S CHANDLER1,3, A DASHWOOD2,3, S RATANJEE1
1Royal Brisbane and Women’s Hospital Nephrology Department, Brisbane, Australia, 2The Prince Charles Advanced Heart Failure and Transplantation Unit, Brisbane, Australia, 3University of Queensland, St Lucia, Australia
A 50 year old male had a subacute presentation with symptoms and signs of heart failure. After extensive investigation he was diagnosed with giant cell myocarditis and was commenced on prednisolone and cyclosporin. Prior to his diagnosis he had no history of kidney disease. Following recurrent acute kidney injuries (AKI) secondary to cardio-renal syndrome and possible cyclosporin toxicity he progressed to stage 4 chronic kidney disease over 6 months. Kidney biopsy was not performed. Unfortunately, he suffered an AKI necessitating urgent dialysis. Due to ongoing issues with fluid overload and uraemia he continued intermittent haemodialysis (IHD). Despite this, his symptoms of heart failure progressed with worsening cardiac function. Hence, he was considered and listed for combined heart-kidney transplant (HKT). Despite maximal heart failure therapy and dialysis, his ejection fraction deteriorated. The decision was made to proceed with left ventricular assist device (LVAD) as a bridge to HKT. Post LVAD, he had successful frequent daily IHD in intensive care unit with doppler assessment of intra-arterial BP and careful monitoring of hemodynamics, anticoagulation, etc. Fortunately, 17 days following LVAD insertion, the patient underwent cadaveric HKT. Current experience in Australia with LVAD use in ESRF remains sparse as the combination of dialysis and LVAD is often not performed due to impacts on quality of life and survival. There are case series from the United States describing destination LVADs and IHD. Whilst our patient was on combination LVAD and IHD for a short period, it represented a challenging situation with multiple factors for discussion and consideration to ensure a successful outcome.
Dr Shaun Chandler is currently undertaking specialist training to become a Nephrologist and General Physician. He is currently working at the Royal Brisbane and Women’s Hospital, with previous employment at the Logan Hospital and Princess Alexandria Hospital.