Simultaneous heart-liver-kidney (HLK) transplants are feasible but require special consideration of donor and recipient selection and the equity of organ allocation, experts cautioned.
At the University of Chicago Medical Center (UCMC), operators have performed 10 of these triple-organ transplants to date since January 1999 — six cases in the last 18 months alone — with one early death and nine patients surviving past 1 year, according to Valluvan Jeevanandam, MD, chief of the Section of Cardiac Surgery and director of the Heart and Vascular Center.
UCMC is notable for having performed 10 HLK transplants when just 23 of these procedures have been reported in the world. Jeevanandam’s group reviewed the key components of their logistical framework in a poster at this year’s virtual Heart Failure Society of America (HFSA) meeting:
- Strict patient selection: candidates must meet listing criteria for each organ independently, with a typical age limit of 60
- Donor selection and allocation: all organs should be received from the same donor
- Interdisciplinary collaboration: various teams see patients together in a structured rounding schedule
- Operation orchestration: procedure consists of three distinct phases with choreographed handoffs
- Post-operation follow-up: patients are routinely followed to identify allograft rejection
“The key element of the UCMC’s success was found to be the team’s ability to procure and achieve success with organs that many other centers would turn down,” the authors emphasized, noting their willingness to accept undersized hearts, donations after circulatory death, hepatitis C seropositive but non-viremic livers, and organs from greater distances.
Jeevanandam and colleagues did not provide data to support this conclusion in their HFSA poster, however.
“The complicated nature of a three-organ transplant requires the ability to use a wider spectrum of donors because you have the organs coming from a single donor. The chances of getting three perfect organs that fit your patient are relatively low,” reasoned Daniel Jacoby, MD, of Yale School of Medicine in New Haven, Connecticut.
“We’ve had a tendency to be conservative in donor selection in the U.S., but more recently there’s an increasing appreciation for the viability of an expanded donor pool with outcomes that are really comparable to the traditional donors,” Jacoby commented in an interview.
Triple-organ transplants are rare enough that there are no criteria or expectations as to how organ recipients might fare after surgery.
“There needs to be criteria for multiorgan transplant,” said Tariq Ahmad, MD, MPH, also of Yale, who noted that he is part of a committee that is currently drafting criteria for heart-kidney transplant.
The sole patient who died early after HLK transplant at UCMC had developed severe coagulopathy within hours of completion of the surgery. The patient suffered cardiac tamponade and circulatory arrest and died 2 days later, according to a previous report from UCMC.
Overall, multiorgan transplantation “can be done” and is limited technically not by the surgeons’ expertise, but rather by the perioperative management of organ recipients, said Serban Constantinescu, MD, PhD, of Temple University’s Lewis Katz School of Medicine in Philadelphia.
Constantinescu told MedPage Today that he favored staged procedures.
To empty the chest during thoracic organ transplant creates an environment that is less than ideal for subsequent placement of a kidney, he explained. For example, lung recipients do not need too much fluid and are therefore kept dry, whereas kidney recipients need to be very wet, he said.
Another major limitation of HLK transplant is finding the right patients — namely people with end-stage heart, kidney, and liver disease without other comorbidities that would make them ineligible for multi-organ transplant and chronic immunosuppressive therapy, said Michael Givertz, MD, of Brigham and Women’s Hospital and Harvard Medical School in Boston.
And even after appropriate recipients are found, fairness is a potential problem with multiorgan transplant given the constant shortage of donors, Constantinescu added.
“Using a lot of organs for one single recipient is a question of equity,” he said. “With two lungs and one heart and one kidney, you can transplant four recipients … It’s a huge ethical issue. What’s the [fair way of] distributing these organs for a growing population of patients who die on the waiting list?”
Expected survival, an important factor in choosing who gets multiorgan transplant, is already “not so great” in heart or lung recipients compared with people who may be expected to use their donor organs for a longer period of time, Constantinescu said.
Yet multiorgan transplant candidates get priority allocation under the United Network for Organ Sharing system, he noted.
Jeevanandam’s group had no disclosures.