Stabilize the kidneys before listing for heart, lung transplantation

The special report on International Society for Heart and Lung Transplant (ISHLT) recognizes the need to stabilize a patient's renal function prior to heart or lung transplantation to reduce post-surgical mortality.

Taking time to stabilize the kidneys may seem contradictory to the urgency of listing critically ill patients for transplants. However, taking more than two weeks to restore kidney function before surgery is worth delayed, according to the report's lead author Irene Hisic, MDMedical Director of Heart Transplants at Cleveland Clinic.

“I want to rescue the patient so I rush to the implant when the patient is very unstable and I'm sure there will be no reversible renal dysfunction after implantation, and I think it's “no big deal” to dialysis after implantation,” she says. “Unfortunately, we lose a third of these patients.”

According to 2025 ISHLT Report Published in Journal of Heart and Lung portif dialysis is required, the mortality rate is above 30% (“early dialysis”). This is a new finding in pediatric lung transplantation, but it enhances early studies of adult lung transplantation and adult and pediatric heart transplantation.

Despite the existing literature, low outcomes associated with early post-transplant dialysis are not widely recognized, Dr. Hisic said.

“We need to communicate the words to more doctors in the transplant community. Kidney problems kill people. “And that's not just a US problem. It's global.”

Do not rely on a heart transplant to retrieve your kidneys

Why is the importance of stabilizing renal function before implantation is less widely known? Dr. Hsich explains, as cardiac pathologists have always been successful in caring for patients with cardiogenic shock, but may not recognize the difference when surgery is involved.

“The patient's kidneys may have been compromised due to hypotension caused by heart and lung failure,” she says. “The general belief is that when the heart and lungs are replaced, the kidneys will recover. But that's not so simple.”

Preoperative hypotension is just the first blow to the kidneys. Transplant surgery, which involves the use of anesthesia, which can destabilize blood pressure, is the second blow.

Furthermore, infusion of fluid during surgery creates more work for the kidneys.

“The kidneys of a healthy person will have a hard time clearing up all of that excess fluid,” says Dr. Hisic. “We can't expect kidneys that will compromise on performing better after surgery than healthy kidneys do on normal days.”

And she points out that post-transplant dialysis may not be a simple fix. After implantation, patients become immune to immunodeficiency and are at increased risk of infection. Adding catheters to facilitate dialysis increases the risk.

On the contrary, ISHLT reports that pre-transplant dialysis patients (and thus had more stable renal function until surgery) have better results after implantation.

“I'm not saying that if your kidneys are not functioning properly, you should withhold a transplant, but it's important to do so if you have the opportunity to recover,” says Dr. Hsich. “That's what we do at Cleveland Clinic. Before listing patients for a heart transplant, we try to make our kidneys (and liver) as strong as possible. That's likely one of our reasons. Porting results It's the best in the world. ”

Survival rates for patients at Cleveland Clinic have not been adjusted after heart transplantation. It was 96.9% in one year and 87.3% in three years.

“Using all the tools and resources to help patients normalize organ function before surgery will play a major role in achieving those outcomes.” Michaelton, MD, MBADirector of Heart Transplant and Mechanical Circulatory Support at Cleveland Clinic.

“If the heart is broken, the kidneys are compromised, just like the liver, brain and other organs,” he says. “To help a failed heart, we use temporary mechanical pumps to normalize blood flow to the body and give patients and organs the opportunity to improve before implantation. In other circumstances, we recommend a left ventricular assistance device that allows patients to live together for years before implantation.”

I'll add it Amanda Best, MBBSsection head of heart failure and recovery at Cleveland Clinic: “We hope that ongoing research will improve strategies for improving cardiogenic shock settings and renal function around implant surgery. One example is the ongoing evolution of temporary pumps that mechanically support weak hearts.”

Early dialysis and survival after heart transplantation

In the ISHLT report, the research group evaluated records from the International Thoracic Organ Transplant Registry.

Of the more than 50,000 adults and nearly 8,000 pediatric patients worldwide who received heart transplants between 1994 and 2018, 9.9% of adults and 6.3% of pediatric patients required early dialysis. These patients had much lower survival rates than patients who did not require early dialysis.

The greatest risk factor associated with early dialysis was renal dysfunction at the time of implantation. The lower the estimated glomerular filtration rate (EGFR), the higher the risk.

Other risk factors are included.

• Heart disease underlying adults
• Congenital heart disease in pediatric patients
• Use of mechanical ventilation or extracorporeal membrane oxygenation (ECMO)
• Longer ischemia times
• Age of age

Early dialysis and survival after lung transplantation

Of the more than 34,000 adults and nearly 1,200 pediatric patients worldwide who received lung transplants between 1994 and 2018, 6.1% of adults and 5.6% of pediatric patients required early dialysis. Similar to the heart transplant cohort, lung transplant patients requiring early dialysis had a much lower survival rate than patients who did not require early dialysis.

Again, the greatest risk factor associated with early dialysis was renal dysfunction at the time of implantation. The lower the EGFR, the higher the risk.

Includes other risk factors for adults.

• Non-chronic obstructive heart disease underlying lung disease
• Use of mechanical ventilation or ECMO
• Higher BMI
• Higher Bilirubin
• Diabetes
• Longer ischemia times
• Age of age

“This analysis highlights the fact that high mortality associated with early dialysis in chest patients is concerning and that providers should consider early renal transplants that seek to reduce the impact of renal replacement therapy using safety net allocations.” Marie Budev, do, mphmedical director of lung transplants at Cleveland Clinic.

How to prevent dialysis after transplant surgery

Approximately half of all heart or lung transplant recipients with early dialysis die within a year of surgery, Dr. Hsich summarizes. This includes children born with healthy kidneys. When transplants occur in situations of renal failure, they have worse outcomes.

“How can you prevent dialysis after transplant surgery?” asks Dr. Hsich. “It starts with making your kidneys healthier before surgery. Even a slight improvement in abnormal EGFR can significantly reduce the risk of post-operative dialysis.”

However, the current allocation system defines medical urgency based on the severity of the heart and lung disease, but not terminal dysfunction. This system allows a two-week window to implant critically ill patients once critically ill patients are placed on the waiting list before changing their strategy towards a durable heart pump.

“We need urgency, but we still need tolerance to stabilize organs that have been rapidly affected by heart and lung failure,” says Dr. Hisic. “It's important to spend time recovering organs if possible. Survival after surgery is poor if not. If you don't have a two-week window, you can ask for an exception later.”

She adds that it is okay to write an exception due to delayed listing of patients as they had to wait for the kidneys and liver to restore function. The function does not need to be normal, but it must be robust enough to withstand implant surgery and give the patient the best chance to achieve good results.