Acute Kidney Injury After Cardiac Transplantation: Foe or Common Innocent Bystander?

BACKGROUND: Heart transplantation (HT) is regarded as the treatment of choice for end-stage heart failure (ESHF) patients. Severe acute kidney injury (AKI) after HT is a frequent clinical problem with devastating consequences for HT recipients. METHODS: Data from 112 ESHF patients undergoing HT in 2010-2015 were retrospectively reviewed. The primary end point was the development of AKI stage III, and secondary outcomes were in-hospital and 1-year mortality according to Kidney Disease Improving Global Outcomes criteria. RESULTS: In total, 81 patients (72.3%) developed AKI, of which 33 (29.4%) developed AKI stage I, 18 (16%) stage II, and 30 (26.7%) stage III; within this group, 27 recipients (24%) required renal replacement therapy (RRT). Overall hospital mortality was 14%. However, when stratifying by AKI stage, hospital mortality increased from 0% to 46% comparing recipients without AKI and those with AKI stage III, respectively (P = .001). In the same way, 1-year mortality increased from 6% to 53% for recipients without AKI compared with those who developed AKI stage III (log-rank test for trend: P = .001). Recipients that required RRT had a 1-year mortality of 59.2% compared with 5.8% in those without RRT requirement. CONCLUSIONS: The findings indicate that AKI stage III is common after HT and adversely affects early and late mortality. Clinical variables together with perioperative hemodynamic assessment could add more powerful prognostic information to predict severe AKI before HT and therefore evaluate potential heart-kidney recipients.

Intraoperative use of several inotropes is associated with increased mid-term mortality in patients undergoing orthotopic heart transplantation.

INTRODUCTION: Orthotopic heart transplantation (OHT) is the gold standard treatment for patients with end-stage heart failure. Inotropic agents are the hemodynamic mainstay in the treatment of implanted donor hearts. However, their infusion, particularly in excess, can have unintended consequences that lead to cardiac toxicity and can originate malignant arrhythmias, myocardial necrosis, and myocyte apoptosis. OBJECTIVE: The aim of the study was to determine the perioperative predictors of mid-term mortality after OHT. METHODS: We retrospectively studied all consecutive adult patients who underwent OHT between January 2009 and July 2013 at a tertiary care university hospital and followed them up until July 2013. Donor and recipient demographic data, hemodynamic profile, and perioperative data were analyzed. The primary endpoint was mid-term survival. RESULTS: The overall survival rate was 80.6% during hospitalization time and 70.1% after 328 (interquartile range, 643) days of follow-up. The univariate analysis showed that patients who died were older, had lower height and body surface area, donor/recipient (D/R) mismatch, prior cardiac surgery, longer cardiopulmonary bypass (CPB) time, postoperative lower left ventricular ejection fraction, sepsis, and primary graft dysfunction. Using Cox survival analysis, the independent risk factors related to mid-term mortality were intraoperative use of more than 2 inotropic drugs (hazard ratio [HR], 3.887; 95% confidence interval [CI], 1.224-12.342; P = .021), CPB duration (HR, 1.008; 95% CI, 1.003-1.014; P = .002), and D/R weight ratio (HR, 1.027; 95% CI, 1.009-1.046; P = .003). CONCLUSION: In patients undergoing OHT, mid-term survival was mostly related to D/R weight mismatch and intraoperative factors, mainly inotropic drugs and CPB duration.