Sequential and Urgent Coronary Artery Bypass Surgery Followed by Kidney Transplantation in a Highly Sensitized Patient With Unstable Angina

We present the case of a 63-year-old man admitted on September 22, 2016, for deceased donor kidney transplantation (KTx). The patient had end-stage renal disease secondary to diabetic nephropathy and was on chronic hemodialysis. His medical history included hypertension, diabetes mellitus type 2, atrial fibrillation, and remote history of hepatitis B and hepatitis C infection without cirrhosis. The patient became highly sensitized from a previous KTx in November 2014, which was complicated by delayed graft function and rejection that culminated in a graft nephrectomy. The patient’s calculated panel-reactive antibody was 100% (class I, 94% and class II, 93%). His pretransplant cardiac workup included a normal cardiac nuclear stress test in August 2013 and a normal transthoracic echocardiogram in January 2015. After 17 months on the waiting list, the patient was offered an expanded criteria donor kidney through the national highly sensitized patient registry run by the Canadian Blood Services. On arrival, the patient complained of a 2-week history of exertional angina. An urgent coronary angiogram demonstrated a distal left main coronary artery lesion of 90% involving the origin of both the left anterior descending and the circumflex coronary artery. The dominant right coronary artery demonstrated minor irregularities, with few lesions between 20% and 30%. There were no other significant lesions. The left ventricular ejection fraction was 40% by ventriculogram, with global hypokinesis. This lesion was deemed not amenable to percutaneous coronary intervention. A multidisciplinary team, composed of nephrologists, cardiologists, cardiac surgeons, transplant surgeons, and anesthesiologists, was convened to discuss the feasibility of performing a coronary artery bypass graft surgery with subsequent KTx transplantation. This decision was especially important given the unlikelihood of finding another well-matched and crossmatch-negative transplant allograft for this highly sensitized patient. The group agreed that KTx would not be performed in the event of complications from the coronary artery bypass graft (CABG) surgery. An informed consent was obtained. The patient underwent a 2-vessel on pump CABG surgery (left internal thoracic artery graft to left anterior descending coronary artery and saphenous vein graft to obtuse marginal coronary artery) on September 23rd. Soon after the initiation of CABG surgery, the donor kidney was procured and immediately placed on the LifePort Kidney Transporter for hypothermic machine perfusion. Immediately postoperatively, the patient required norepinephrine 25 μg/min and epinephrine 2 μg/min. Vasopressors were discontinued by 12 hours post-CABG, at which point, the patient underwent an uncomplicated KTx to the left iliac fossa on September 24th (Figure 1). The total cold ischemia time was 18 hours.FIGURE 1: Timeline of clinical events. Day 0 represents the day of hospital admission.The donor kidney was from a 66-year-old male donor who was declared to be brain dead after a cerebrovascular event. The donor was deemed an expanded criteria donor based on age. The Kidney Donor Risk Index was 1.6, and the Kidney Donor Profile Index was 91%. The preprocurement creatinine was 155 μmol/L (estimated glomerular filtration rate [eGFR], 46 mL/min). Our patient had only 1 HLA A mismatch with the donor. Immunosuppression consisted of alemtuzumab and maintenance tacrolimus, mycophenolic acid, and prednisone. The patient was dialyzed before CABG and did not require dialysis posttransplant. Postoperatively, the patient was started on aspirin 80 mg daily, metoprolol 100 mg twice daily BID, and atorvastatin 20 mg daily. Serum creatinine (Scr) was 723 μmol/L on September 25th and subsequently decreased to 344 μmol/L by September 30th. He was discharged on postoperative day 12 with a Scr of 180 μmol/L. At 2-week postdischarge, patient’s Scr was 160 μmol/L (eGFR, 39 mL/min per 1.73 m2). The patient was readmitted on November 11th with pyelonephritis and acute kidney injury. He also developed borderline T cell–mediated rejection on February 1, 2017, requiring treatment with high-dose corticosteroids. Since then, 1 year posttransplantation, he has not had other complications from his KTx and he has not had any complications from his CABG surgery. One year posttransplantation, the patient remains dialysis free. On September 7, 2017, the patient’s Scr was 266 μmol/L (eGFR, 21 mL/min per 1.73 m2). Preoperative screening and monitoring guidelines for KTx candidates differ from the preoperative recommendations for the general population, in part due to the higher prevalence and incidence of cardiovascular disease in this patient population.1 There is little data on outcomes of KTx immediately after CABG. Kashu et al2 reported a case of a successful simultaneous single CABG and living donor KTx in a patient found to have ischemic electrocardiogram changes upon admission to hospital. Kocher et al3 reported a single case of simultaneous CABG and KTx and 16 cases of KTx within 180 days after CABG. One must be aware of the infectious complications after CABG and KTx (especially high risk of respiratory infections and sternal wound infections), which represent a significant cause of morbidity and mortality in the heart transplant literature.4 Although similar future clinical situations must be approached in a case by case basis, we felt at the time that this course of action would be the patient’s best chance of obtaining a successful KTx. With prompt recognition of symptoms, appropriate planning and teamwork, we show that KTx can be safely and successfully performed immediately after urgent open-heart surgery for coronary artery disease.

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