Infectious outcomes in heart-after-liver transplantation with or without domino (HALT+/-D): A case series with comparison to isolated heart and isolated liver transplantation
Abstract
Heart-after-liver transplantation with or without domino (HALT+/-D) has emerged as a strategy to expand access for highly sensitized patients who face limited transplant options due to donor-specific antibodies (DSAs). While the liver's immunoprotective effect may mitigate antibody-mediated rejection, the infectious risks of this approach remain poorly defined. We performed a retrospective single-center case series of all HALT+/-D recipients (n = 4) at the University of Washington, with detailed characterization of infectious complications. For context, we compared outcomes to highly sensitized (cPRA ≥ 89%) isolated heart (n = 6) and liver (n = 5) transplant recipients. All 4 HALT+/-D recipients were female with extreme allosensitization (median cPRA 99%) and prolonged pre-transplant hospitalization (mean 64 days). Median time for the first post-transplant infection was 29 days (range 6-52). Three of four (75%) developed Clostridioides difficile infection, associated with broad-spectrum antibiotic use. HALT+/-D recipients had median infection-related hospital days of 37, vs 7 in heart and 0 in liver transplant recipients. All 4 patients survived to one year with functioning grafts. HALT+/-D recipients experience a substantial infectious burden, particularly CDI. This case series provides clinical information to guide infection management. Prospective multicenter studies are needed to optimize protocols.
How strong is the evidence?
Evidence Hub reads this as a case series, done in people. Its evidence level is 5 of 5 (Very low · case / narrative / animal / in vitro / in silico). Case reports, narrative reviews, and animal, cell or computer-model studies give the weakest evidence for human health. Reported size: 6 participants or records.
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