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Association of Donors With US Public Health Service Risk Criteria and Outcomes After Adult vs Pediatric Cardiac
Danielle S Burstein1, Joseph W Rossano1, JoAnn Lindenfeld2
1Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
Insights
Adults receive 3x more PHS risk criteria heart donors than children, yet survival is similar. These underused donors could help address organ shortages.
Area of Science:
- Transplantation immunology
- Infectious disease transmission in organ donation
- Public Health Service (PHS) risk criteria in organ transplantation
Background:
- The United Network for Organ Sharing (UNOS) uses US Public Health Service (PHS)-specific criteria to assess donor risk for HIV, hepatitis B, or hepatitis C transmission.
- Data on the utilization and outcomes of PHS risk criteria donors in pediatric and adult heart transplant recipients are limited.
- Understanding donor risk criteria is crucial for optimizing organ allocation and improving transplant success rates.
Purpose of the Study:
- To compare the utilization and outcomes of heart grafts from donors with PHS risk criteria versus standard-risk donors (SRD) in pediatric and adult recipients.
- To analyze contemporary trends in the use of PHS risk criteria donors in heart transplantation.
- To evaluate patient survival rates associated with PHS risk criteria donors compared to SRD in different age groups.
Main Methods:
- A nationwide analysis of heart transplant data from the UNOS database (January 1, 2010, to December 31, 2021).
- Inclusion of pediatric (<18 years) and adult (≥18 years) heart transplant recipients.
- Analysis of UNOS-defined donor risk status, patient survival using Kaplan-Meier curves and Cox proportional hazards models, and trends in PHS risk criteria use.
Main Results:
- PHS risk criteria donors comprised 8% of pediatric and 25% of adult heart transplants.
- The proportion of recipients transplanted with PHS risk-criteria donors was approximately 3 times greater in adults than in children.
- Patient survival was similar between pediatric recipients of PHS risk-criteria grafts and SRD grafts, and slightly higher in adult recipients of PHS risk-criteria grafts compared to SRD grafts.
Conclusions:
- Adults are significantly more likely to receive PHS risk criteria heart grafts than children, despite similar post-transplant survival rates.
- PHS risk criteria donors remain underutilized, particularly in pediatric heart transplantation.
- The organ donor shortage necessitates broader consideration and utilization of PHS risk criteria donors to improve access to heart transplantation.
Importance:
The United Network for Organ Sharing (UNOS) evaluates donor risk for acute transmission of HIV, hepatitis B, or hepatitis C based on US Public Health Services (PHS)-specific criteria. However, recent data regarding use and outcomes of those donors with PHS risk criteria among pediatric and adult heart transplant recipients are lacking.
Objective:
To compare use and outcomes of graft from donors with PHS risk criteria vs those with a standard-risk donor (SRD) in children vs adults in a contemporary cohort.
Design, Setting, And Participants:
This cohort was a nationwide analysis of heart transplants in the US that used data from the UNOS database. Participants were children (<18 years old) and adults (≥18 years old) who received a heart transplant from January 1, 2010, to December 31, 2021.
Exposures:
UNOS-defined donor risk status.
Main Outcomes And Measures:
Trend analysis compared changes in PHS risk criteria use among children and adults. Patient survival was analyzed using Kaplan-Meier curves with log rank and Cox proportional hazards to compare PHS risk-criteria outcomes vs SRD-criteria outcomes in children and adult heart transplant recipients. Additional analysis was performed among adults who received a PHS-risk criteria graft that was previously declined for pediatric recipients.
Results:
Of 5115 pediatric transplant recipients (donor without PHS risk median [IQR] age, 5 [0-13] years and donor with PHS risk median [IQR] age, 8 [0-14] years) and 30 289 adult heart transplant recipients (donor without PHS risk median [IQR] age, 56 [46-63] years and donor with PHS risk median [IQR] age, 57 [47-63] years), PHS risk criteria comprised 8% in children vs 25% in adults. PHS criteria are being increasingly used over the past decade with the proportion of recipients transplanted with PHS risk-criteria donors being approximately 3 times greater among adult recipients than children recipients. Pediatric recipients of a PHS risk-criteria donor had greater pretransplant ventilatory support, whereas adult recipients of a PHS risk-criteria donor had greater pretransplant extracorporeal membrane oxygenation use. Patient survival was similar between pediatric recipients of PHS risk-criteria grafts vs SRD-criteria grafts and slightly higher among adult recipients of PHS risk-criteria grafts vs SRD-criteria grafts. The 1778 adult recipients who received a PHS criteria-risk donor that was previously declined for pediatric recipients had similar patient survival recipients compared with SRD-criteria donors (HR, 0.92; 95% CI, 0.81-1.03; P = .18).
Conclusions And Relevance:
In the current era, a 3-fold greater proportion of adult recipients receive a PHS risk-criteria graft compared with children despite similar posttransplant patient survival. The ongoing organ donor shortage underscores the need for consideration of PHS risk criteria where these donors remain underused.
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