UPMC Performs First Bloodless Heart-Kidney Transplant
April 9, 2025
Another impressive milestone for the UPMC Heart and Kidney Transplant teams has been achieved. Last month, UPMC performed the first bloodless heart-kidney transplant. The highly complex procedure was successfully performed on a patient with advanced heart failure and renal insufficiency who declined blood transfusions due to religious beliefs. While bloodless transplants have been conducted before, this case is believed to be the first bloodless combined heart and kidney transplant performed anywhere. The procedure was led by David J. Kaczorowski, MD, surgical director of the UPMC Heart Transplant Program, and Vikraman Gunabushanam, MD, abdominal transplant surgeon and assistant professor of Surgery, and required months of planning and collaboration among multiple disciplines.
The Challenge of Bloodless Transplantation
Blood transfusions are common in organ transplantation, particularly in heart surgery, where the use of cardiopulmonary bypass often leads to hemodilution and significant blood loss. Approximately 40% of heart surgery patients require transfusions, making the successful execution of a bloodless heart transplant much more challenging.
“There are patients around the country that, for religious reasons or native physiology, cannot accept the transfusion of blood. Traditionally, this makes it difficult to do cardiac surgery because even in routine procedures, transfusion is not uncommon,” says Dr. Kaczorowski.
This challenge becomes magnified in cases involving multiple organ transplants. The patient in this case required both a new heart and a kidney, adding to the surgical complexity and the blood conservation strategy. Many transplant centers have experience with bloodless medicine techniques and even bloodless heart transplants, but the combination of a heart and kidney transplant without transfusion was something that had yet to be accomplished.
The complexity of performing this kind of transplant while maintaining hemodynamic stability without the safety net of transfusion required the UPMC team to create an innovative surgical and perioperative protocol that could ensure a successful outcome.
Developing the Bloodless Transplant Protocol
Because this was the first bloodless heart transplant performed at UPMC – and the first bloodless combined heart/kidney transplant anywhere – Dr. Kaczorowski and the entire team had to design a comprehensive and multidisciplinary protocol with strict preoperative, intraoperative, and postoperative measures designed to prevent the need for blood transfusion while ensuring an optimal surgical outcome could be achieved. The protocol – and the patient’s entire plan of care – required collaboration between cardiothoracic surgery, anesthesiology, critical care medicine, transfusion medicine, nephrology, perfusion, hematology, and pharmacy areas.
“Managing complex transplant cases like this takes a village. Being able to provide this level of lifesaving care would not be possible without such a dedicated team and the resources we have available across the UPMC system,” says Dr. Kaczorowski.
A critical component of the protocol involved preoperative hematologic optimization. Given the patient’s preexisting level of anemia, the team initiated a regimen of erythropoiesis-stimulating agents, iron supplementation, folate, and vitamin B12 to enhance red blood cell production prior to surgery. A concerted effort was made to reduce unnecessary blood draws to preserve the patient’s existing blood volume before surgery.
The protocol developed also entails that for any patient to be eligible for a bloodless transplant they must meet stringent inclusion criteria, including specific hemoglobin levels and platelet counts before undergoing surgery. Additionally, the protocol requires that patients accept cardiopulmonary bypass, autologous transfusion techniques, and cell saver technology, while also consenting to the use of alternative clotting agents.
During surgery, a number of blood conservation techniques were employed. The cardiopulmonary bypass circuit was modified to minimize hemodilution because it can be a significant contributor to intraoperative blood loss. The use of a dry venous line and limiting the circuit volume helped to avoid hemodilution in this case.
Advanced intraoperative monitoring was used to detect and control even the smallest sources of bleeding. Hemostatic agents, including tranexamic acid, fibrinogen concentrates, and desmopressin (DDAVP), were administered to enhance clot stability.
“Surgical precision also plays an outsized role in the success of this type of procedure,” says Dr. Kaczorowski. “We used electrocautery and bone wax to seal bleeding surfaces - every possible measure was taken to achieve and maintain hemostasis, as even minor blood loss could compromise the patient’s stability during and after surgery.”
Blood conservation in the postoperative period was also addressed in the protocol. This entailed that the patient underwent strict hematologic monitoring with minimal blood draws, utilizing low-volume syringes and carefully structured laboratory testing schedules. Iron therapy, erythropoietin, and folate supplementation were continued to support red blood cell recovery.
“Every aspect of postoperative management was tailored to sustain the patient’s hematocrit without resorting to transfusion, demonstrating the effectiveness of the protocol,” says Dr. Kaczorowski.
The Procedure and Outcome: Case Details
The patient, who had been on temporary mechanical circulatory support (Impella device) due to decompensated heart failure, was referred to UPMC after multiple other transplant centers declined to accept the case. The heart transplant portion was performed first, followed by the kidney transplant early the next morning, minimizing ischemic time between procedures.
“The heart transplant started on Monday night and continued into the early hours of Tuesday morning. The kidney transplant followed about six hours later,” says Dr. Kaczorowski.
Despite the complexity and added risks of avoiding transfusion, the patient had an uneventful recovery and was discharged in good condition.
“His hospital course was very smooth. The biggest challenge for us was limiting blood draws, as we typically perform extensive postoperative monitoring. But with careful planning, we were able to maintain his hematocrit without the need for a transfusion,” says Dr. Kaczorowski.
The case was particularly remarkable given that, according to a previous study, a significant proportion of heart transplant recipients require multiple units of blood, on average, throughout the perioperative period. This patient, however, underwent the entire procedure and recovery without any transfusion support.
“We believe that the protocol we developed to handle this case could serve as a model for future bloodless transplant cases, including in multi-organ transplantation,” says Dr. Kaczorowski.
This case highlights the skill and advancement of UPMC, and its organ transplantation programs, but also the importance of interdisciplinary collaboration, careful surgical planning, and advances in blood conservation technology in expanding access to transplantation for patients who cannot accept blood transfusions. The success of this first bloodless heart-kidney transplant shows the potential for conserving and reducing reliance on blood products even in highly complex procedures.
“There is significant variability in blood transfusion requirements for heart transplants,” says Dr. Kaczorowski. “By developing a comprehensive approach to blood conservation techniques before, during, and postoperatively, we can potentially reduce transfusion needs across the board for all of our transplant cases.”
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