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Rejection Requiring Treatment within the First Year following Heart Transplantation: The UNOS Insight
Marco Gemelli1, Ilias P Doulamis2, Aspasia Tzani3
1Department of Cardiac, Thoracic, Vascular and Public Health Sciences, University of Padua, 35122 Padova, Italy.
Insights
Heart transplant recipients needing anti-rejection treatment within one year face significantly higher mortality risks, both short-term and long-term. This highlights the critical need for careful patient selection and management post-transplant.
Area of Science:
- Cardiology
- Transplantation Immunology
- Medical Statistics
Background:
- Heart failure is a growing public health concern with limited donor organs for transplantation.
- Graft rejection and the subsequent need for immunosuppression are significant challenges in heart transplantation.
- Meticulous donor-recipient selection is crucial to optimize outcomes and minimize graft failure.
Purpose of the Study:
- To identify patient characteristics associated with the need for anti-rejection treatment within one year of heart transplantation.
- To evaluate the impact of early anti-rejection treatment on mid-term and long-term mortality after heart transplant.
Main Methods:
- Utilized the United Network for Organ Sharing (UNOS) Registry for data from 2000-2021 in the US.
- Categorized 43,763 isolated heart transplant recipients into two groups: those needing anti-rejection treatment within one year and those who did not.
- Compared patient demographics, clinical factors, and 1-year and 10-year mortality rates between the groups.
Main Results:
- 22.7% of patients required anti-rejection treatment in the first year post-transplant.
- Patients needing early treatment were younger, more often female, had higher CPRA, and a greater history of cardiac surgery.
- Early anti-rejection treatment was linked to significantly higher unadjusted and adjusted mortality risks at 1, 5, and 10 years.
Conclusions:
- Medical treatment for acute rejection within the first year post-heart transplant is associated with increased mortality.
- The elevated mortality risk persists up to 10 years following transplantation.
- Further research is needed to understand the long-term implications of anti-rejection therapy in heart transplant recipients.
Abstract:
(1) Background: Heart failure is an extremely impactful health issue from both a social and quality-of-life point of view and the rate of patients with this condition is destined to rise in the next few years. Transplantation remains the mainstay of treatment for end-stage heart failure, but a shortage of organs represents a significant problem that prolongs time spent on the waiting list. In view of this, the selection of donor and recipient must be extremely meticulous, considering all factors that could predispose to organ failure. One of the main considerations regarding heart transplants is the risk of graft rejection and the need for immunosuppression therapy to mitigate that risk. In this study, we aimed to assess the characteristics of patients who need immunosuppression treatment for rejection within one year of heart transplantation and its impact on mid-term and long-term mortality. (2) Methods: The United Network for Organ Sharing (UNOS) Registry was queried to identify patients who solely underwent a heart transplant in the US between 2000 and 2021. Patients were divided into two groups according to the need for anti-rejection treatment within one year of heart transplantation. Patients' characteristics in the two groups were assessed, and 1 year and 10 year mortality rates were compared. (3) Results: A total of 43,763 patients underwent isolated heart transplantation in the study period, and 9946 (22.7%) needed anti-rejection treatment in the first year. Patients who required treatment for rejection within one year after transplant were more frequently younger (49 ± 14 vs. 52 ± 14 years, p < 0.001), women (31% vs. 23%, p < 0.001), and had a higher CPRA value (14 ± 26 vs. 11 ± 23, p < 0.001). Also, the rate of prior cardiac surgery was more than double in this group (27% vs. 12%, p < 0.001), while prior LVAD (12% vs. 11%, p < 0.001) and IABP (10% vs. 9%, p < 0.01) were more frequent in patients who did not receive anti-rejection treatment in the first year. Finally, pre-transplantation creatinine was significantly higher in patients who did not need treatment for rejection in the first year (1.4 vs. 1.3, p < 0.01). Most patients who did not require anti-rejection treatment underwent heart transplantation during the new allocation era, while less than half of the patients who required treatment underwent transplantation after the new allocation policy implementation (65% vs. 49%, p < 0.001). Patients who needed rejection treatment in the first year had a higher risk of unadjusted 1 year (HR: 2.25; 95% CI: 1.88-2.70; p < 0.001), 5 year (HR: 1.69; 95% CI: 1.60-1.79; p < 0.001), and 10 year (HR: 1.47; 95% CI: 1.41-1.54, p < 0.001) mortality, and this was confirmed at the adjusted analysis at all three time-points. (4) Conclusions: Medical treatment of acute rejection was associated with significantly increased 1 year mortality compared to patients who did not require anti-rejection therapy. The higher risk of mortality was confirmed at a 10 year follow-up. Further studies and newer follow-up data are required to investigate the role of anti-rejection therapy in the heart transplant population.
