1. Dual Organ Transplantation Tejas Desai, MD

3. Our Case A 58 year old male with significant CAD, multiple myocardial infarctions, resulting in an ischemic cardiomyopathy & ejection fraction of 15%. The patient’s baseline creatinine was 1.3 mg/dl, but had been persistently elevated between 2.5-3.0 mg/dl. This had been attributed to decompensated heart failure. Past Medical History: Type II diabetes mellitus Essential hypertension

4. Our Case (cont’d) Urine protein/Cr ratio: 122 mg/G CrCl: 31 ml/min (at a Cr of 3.0 mg/dl) Urine microscopy: bland urinary sediment Renal Ultrasonagraphy: R kidney 11.3 cm L kidney 9.8 cm Normal Echogenicity Cortical atrophy (L > R)

5. Our Case (cont’d) The patient was considered an appropriate candidate for a heart transplantation. Is the patient a candidate for a kidney transplantation as well? What are the criteria for a dual heart-kidney transplantation? Does our patient meet the criteria for a dual organ transplantation? + versus

6. By the Numbers… (The Organ Procurement and Transplantation Network; http://www.optn.org) (Living & Cadaveric) Nationwide 2007 2006 2005 # of KTx 8,304 17,090 16,481 # of LTx 3,260 6,650 6,443 # of HTx 1,140 2,192 2,125 # of LKTx 244 399 337 # of HKTx 23 39 57

7. By the Numbers… (The Organ Procurement & Transplantation Network: http://www.optn.org) (Living & Cadaveric) Emory 2007 2006 2005 # of KTx 77 141 117 # of LTx 36 77 86 # of HTx 10 21 21 # of LKTx 10 7 4 # of HKTx 0 0 0

8. Two Schools of Thought Purists Physicians who believe that each organ should have it’s own set of criteria regarding transplantation, & that dual-organ transplant candidates should be evaluated for each organ independently of the other. Liberalists Physicians who believe that in dual-organ transplant candidates, one organ is primary & the other is secondary. All steps should be taken to ensure graft survival of the primary organ, including, if needed, transplantation of the secondary organ.

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11. ( Combined Liver-Kidney Transplantation: What are the Indications? Transplantation . 1997: 64(8); pp. 1091-1096.)

12. ( Identification of Patients Best Suited for Combined Liver-Kidney Transplantation: Part II . Liver Transplantation . 2002: 8(3); pp. 193-211.)

13. ( Identification of Patients Best Suited for Combined Liver-Kidney Transplantation: Part II . Liver Transplantation . 2002: 8(3); pp. 193-211.) <= 67 ml/min GFR (pre-Tx) 67 - 95 ml/min 96 - 120 ml/min >=121 ml/min

14. 8 ( Clinical Transplantation . 1998; 12:123-129) 19 ( Clinical Nephrology . 1997; 48:159-164) 24 ( Clinical Transplantation . 1997; 11:354-360) 57 ( Transplantation . 1997; 64:1091-1096) Table Acquired from: Identification of Patients Best Suited for Combined Liver-Kidney Transplantation: Part II . Liver Transplantation . 2002: 8(3); pp. 193-211.

16. ( Combined Liver-Kidney Transplantation: What are the Indications? Transplantation . 1997: 64(8); pp. 1091-1096)

18. ( Identification of Patients Best Suited for Combined Liver-Kidney Transplantation: Part II . Liver Transplantation . 2002: 8(3); pp. 193-211.) Critical Care Medicine 1991; 19:8-11 Nephrology Dialysis Transplantation 2000; 15:224-230 Am J Kidney Dis 1998; 32:432-443

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20. ( Outcomes in Recipients of Combined Heart-Kidney Transplantation: Multiorgan, Same Donor Transplant Study of the International Society of Heart and Lung Transplantation/United Network for Organ Sharing Scientific Registry . Transplantation . 1997: 63(6): 861-867)

21. ( Outcomes in Recipients of Combined Heart-Kidney Transplantation: Multiorgan, Same Donor Transplant Study of the International Society of Heart and Lung Transplantation/United Network for Organ Sharing Scientific Registry . Transplantation . 1997: 63(6): 861-867) Heart & Kidney (59 patients) Heart (911 patients) Transplant Cardiologists Research Database

23. ( Outcomes in Recipients of Combined Heart-Kidney Transplantation: Multiorgan, Same Donor Transplant Study of the International Society of Heart and Lung Transplantation/United Network for Organ Sharing Scientific Registry . Transplantation . 1997: 63(6): 861-867) UNOS Scientific Registry Heart & Kidney (82 patients) Heart (14,340 patients)

24. ( Simultaneous Heart and Kidney Transplantation as Treatment for End-Stage Heart and Kidney Failure . Transplantation . 1997: 64(8): 1129-1134) p 0.21 University of Vienna

25. ( Simultaneous Heart and Kidney Transplantation as Treatment for End-Stage Heart and Kidney Failure . Transplantation . 1997: 64(8): 1129-1134) Not statistically significant At 36 months University of Vienna

26. ( Simultaneous Heart and Kidney Transplantation as Treatment for End-Stage Heart and Kidney Failure . Transplantation . 1997: 64(8): 1129-1134) Not statistically significant University of Vienna

27. ( Simultaneous Heart and Kidney Transplantation as Treatment for End-Stage Heart and Kidney Failure . Transplantation . 1997: 64(8): 1129-1134) Not statistically significant University of Vienna

30. Our Case -- Revisited A lengthy discussion between the Transplant Nephrologist, the primary Cardiologist, the patient and his wife was conducted. The Cardiologist explained that the literature supported a dual heart-kidney transplant to improve patient outcomes. He/She suggested a CrCl of 50 ml/min or less as the threshold for dual transplantation.

31. Our Case -- Revisited The Transplant Nephrologist felt the patient had acute renal failure in the context of chronic kidney disease. However, neither the degree of acute renal failure nor the underlying chronic kidney disease was of sufficient irreversibility or severity (respectively) to warrant a kidney transplant.

32. The patient was discharged with aggressive medical management.