Perioperative Timing Impacts Renal Graft Outcomes in Simultaneous Heart‐Kidney Transplantation

Background Simultaneous heart‐kidney (SHK) transplantation is widely administered as a treatment for end‐stage cardiorenal disease. However, the impact of renal transplant timing as a concurrent (heart and kidney transplanted simultaneously) or staggered (heart transplant followed by kidney transplant) procedure on post‐transplant outcomes has not been investigated. Methods We conducted a retrospective analysis of the UNOS STAR for SHK transplants that occurred in the United States between 2010 and 2024. Institutional SHK transplant data were similarly reviewed for specific patient‐level factors. Results Approximately two‐thirds ( N = 1668) of SHK transplants were performed using the staggered approach, with the remaining one‐third performed concurrently ( N = 868). Univariate analysis of concurrent versus staggered SHK transplants indicated that staggered SHK transplant was associated with a higher rate of delayed graft function (DGF; 31.4 vs. 25.6%, respectively; p = 0.003) and lower 1‐year renal graft survival (89.9 vs. 84.5%, respectively; p < 0.001). A multivariable regression analysis showed that these differences in DGF (HR 1.29, 95% CI 1.05–1.58, p = 0.014) and 1‐year graft survival (HR 1.39, 95% CI 1.05–1.83, p = 0.020) remained when other factors were controlled. In multivariable Cox analysis, staggered SHK was associated with lower overall patient survival (HR 0.81, p = 0.045) but no differences in death‐adjusted graft survival or need for renal retransplantation (both p > 0.05). Conclusions The results from this study indicate that discrepant outcomes in SHK transplantation result from the timing of renal transplantation, with concurrent SHK demonstrating superior outcomes in a large national dataset.