Simultaneous heart-liver and heart-kidney transplantation: a case series from the University Hospital Centre Zagreb

    Authors

    Keywords

    heart-liver transplantation, heart-kidney transplantation, ischemic heart disease, hereditary amyloidosis, polycystic kidney disease

    DOI

    https://doi.org/10.15836/ccar2024.424

    Full Text

    **Introduction:** Dual organ transplantation, such as heart-liver or heart-kidney, is a rare but essential option for patients with multi-organ failure. While outcomes for single-organ transplants are well-documented, reports of dual transplants are limited. (1-3) This case series presents two heart-liver and one heart-kidney transplant cases to provide insights into clinical outcomes and management. Aim: To analyze the clinical characteristics, clinical course, perioperative management, and post-transplant outcomes of patients undergoing simultaneous heart-liver and heart-kidney transplantation at the University Hospital Centre (UHC) Zagreb, Croatia. **Case series:** Three patients underwent dual organ transplantation between January 2023 and September 2024. Two patients received heart-liver transplants for heart failure due to hereditary transthyretin amyloidosis, while one patient underwent heart-kidney transplantation for end-stage heart failure secondary to ischemic heart disease and renal failure associated with polycystic kidney disease. Surgical techniques and postoperative care were tailored to each patient’s clinical profile. The first patient, a 49-year-old male who underwent heart-liver transplantation, has a 20-month follow-up. His course included early liver graft rejection, successfully treated with pulse corticosteroids. Heart function remains preserved, and he initially had transient, low-intensity donor-specific antibodies (DSAs). The second patient, a 52-year-old male with heart-liver transplantation, has a one -month follow-up with preserved organ function, no rejection, and no DSAs. The third patient, a 54-year-old male who underwent heart-kidney transplantation, has a one-month follow-up complicated by prolonged postoperative peritoneal drainage, but both grafts are functioning well, with no rejection or DSAs (**Table 1**). ### TABLE 1: Patient characteristics in dual-organ transplantation. | **Patient characteristics** | **Patient characteristics** | **CASE 1** | **CASE 2** | **CASE 3** | | --- | --- | --- | --- | --- | | Age, sex | | 49, male | 52, male | 54, male | | Follow up | | 20 months | 1 month | 1 month | | Transplanted organs | | Heart and liver | Heart and liver | Heart and kidney | | Etiology of primary organ failure | | Hereditary TTR amyloidosis | Hereditary TTR amyloidosis | Ischemic heart disease Polycystic kidney disease | | Pretransplant laboratory values | Erythrocytes Hemoglobin | 4.38 x 1012/L 142 g/L | 4.02 x 1012/L 128 g/L | 3.83 x 1012/L 109 g/L | | Leukocytes | 4.2 x 109/L | 6.1 x 109/L | 7.6 x 109/L | | | Platelets | 170 x 109/L | 196 x 109/L | 129 x 109/L | | | Total bilirubin PV-INR AST ALT GGT ALP | 27 µmol/L 1.55 43 U/L 18 U/L 97 U/L 148 U/L | 15 µmol/L 1.06 46 U/L 93 U/L 33 U/L 73 U/L | 28 µmol/L 1.04 68 U/L 21 U/L 14 U/L 48 U/L | | | BUN Creatinine eGFR | 10.5 mmol/L 114 µmol/L 66 mL/min/1,73 m2 | 8.5 mmol/L 113 µmol/L 64 mL/min/1,73 m2 | 16.9 mmol/L 243 µmol/L 25 mL/min/1,73 m2 | | | NT-proBNP Troponin I | 6759 ng/L 172.7 ng/L | 5407 ng/L 105.5 ng/L | 4101 ng/L 37.0 ng/L | | | Posttransplant events | Surgical | Pericardial effusion | Pericardial effusion | Prolonged peritoneal drainage Pericardial effusion | | Infective | None | None | None | | | Neoplastic | None | None | None | | | Organ rejection | | Early cellular liver graft rejection | None | None | | Graft organ function | | Both preserved | Both preserved | Both preserved | | Donor-specific antibodies | | Transient low intensity | None | None | **Conclusion:** Dual organ transplantation is a viable option in selected patients with favorable outcomes when managed appropriately. This case series from the UHC Zagreb highlights the importance of individualized care and follow-up to optimize survival and graft function. Further studies are needed to standardize protocols for these complex procedures.

