Traditionally, significant kidney disease has been a contraindication for heart transplantation. Transplant cardiologists and surgeons at UCSF are aggressively taking an alternative approach by performing simultaneous heart and kidney transplantation. In the process, they are helping those who did not seem to have much hope of ever getting a new heart.
Many patients with heart failure also have kidney dysfunction due to the lack of adequate perfusion to the kidney tissue as a result of poor heart function or from kidney disease associated with other conditions, such as high blood pressure or diabetes mellitus. Kidney dysfunction, in turn, can lower the odds for successful heart transplantation. Diseased kidneys pose such a risk either through poor hemodynamic regulation or because the kidneys are not able to cope with antirejection drugs needed after transplantation.
Although most heart transplant centers see these difficulties as an obstacle to successful heart transplantation, a growing number of physicians see kidney dysfunction as another challenge that can be addressed as part of transplantation surgery.
With the possibility of performing simultaneous transplantation of the heart and kidney, far more patients become eligible to receive a transplanted heart. "One of the distinguishing features of our program is that we create opportunities for transplantation, rather than limiting them," says Teresa De Marco, M.D., director of heart transplantation in the UCSF Heart and Vascular Center.
This principle extends to other factors that are weighed by the heart transplant team. UCSF transplant physicians have found, for instance, that many patients in end-stage heart failure who would generally be rejected as transplant candidates can be given a good chance of success if put on a ventricular assist device for a time before transplantation. The near-normal blood flow produced by the ventricular assist device allows tissues to become healthier, increasing the chance of successful organ transplantation.
In other cases, a patient who shows all the physical signs of being a good candidate for heart transplantation may be excluded from the operation at other medical centers because he or she is deemed too old. UCSF surgeons deal with this differently. "We may take an older individual who is in robust health," De Marco says. "We don't exclude a patient simply because of age."
The practice of performing simultaneous heart and kidney transplantation is not new, De Marco points out, "but we are fairly aggressive in this approach." While other medical centers are doing heart-kidney transplantation, UCSF remains the only medical center in the West and one of the few nationwide to perform such procedures on a regular basis.
Although transplanting a kidney along with the heart can increase the chance of a good outcome in cases in which the patient's own kidney is damaged, researchers are still working to compile data that will reliably predict outcomes.
"By reviewing UCSF data on combined heart-kidney transplantation, we have determined that post-transplant survival is equivalent to heart transplantation alone, and that patients often return to normal kidney function," says Kiran Khush, M.D., transplant cardiologist. "Our main challenge lies in deciding which heart failure patients with kidney dysfunction actually need a kidney transplant at the time of the heart transplant."
UCSF researchers are currently investigating biological markers that may help them answer that question.
Although there have been some questions about whether such dual heart-kidney operations are the best use of scarce kidneys, the UCSF physicians say they make no apologies. "We have to always act in the best interests of our patients," De Marco says. "I always must choose the best therapy possible."
For De Marco and Charles Hoopes, M.D.;, director of the heart and lung transplant program, the answer is clear. "Dual heart and kidney transplantation is the best strategy to achieve excellent long-term survival and improved quality of life for patients with concomitant heart and kidney failure," Hoopes says.
To contact Dr. Teresa De Marco, call (415) 476-3117. To contact Dr. Kiran Khush, call (415) 476-0636. To contact Dr. Charles Hoopes, call (415) 353-1606.
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