Surgical Considerations for Kidney Transplant in Simultaneous Versus Sequential Heart-Kidney Transplant: A Systematic Review.

OBJECTIVES: We aimed to answer a key kidney-focused question in simultaneous heart-kidney transplant of whether the kidney should be implanted immediately, staged after short-term stabilization, or deferred to sequential kidney-after-heart transplant. MATERIALS AND METHODS: We used PRISMA to guide our systematic review using PubMed as the primary database, with supplementary Embase and Cochrane searches and separate review of current Organ Procurement and Transplant Network policies. PubMed was searched on March 21, 2026, using ( ( (heart -kidney transplant) OR (sequential kidney transplant in heart transplant) ) OR (simultaneous heart and kidney transplant) ), limited to English, humans, adult: 19+ years, MEDLINE, and January 1, 2006, through March 21, 2026. Our review yielded 303 records; 62 abstracts underwent review, of which 26 were selected for full- text review. Embase search yielded 264 records across 7 targeted searches; 14 studies underwent review, of which 7 were duplicates and 7 unique studies underwent full-text review. No Cochrane record met final inclusion criteria. Two Organ Procurement and Transplant Network policy reports were reviewed separately. Final qualitative synthesis included 35 full-text records. RESULTS: Simultaneous heart-kidney transplant was most consistently supported in dialysis-dependent recipients and in recipients with severe, likely irreversible renal dysfunction. Kidney delayed graft function occurred in approximately one-fourth to one-third of simultaneous heart-kidney transplant recipients and was associated with worse patient and kidney graft survival. Primary nonfunction, early kidney graft loss, and renal allograft futility were highly consequential, especially in hemodynamically fragile and surgically complex recipients. Comparative studies suggested that sequential kidney-after-heart transplant is a reasonable strategy when renal reversibility is uncertain or when the postsurgery heart transplant environment is hostile to renal graft perfusion. CONCLUSIONS: Simultaneous allocation should be distinguished from simultaneous implantation. In selected recipients, staged or sequential kidney transplant may better protect kidney outcomes and better align with utility, justice, and organ stewardship.