Outcomes of Orthotopic Heart Transplantation in the Setting of Acute Kidney Injury and Renal Replacement Therapy.

OBJECTIVE: Heart transplantation in the setting of renal insufficiency is controversial. The objective of this study was to perform a descriptive analysis of patients who underwent orthotopic heart transplantation and renal replacement therapy (RRT) due to acute kidney injury (AKI). DESIGN: An observational cohort study with retrospective data collection. SETTING: A tertiary care hospital. PARTICIPANTS: Fifty-one patients underwent orthotopic heart transplantation with cardiogenic shock under inotrope dependence, with nine patients having preoperative RRT and 42 patients not having preoperative RRT. INTERVENTIONS: There were no interventions. MEASUREMENTS AND MAIN RESULTS: Hospital mortality occurred in eight (15.6%) patients. Although there were no significant differences between the study groups (preoperative RRT 33.3% v controls 11.9%, p = 0.1), this study was underpowered to detect differences in mortality. Dialysis also was required in 52.4% of patients who were not on preoperative RRT. All survivors had full recovery of kidney function with similar timing after transplant (18.5 days v 15 days, p = 0.75). Actuarial survival was 82.4%, 76.5%, and 66.5% at six months, one year, and five years, respectively. A cold ischemic time greater than 180 minutes (hazard ratio [HR] 4.37 95% confidence interval [CI] 1.51-12.6; p = 0.006) and pretransplant RRT (HR = 7.19 95% CI 1.13-45.7; p = 0.04) were independent predictors of long-term mortality. CONCLUSIONS: In a health system with limited funding and availability of mechanical circulatory support, heart transplantation in the setting of AKI, RRT, and low Interagency Registry for Mechanically Assisted Circulatory Support profile was associated with important hospital mortality. Among hospital survivors, however, all patients had full renal recovery and by 25 months there was no difference in mortality between those who required preoperative RRT and those who did not.

Is shortage of heart donors a real problem? Insights from a Brazilian Mid-West heart transplant program.

BACKGROUND AND AIM OF THE STUDY: In developed countries, the shortage of viable donors is the main limiting factor of heart transplantation. The aim of this study is to determine whether the same reality applies to Brazil. METHODS: Between January 2012 and December 2014, 299 adult heart donor offers were studied in terms of donor profiles and reasons for refusal. The European donor scoring system was calculated, being high-risk donors defined as more than 17 points. The donor scoring system was used to objectively determine the donor profile and correlate with donor acceptance and posttransplant primary graft dysfunction and recipient survival. Cox proportional hazard model was used in determining the predictors of long-term mortality. RESULTS: The rates of donor acceptance and heart transplants performed were 45.8% and 19.3%, respectively. Reasons for refusal were mostly nonmedical (53.7%). The majority of donors were classified as high-risk (65.5%). Hearts from high-risk donors did not impact primary graft dysfunction (14.3% vs 10%; P = .6), neither long-term survival (P = .4 by logrank test). Recipient's age was greater than 50 years (hazard ratio, 6.02; 95% confidence interval, 2.41-16.08; P < .0001) and was the only predictor of long-term mortality. CONCLUSIONS: The shortage of donors is not the main limiting factor of heart transplantation in the Mid-West of Brazil. Nonmedical issues represent the main reason for organ discard. Most of the donors are classified as high risk which indicates that an expanded donor pool is a routine practice in our region, and donor scoring does not seem to influence to proceed with the transplant.