    Literature

    1. Itagaki S, Toyoda N, Moss N, Mancini D, Egorova N, Mikami T, et al. Outcomes of Simultaneous Heart and Kidney Transplantation. J Am Coll Cardiol. 2023 February 28;81(8):729–40. https://doi.org/10.1016/j.jacc.2022.11.053
    2. Guendouz S, Grimbert P, Radu C, Cherqui D, Salloum C, Mongardon N, et al. Heart Transplantation, Either Alone or Combined With Liver and Kidney, a Viable Treatment Option for Selected Patients With Severe Cardiac Amyloidosis. Transplant Direct. 2022 June 17;8(7):e1323. https://doi.org/10.1097/TXD.0000000000001323
    3. Huang X, Salerno D, Kovac D, Scheffert J, Hedvat J, Carver B, et al. Contemporary Immunosuppression Management and 1-Year Outcomes in Dual Organ Heart Transplantation. Clin Transplant. 2024 August;38(8):e15420. https://doi.org/10.1111/ctr.15420
    Cardiologia Croatica
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    Simultaneous heart-liver and heart-kidney transplantation: a case series from the University Hospital Centre Zagreb

    Extended Abstract
    Issue11-12
    Published
    Pages424-425
    PDF via DOIhttps://doi.org/10.15836/ccar2024.424
    heart-liver transplantation
    heart-kidney transplantation
    ischemic heart disease
    hereditary amyloidosis
    polycystic kidney disease

    Authors

    Antun Zvonimir Kovač*ORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Ivo PlanincORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Boško SkorićORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Nina JakušORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Dora FabijanovićORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Anna MrzljakORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Nikolina Bašić-JukićORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Hrvoje GašparovićORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Ante LekićUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Željko ČolakORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Hrvoje SilovskiORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Igor PetrovićORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Ognjan DebanORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Željko KaštelanORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Maja ČikešORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Davor MiličićORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia

    *Correspondence email: azkovac@gmail.com

    Full Text

    Introduction: Dual organ transplantation, such as heart-liver or heart-kidney, is a rare but essential option for patients with multi-organ failure. While outcomes for single-organ transplants are well-documented, reports of dual transplants are limited. (1–3) This case series presents two heart-liver and one heart-kidney transplant cases to provide insights into clinical outcomes and management. Aim: To analyze the clinical characteristics, clinical course, perioperative management, and post-transplant outcomes of patients undergoing simultaneous heart-liver and heart-kidney transplantation at the University Hospital Centre (UHC) Zagreb, Croatia.

    Case series: Three patients underwent dual organ transplantation between January 2023 and September 2024. Two patients received heart-liver transplants for heart failure due to hereditary transthyretin amyloidosis, while one patient underwent heart-kidney transplantation for end-stage heart failure secondary to ischemic heart disease and renal failure associated with polycystic kidney disease. Surgical techniques and postoperative care were tailored to each patient’s clinical profile. The first patient, a 49-year-old male who underwent heart-liver transplantation, has a 20-month follow-up. His course included early liver graft rejection, successfully treated with pulse corticosteroids. Heart function remains preserved, and he initially had transient, low-intensity donor-specific antibodies (DSAs). The second patient, a 52-year-old male with heart-liver transplantation, has a one -month follow-up with preserved organ function, no rejection, and no DSAs. The third patient, a 54-year-old male who underwent heart-kidney transplantation, has a one-month follow-up complicated by prolonged postoperative peritoneal drainage, but both grafts are functioning well, with no rejection or DSAs (Table 1).

    TABLE 1: Patient characteristics in dual-organ transplantation.

