Impact on survival of T cell-depleting or interleukin-2 receptor antagonist induction therapy in simultaneous heart-kidney transplantation: A national registry analysis.

Simultaneous heart-kidney transplantation (SHKT) recipients present an elevated risk profile, and optimal induction immunosuppression remains unclear. We analyzed the Organ Procurement and Transplantation Network registry for adult SHKT recipients (N = 1375) who received T cell-depleting agents (TC-DAs; n = 754) or IL-2 receptor antagonists (n = 621) between April 2015 and March 2025. Using 12 prespecified covariates, 1:1 propensity score matching yielded 1152 recipients (576 per group). Three-year survival was higher in the TC-DA group (87.4% vs 81.1%; hazard ratio 0.61; 95% confidence interval 0.45-0.83; P = .001), with fewer in-hospital acute cardiac rejection episodes (4.5% vs 8.5%; P = .009). Deaths from infection and multiorgan failure were less frequent with TC-DAs (4.3% vs 7.5%; P = .033), while graft failure, rejection, and cardiovascular deaths did not differ. TC-DAs were associated with higher cumulative incidence of cardiac allograft vasculopathy (subdistribution hazard ratio 1.64; 95% confidence interval 1.14-2.37; P = .008). These findings were directionally consistent across sensitivity analyses. TC-DA induction was associated with improved survival; however, the concurrent increase in cardiac allograft vasculopathy underscores the need for prospective studies to define the optimal induction strategy in SHKT.