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Kidney After Heart versus Simultaneous Heart-Kidney Transplantation: Perioperative Outcomes since the 2023 Safety Net Policy Change
Abstract   Peer reviewed

Kidney After Heart versus Simultaneous Heart-Kidney Transplantation: Perioperative Outcomes since the 2023 Safety Net Policy Change

Hedwig Zappacosta, Malini Daniel, Peter Cho, Stephanie McKay, John White, Joseph Song and Abbas Ardehali
The Journal of thoracic and cardiovascular surgery, v 171(4), pp S174-S174
May 2026
DOI: https://doi.org/10.1016/j.jtcvs.2026.03.541

Abstract

Objective: The prevalence of concurrent cardiac and renal failure as well as renal dysfunction following heart transplantation initiated the implementation of a safety net policy, an effort to refine donor kidney allocation in heart transplant recipients. This study aims to summarize perioperative outcomes of kidney-after-heart transplant (KAH) versus simultaneous heart-kidney transplant (SHK) since the policy change in September 2023. Methods: The United Network for Organ Sharing database was queried for all adult KAH and SHK recipients between November 2023 and June 2025 based on date of heart transplantation, with KAH defined by placement on the kidney waitlist between 60 and 365 days after heart transplantation. Patients undergoing either heart or kidney re-transplantation were excluded. Outcomes of interest included severe primary graft dysfunction (PGD), acute cardiac rejection, need for renal replacement therapy, and overall survival. Results: During the study period, 59 KAH recipients and 336 SHK recipients were identified. KAH recipients began regularly administered dialysis at an average of 97 days post heart transplant and were listed for kidney transplant at an average of 238 days post heart transplant. No recipients in the SHK group required post-transplant dialysis. Severe PGD (7 (11.9%) vs 6 (1.8%); p<0.001), acute cardiac rejection (9 (15.3%) vs 24 (7.1%); p=0.038), and a longer length of stay to discharge (31 days vs 21 days; p<0.001) were more prevalent in the KAH group. KAH recipients were more likely to require renal replacement therapy during their index heart transplantation hospitalization (47 (79.7%) vs 127 (37.8%); p<0.001). 30-day mortality post-heart transplant did not differ significantly between groups. Conclusions: KAH transplantation is associated with worsened perioperative outcomes when compared to SHK transplantation. These findings should be taken into consideration when determining kidney allocation in the heart transplant population.

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