Diaz-Cordova ME, Rega M, Sharma I, Misawa R, Dhand A, Nishida S, Okumura K. Higher model for end-stage liver disease excluding international normalized ratio scores predict worse kidney graft outcomes in simultaneous heart-kidney transplantation. World J Transplant 2026; 16(3): 119505 [DOI: 10.5500/wjt.119505]
Corresponding Author of This Article
Kenji Okumura, MD, Associate Faculty, Department of Surgery, Westchester Medical Center and New York Medical College, 100 Woods Road, Valhalla, NY 10595, United States. kenji.okumura@wmchealth.org
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Transplantation
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research-article
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Diaz-Cordova ME, Rega M, Sharma I, Misawa R, Dhand A, Nishida S, Okumura K. Higher model for end-stage liver disease excluding international normalized ratio scores predict worse kidney graft outcomes in simultaneous heart-kidney transplantation. World J Transplant 2026; 16(3): 119505 [DOI: 10.5500/wjt.119505]
World J Transplant. Sep 18, 2026; 16(3): 119505 Published online Sep 18, 2026. doi: 10.5500/wjt.119505
Higher model for end-stage liver disease excluding international normalized ratio scores predict worse kidney graft outcomes in simultaneous heart-kidney transplantation
Marco E Diaz-Cordova, Matthew Rega, Ishani Sharma, Ryosuke Misawa, Abhay Dhand, Seigo Nishida, Kenji Okumura
Marco E Diaz-Cordova, Matthew Rega, Ishani Sharma, Abhay Dhand, Seigo Nishida, Kenji Okumura, Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, NY 10595, United States
Ryosuke Misawa, Department of Surgery, Westchester Medical Center, Valhalla, NY 10595, United States
Author contributions: Diaz-Cordova ME and Okumura K contributed to conceptualization, study design, data analysis, data interpretation, and writing-original draft preparation; Rega M contributed to data analysis, data interpretation, and writing-review and editing; Sharma I contributed to data review and manuscript review; Misawa R, Dhand A, and Nishida S contributed to writing-review and editing and critical revisions of the manuscript; all authors reviewed and approved the final version of the manuscript.
Institutional review board statement: This study was considered exempt by our local Institutional Review Board due to the nature of the study.
Informed consent statement: Informed consent was not required.
Conflict-of-interest statement: All authors declare that they have no conflicts of interest and nothing to disclose.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement- checklist of items.
Data sharing statement: The data used in this study were obtained from the United Network for Organ Sharing (UNOS) registry and are not publicly available due to data use agreements. Data may be obtained directly from UNOS with appropriate permissions. The statistical analysis and analytic code used in this study are available from the corresponding author upon request.
Corresponding author: Kenji Okumura, MD, Associate Faculty, Department of Surgery, Westchester Medical Center and New York Medical College, 100 Woods Road, Valhalla, NY 10595, United States. kenji.okumura@wmchealth.org
Received: February 6, 2026 Revised: April 1, 2026 Accepted: June 5, 2026 Published online: September 18, 2026 Processing time: 213 Days and 6.1 Hours
Abstract
BACKGROUND
While the model for end-stage liver disease excluding international normalized ratio (MELD-XI) is known to be associated with adverse outcomes following cardiac surgery and heart transplantation, its predictive value in outcomes of simultaneous heart–kidney transplant (SHKT) remains unclear. To identify a reliable pre-transplant risk marker for graft and patient survival among SHKT recipients, we hypothesized that higher MELD-XI scores are linked to worse post-transplant outcomes.
AIM
To determine the association between MELD-XI and post-transplant outcomes in SHKT recipients.
METHODS
We performed a retrospective cohort study in adult SHKT recipients using the United Network for Organ Sharing database from 2014 to 2023. MELD-XI was calculated and categorized into tertiles (high, medium and low). Multivariable Cox proportional hazards models and generalized additive models were used to evaluate the association between MELD-XI and patient mortality and kidney graft failure.
RESULTS
Among the cohort of 2148 SHKT recipients the MELD-XI tertile distribution was: High (11%), medium (56%), and low (36%). Statistically significant differences among recipients in the highest tertile were seen and they were younger, more frequently female, had higher rates of dialysis, and shorter waitlist times. Recipients in the higher MELD-XI tertile also had significant increase in the delayed kidney graft function and longer hospital stays after transplantation. On multivariable analysis, MELD-XI independently predicted increase in 90-day graft failure, and 1-year graft failure and mortality.
CONCLUSION
Higher MELD-XI is associated with increased early mortality and kidney graft failure in SHKT recipients. MELD-XI can provide an objective risk-stratification tool to help identify candidates who should undergo SHKT vs kidney-after-heart transplantation.
Core Tip: The incidence of simultaneous heart-kidney transplantation (SHKT) has increased substantially in recent years. Early studies suggested benefit, but recent data are conflicting. No reliable prognostic marker exists for this population. The model for end-stage liver disease excluding international normalized ratio (MELD-XI) was previously validated in heart transplantation and cardiac surgery and may serve as a risk-stratification tool. In this study, higher MELD-XI scores were linked to early mortality and kidney graft failure. This supports its potential role in guiding selection between SHKT and kidney-after-heart transplantation under current allocation policies.
