2026 Southeastern Residency Conference

Title: Impact of pre-transplant midodrine use on simultaneous liver-kidney transplant outcomes

Authors: Matthew Molk1, Mojibola Awe2, Teresa Gennaro1, Heather Snyder1, Farjad Siddiqui1; Emory University Hospital, Atlanta, GA1; The Johns Hopkins Hospital; Baltimore, MD2

Objective: Determine the impact of pre-transplant midodrine use on outcomes after SLK transplant related to delayed graft function.

Self Assessment Question: Does midodrine use prior to simultaneous liver-kidney transplant increase the incidence of specific kidney delayed graft function. 

Background: Midodrine is commonly used in patients with end-stage kidney and liver diseases for various indications. A previous study suggested that midodrine use prior to kidney transplant worsens post-transplant outcomes, including delayed graft function (DGF), graft failure, and death. Alternatively, another study among simultaneous liver-kidney (SLK) transplant recipients found no significant difference in hospitalization, graft failure, or death in patients treated with pre-transplant midodrine. Given the paucity of data, the purpose of this study was to determine the impact of pre-transplant midodrine use on outcomes after SLK transplant.

Methods: This was a single-center, retrospective chart review of adult patients who received a SLK transplant at Emory Transplant Center between February 2015 and June 2024. Patients who died within 7 days post-transplant were excluded. Patients were placed into 2 study arms determined by their pre-transplant midodrine use. Pre-transplant midodrine use was defined as treatment with midodrine for at least 3 months prior to transplant. The primary outcome was the incidence of kidney-specific DGF, defined as the requirement for dialysis within the first 7 days after transplant. Secondary outcomes included post-transplant hospital length of stay, midodrine use at discharge from index admission, estimated glomerular filtration rate (eGFR) at discharge and 1 year, readmission rates, and kidney allograft survival and patient survival at 1-year post-transplant. Primary and secondary outcomes were analyzed using descriptive statistics.

Results: Of the 104 patients screened, 94 patients met inclusion criteria with 13 patients in the midodrine group and 81 in the non-midodrine group. Median age was similar between groups (57 vs. 58 years) and a majority of patients in both arms were Caucasian and male. Patients in the midodrine had a higher median MELD score at the time of transplant compared to the non-midodrine group (34 vs. 31; p < 0.001). Kidney-specific DGF occurred more frequently in the midodrine group vs. the non-midodrine group, however this difference was not statistically significant (30.8% vs. 12.3%, p = 0.083). The midodrine group had a significantly longer median post-transplant length of stay (17 vs. 11 days, p < 0.001) and a higher incidence of midodrine use at discharge (15.4% vs. 2.5%, p = 0.032). While eGFR at discharge trended lower in the midodrine group (47 vs. 66 mL/min/1.73m², p = 0.075), eGFR at 1-year post-transplant was comparable between groups (53 vs. 56 mL/min/1.73m², p = 0.462). Readmission rates at 6-12 months post-transplant were greater in the midodrine group (54% vs. 17%; p = 0.003). Kidney allograft survival and patient survival at 1-year post-transplant were similar between groups.

Conclusion: Pre-transplant midodrine use in SLK recipients does not appear to affect short term outcomes after transplant; however larger studies need to be conducted.