Low-Urgency Heart Transplant Recipients More Likely to Receive Organs From Higher-Risk Donors

NEW YORK (Reuters Health) – Heart-transplant recipients with the lowest medical urgency receive hearts from donors with an increased number of comorbidities, including hepatitis C and diabetes, compared with higher-urgency patients, according to new findings.

Despite the difference in donors’ comorbidity profiles, both low-urgency and high-urgency patients in the study had similar outcomes at one year after transplantation, Dr. Tariq Ahmad of Yale School of Medicine, in New Haven, Connecticut, and colleagues report in the Journal of the American Heart Association. Publication of the findings coincided with a presentation at the American Heart Association Scientific Sessions in Boston.

Dr. Ahmad’s team analyzed data from the United Network for Organ Sharing (UNOS) database on patients listed for heart transplant between 2011 and 2020. They focused on the years prior to and after the 2018 allocation-system change, which replaced a three-tiered system with a six-tier system in an effort to increase organ availability for higher-urgency patients.

In the old system, lower-urgency patients (n=570, UNOS status 2) were significantly older (59 vs. 56 years) and more likely to be women (54% vs. 24%) than high-urgency patients (n=11,455, UNOS status 1).

Donors for lower-urgency patients were also older and more likely to be female and to have a history of cytomegalovirus (66% vs. 60%), hepatitis C (2.8% vs. 1.0%), or diabetes (6.3% vs. 3.5%).

The new allocation system included 2,614 higher-urgency patients (UNOS Status 1 or 2) and 181 lower-urgency patients (UNOS status 6). Patients under this system who had the lowest medical urgency for transplant had significantly longer waiting list times (58 vs. 19 days) and received heart transplants with shorter cold ischemic times (3.1 vs. 3.5 hours; P <0.001).

Under the new system, lower-urgency patients were also more likely to have high-risk donors (42% vs. 34%; P=0.029) and donors with hepatitis C (9.9% vs. 5.4%; P=0.011) and a prior history of malignancy (2.8% vs. 0.7%, P=0.002) and diabetes (7.2% vs. 2.2%; P<0.001).

No significant differences in one-year post-transplant survival were found between lower- and higher-urgency patients under either system.

Dr. Ahmad told Reuters Health by email that the organs received by lower-urgency patients “might have been offered to higher-urgency candidates first and then declined by those candidates due to the comorbidities of the donors.”

The organs would then be offered to lower-priority candidates in accordance with the allocation criteria, he said.

Dr. Jeffrey Teuteberg, a transplant cardiologist at Stanford University in California who was not involved in the study, said patients with lower medical urgency, or those who are less sick overall, tend to receive transplants with greater comorbidities given their overall healthier state.

He added that risks related to transplant are also viewed through the lens of the transplant program, not just the absolute risk factors themselves. “I think a lot of these single risk factors probably aren’t as risky in and of themselves, and it really matters what other recipient-specific risk factors go along with them,” he said in an email.

Hepatitis C was a risk factor identified in this study that can negatively impact survival in cardiac transplantation, Dr. Ahmad added.

“Given the advent of antiviral treatments for hepatitis C, however, studies have shown that transplantation of hepatitis C-positive donors is safe but only about 5% of hepatitis C positive organs are transplanted,” he said. “This could be an addressable area to increase the donor pool.”

SOURCE: https://bit.ly/3quz8vR Journal of the American Heart Association, online November 8, 2021.

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