The state of combined thoracoabdominal triple-organ transplantation in the United States

Background

As triple-organ transplantation (TOT) has become more common, we evaluate patient characteristics, risk factors, and clinical outcomes of patients undergoing thoracoabdominal TOT.

Methods

This retrospective study utilized data from heart-lung-liver (HLL), heart-lung-kidney (HLK), heart-kidney-liver (HKL), and heart-kidney-pancreas (HKP) recipients from the United Network for Organ Sharing registry between 1989 and 2023. Recipient and donor characteristics and risk factors for mortality were analyzed using Cox regression hazard models. Recipient survival up to 10 years was analyzed using the Kaplan-Meier method.

Results

During the study period, 81 TOTs were performed (13 HLLs, 13 HLKs, 46 HKLs, and 9 HKPs). There were no statistically significant differences in long-term survival between TOTs (p = 0.13). However, HLL and HLK recipients had significantly worse (p < 0.0001) and improved (p < 0.0001) survival, respectively, when compared to heart-lung, isolated heart, and lung transplant recipients. HLK was associated with improved survival (hazard ratios [HR]: 0.22, p = 0.033). We found no differences in survival among HKL (p = 0.24) and HKP (p = 0.19) recipients compared to their dual- and single-organ counterparts. TOTs after 2007 (HR: 0.29, p = 0.003) were associated with improved survival, whereas increased recipient age (HR: 1.06, p = 0.037), estimated glomerular filtration rate (HR: 1.02, p = 0.005), and donor age (HR:1.05, p = 0.031) were associated with higher mortality.

Conclusions

The prevalence of TOTs has dramatically increased over the past decade. While overall survival between TOTs appears similar, adding a liver to a heart-lung transplant may be associated with a poorer prognosis compared to adding a kidney. A careful, multidisciplinary approach to patient selection and management remains paramount in optimizing outcomes for high-risk patients undergoing TOTs.