. Haemodia lysis (HD) was the first-line treatment (mean Kt/V 1.35 +/- 0.4). Vasc ular access was unsuccessful in six patients (37.5%) due to peripheral arteriopathy and they were treated with tunnelled catheters for an av erage 15 months without bacterial infection. Mean weight was 68.4 +/- 10 kg at onset of KD and 61.7 +/- 9 kg one month later. Despite this r eduction in extracellular overload, one antihypertensive drug was requ ired in 75% of patients and two drugs in 12.5%. One patient tolerated automated peritoneal dialysis (PD) for 16 months (weekly Kt/V 2.1) des pite persistent anuria. Renal transplantation (RT) was contraindicated in eight patients because of aortoiliac arteriopathy (n = 5), poor ge neral status (n = 2), or ischaemic heart disease (n = 2). RT was perfo rmed in eight patients with no acute episode of heart or renal graft r ejection. There were no serious infectious complications. Three months after RT, mean serum creatinine was 115 mu mol/l. One patient develop ed post-transplant lymphoproliferative disorder 3.5 months after RT an d was successfully treated with transplant nephrectomy. Sudden death o ccurred in two patients 18 and 33 months after RT. Overall patient sur vival was 100, 78, and 59%, 1, 2 and 3 years after HD onset respective ly. Using st time-dependent variable, the Cox model analysis demonstra ted that heart-transplant recipients with ESRF have a relative risk of death 3.2 times higher than those without ESRF (95% CI = 1.3-7.8). Co nclusions. HD, PD, and RT can be useful for the treatment of ESRF afte r heart transplantation. After initiating KD, patient survival is near ly the same as that reported in patients in Europe undergoing HD for o ther causes. But ESRF seems to reduce life expectancy in heart-transpl ant recipients.