    Age, sex
    CASE 1
    49, male
    CASE 2
    52, male
    CASE 3
    54, male
    Follow up
    CASE 1
    20 months
    CASE 2
    1 month
    CASE 3
    1 month
    Transplanted organs
    CASE 1
    Heart and liver
    CASE 2
    Heart and liver
    CASE 3
    Heart and kidney
    Etiology of primary organ failure
    CASE 1
    Hereditary TTR amyloidosis
    CASE 2
    Hereditary TTR amyloidosis
    CASE 3
    Ischemic heart disease Polycystic kidney disease
    Pretransplant laboratory values
    Patient characteristics
    Erythrocytes Hemoglobin
    CASE 1
    4.38 x 1012/L 142 g/L
    CASE 2
    4.02 x 1012/L 128 g/L
    CASE 3
    3.83 x 1012/L 109 g/L
    Leukocytes
    Patient characteristics
    4.2 x 109/L
    CASE 1
    6.1 x 109/L
    CASE 2
    7.6 x 109/L
    Platelets
    Patient characteristics
    170 x 109/L
    CASE 1
    196 x 109/L
    CASE 2
    129 x 109/L
    Total bilirubin PV-INR AST ALT GGT ALP
    Patient characteristics
    27 µmol/L 1.55 43 U/L 18 U/L 97 U/L 148 U/L
    CASE 1
    15 µmol/L 1.06 46 U/L 93 U/L 33 U/L 73 U/L
    CASE 2
    28 µmol/L 1.04 68 U/L 21 U/L 14 U/L 48 U/L
    BUN Creatinine eGFR
    Patient characteristics
    10.5 mmol/L 114 µmol/L 66 mL/min/1,73 m2
    CASE 1
    8.5 mmol/L 113 µmol/L 64 mL/min/1,73 m2
    CASE 2
    16.9 mmol/L 243 µmol/L 25 mL/min/1,73 m2
    NT-proBNP Troponin I
    Patient characteristics
    6759 ng/L 172.7 ng/L
    CASE 1
    5407 ng/L 105.5 ng/L
    CASE 2
    4101 ng/L 37.0 ng/L
    Posttransplant events
    Patient characteristics
    Surgical
    CASE 1
    Pericardial effusion
    CASE 2
    Pericardial effusion
    CASE 3
    Prolonged peritoneal drainage Pericardial effusion
    Infective
    Patient characteristics
    None
    CASE 1
    None
    CASE 2
    None
    Neoplastic
    Patient characteristics
    None
    CASE 1
    None
    CASE 2
    None
    Organ rejection
    CASE 1
    Early cellular liver graft rejection
    CASE 2
    None
    CASE 3
    None
    Graft organ function
    CASE 1
    Both preserved
    CASE 2
    Both preserved
    CASE 3
    Both preserved
    Donor-specific antibodies
    CASE 1
    Transient low intensity
    CASE 2
    None
    CASE 3
    None

    Conclusion: Dual organ transplantation is a viable option in selected patients with favorable outcomes when managed appropriately. This case series from the UHC Zagreb highlights the importance of individualized care and follow-up to optimize survival and graft function. Further studies are needed to standardize protocols for these complex procedures.

    Literature

    1. 1.
      Itagaki S, Toyoda N, Moss N, Mancini D, Egorova N, Mikami T, et al. Outcomes of Simultaneous Heart and Kidney Transplantation. J Am Coll Cardiol. 2023 February 28;81(8):729–40.DOI
    2. 2.
      Guendouz S, Grimbert P, Radu C, Cherqui D, Salloum C, Mongardon N, et al. Heart Transplantation, Either Alone or Combined With Liver and Kidney, a Viable Treatment Option for Selected Patients With Severe Cardiac Amyloidosis. Transplant Direct. 2022 June 17;8(7):e1323.DOI
    3. 3.
      Huang X, Salerno D, Kovac D, Scheffert J, Hedvat J, Carver B, et al. Contemporary Immunosuppression Management and 1-Year Outcomes in Dual Organ Heart Transplantation. Clin Transplant. 2024 August;38(8):e15420.DOI