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Validating patient prioritization in the 2018 Revised United Network for Organ Sharing Heart Allocation System: A
Aditi Nayak1, Tiffany Dong1, Yi-An Ko2
1Emory University School of Medicine, Atlanta, GA, USA.
Insights
The 2018 Heart Allocation System (HAS) generally prioritizes sicker patients, but factors like BMI and blood type can affect waitlist outcomes, suggesting system refinement is needed.
Area of Science:
- Transplantation Science
- Organ Allocation Systems
- Cardiovascular Research
Background:
- The 2018 United Network for Organ Sharing Heart Allocation System (HAS) aimed to reclassify heart transplant candidates by acuity.
- The current HAS may not fully account for factors like body mass index (BMI) and blood group, which can impact waitlist outcomes.
Purpose of the Study:
- To validate the prioritization of the 2018 HAS at a single center.
- To assess the influence of BMI and blood group on waitlist outcomes within the new HAS tiers.
Main Methods:
- Retrospective analysis of 214 heart transplant candidates listed from 2011-2017.
- Reclassification of patients into the 6-tier HAS.
- Multistate modeling and competing risk analysis, with stratified sensitivity analysis by BMI and blood group.
Main Results:
- Higher HAS tiers (3 and 2) showed a significantly increased hazard of waitlist death or deterioration compared to tier 4.
- No significant difference in transplantation outcomes was observed between these tiers.
- The hierarchical association of HAS tiers with outcomes was not consistently valid for patients with BMI ≥30 kg/m² and non-O blood groups.
Conclusions:
- The 2018 HAS effectively prioritizes the sickest patients in this cohort.
- BMI and blood group are significant factors that influence waitlist outcomes and necessitate further refinement of the HAS.
- The findings support the need for a more nuanced approach to heart allocation that incorporates individual patient characteristics.
Abstract:
The 2018 Revised United Network for Organ Sharing Heart Allocation System (HAS) was proposed to reclassify status 1A candidates into groups of decreasing acuity; however, it does not take into account factors such as body mass index (BMI) and blood group which influence waitlist (WL) outcomes. We sought to validate patient prioritization in the new HAS at our center. We retrospectively evaluated patients listed for heart transplantation (n = 214) at Emory University Hospital from 2011 to 2017. Patients were reclassified into the 6-tier HAS. Multistate modeling and competing risk analysis were used to compare outcomes of transplantation and WL death/deterioration between new tiers. Additionally, a stratified sensitivity analysis by BMI and blood group was performed. Compared with tier 4 patients, there was progressively increasing hazard of WL death/deterioration in tier 3 (HR: 2.52, 95% CI: 1.37-4.63, P = .003) and tier 2 (HR: 5.03, 95% CI: 1.99-12.70, P < .001), without a difference in transplantation outcome. When stratified by BMI and blood group, this hierarchical association was not valid in patients with BMI ≥30 kg/m2 and non-O blood groups in our cohort. Therefore, the 2018 HAS accurately prioritizes the sickest patients in our cohort. Factors such as BMI and blood group influence this relationship and iterate that the system can be further refined.
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