Cardiac Transplantation With Increased-risk Donors: Trends And Clinical Outcomes

Background Heart transplantation (HT) is the definitive treatment for patients with end-stage heart failure. A seminal event that led to HIV transmission, from a seronegative donor to a recipient in 1991, prompted the Center for Disease Control and the Public Health Service to issue guidelines in 1994. These guidelines not only standardized serologic testing, but also identified specific donor behavior that would classify such donors as “High Risk”. In 2013 these guidelines were revised and were expanded to include both hepatitis B and C; and the term “High Risk” was replaced with “Increased Risk Donors” (IRD). Studies have shown low risk of infectious transmission from IRD. But despite the evidence, recipients and some clinicians remain hesitant to accept organs from these donors. This study aims to report trends in acceptance of donors from IRD donors, and long-term outcomes. Methods This study is an analysis of OHT recipients captured in the United Network of Organ Sharing (UNOS) registry from 2004-2021. HT recipients were dichotomized by IRD status. Primary objective was survival following HT, secondary objectives were to report trends in IRD use, all cause hospitalizations, hospitalizations for infection, treated rejection, and graft failure. Results Of the 36,989 HT recipients within the study period, 7,779 (21%) were identified as recipients of IRD. Recipients of IRD were older (57 years vs 56 years, p=<.001), more likely to be African American (23% vs 21%, p=0.006), blood group O (40% vs 38%, p=0.02), have public insurance (52% vs 50%, p=.02), and have a BMI >30 (30% vs 29%, p=.003). IRD recipients had shorter waitlist time (69 days vs 76 days, p=.009), and similar long-term unadjusted survival (Figure 1). During the study period IRD use increased from 2004-2021 (Figure 2). In unadjusted analysis, IRD recipients had lower all cause hospitalization rates (54% vs. 58%, p=<.001), hospitalization for infection (25% vs 27%, p=<.001), treated rejection (24% vs. 27%, p=<.001), and similar rates of graft failure at 15 years post-HT (58.6% vs 58.6%, p=.20). Conclusions In this large multicenter study, we report that recipients of IRD had similar long-term survival, and incidence of graft failure as recipients of standard risk donors. Further analysis is needed to understand observed differences in IRD recipient demographics, and outcomes of hospitalizations, and treated rejection. Heart transplantation (HT) is the definitive treatment for patients with end-stage heart failure. A seminal event that led to HIV transmission, from a seronegative donor to a recipient in 1991, prompted the Center for Disease Control and the Public Health Service to issue guidelines in 1994. These guidelines not only standardized serologic testing, but also identified specific donor behavior that would classify such donors as “High Risk”. In 2013 these guidelines were revised and were expanded to include both hepatitis B and C; and the term “High Risk” was replaced with “Increased Risk Donors” (IRD). Studies have shown low risk of infectious transmission from IRD. But despite the evidence, recipients and some clinicians remain hesitant to accept organs from these donors. This study aims to report trends in acceptance of donors from IRD donors, and long-term outcomes. This study is an analysis of OHT recipients captured in the United Network of Organ Sharing (UNOS) registry from 2004-2021. HT recipients were dichotomized by IRD status. Primary objective was survival following HT, secondary objectives were to report trends in IRD use, all cause hospitalizations, hospitalizations for infection, treated rejection, and graft failure. Of the 36,989 HT recipients within the study period, 7,779 (21%) were identified as recipients of IRD. Recipients of IRD were older (57 years vs 56 years, p=<.001), more likely to be African American (23% vs 21%, p=0.006), blood group O (40% vs 38%, p=0.02), have public insurance (52% vs 50%, p=.02), and have a BMI >30 (30% vs 29%, p=.003). IRD recipients had shorter waitlist time (69 days vs 76 days, p=.009), and similar long-term unadjusted survival (Figure 1). During the study period IRD use increased from 2004-2021 (Figure 2). In unadjusted analysis, IRD recipients had lower all cause hospitalization rates (54% vs. 58%, p=<.001), hospitalization for infection (25% vs 27%, p=<.001), treated rejection (24% vs. 27%, p=<.001), and similar rates of graft failure at 15 years post-HT (58.6% vs 58.6%, p=.20). In this large multicenter study, we report that recipients of IRD had similar long-term survival, and incidence of graft failure as recipients of standard risk donors. Further analysis is needed to understand observed differences in IRD recipient demographics, and outcomes of hospitalizations, and treated rejection.