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Evolving Trends and Impact of Waitlist Transfusion on Recipient Outcomes Following Heart Transplantation
Yeahwa Hong1,2, Nidhi Iyanna3, Nicholas R Hess2
1Department of Surgery, University of Pittsburgh Medical Center Pittsburgh, Pittsburgh, Pennsylvania, USA.
Insights
Waitlist blood transfusions in heart transplant recipients decreased after a 2018 policy change. While initially appearing linked to worse survival, this association disappeared after accounting for patient condition, with ECMO, Impella, and dialysis predicting transfusion need.
Area of Science:
- Cardiology
- Transplantation Medicine
- Hematology
Background:
- Evaluating clinical trends, risk factors, and outcomes of waitlist blood transfusions in isolated heart transplantation.
- Assessing the impact of transfusion policies on patient management and post-transplant results.
Purpose of the Study:
- To analyze the incidence and predictors of blood transfusion in heart transplant candidates on the waitlist.
- To determine the association between waitlist transfusion and post-transplant survival outcomes.
Main Methods:
- Utilized the UNOS registry for adult heart transplant recipients (Jan 2014-June 2022).
- Stratified recipients based on waitlist transfusion status and compared incidence before/after the 2018 allocation policy change.
- Employed propensity score-matching and multivariable logistic regression to identify predictors and adjust for confounding factors.
Main Results:
- 19.2% of 21,926 recipients received waitlist transfusions; incidence decreased post-2018 policy change (23.7% vs. 14.3%).
- Unmatched analysis showed reduced 1-year survival with waitlist transfusion (88.8% vs. 91.9%), but this difference vanished in propensity score-matched analysis (90.0% vs. 90.4%).
- Predictors of waitlist transfusion included ECMO, Impella, and pretransplant dialysis; transfusion odds increased with longer waitlist times.
Conclusions:
- The 2018 allocation system is associated with a lower incidence of waitlist transfusions.
- Waitlist transfusion is a marker of patient acuity, not an independent predictor of adverse post-transplant outcomes.
- ECMO, Impella, and pretransplant dialysis are significant predictors of the need for waitlist transfusion.
Background:
This study evaluates the clinical trends, risk factors, and impact of waitlist blood transfusion on outcomes following isolated heart transplantation.
Methods:
The UNOS registry was queried to identify adult recipients from January 1, 2014, to June 30, 2022. The recipients were stratified into two groups depending on whether they received a blood transfusion while on the waitlist. The incidence of waitlist transfusion was compared before and after the 2018 allocation policy change. The primary outcome was survival. Propensity score-matching was performed. Multivariable logistic regression was performed to identify predictors of waitlist transfusion. A sub-analysis was performed to evaluate the impact of waitlist time on waitlist transfusion.
Results:
From the 21 926 recipients analyzed in this study, 4201 (19.2%) received waitlist transfusion. The incidence of waitlist transfusion was lower following the allocation policy change (14.3% vs. 23.7%, p < 0.001). The recipients with waitlist transfusion had significantly reduced 1-year posttransplant survival (88.8% vs. 91.9%, p < 0.001) compared to the recipients without waitlist transfusion in an unmatched comparison. However, in a propensity score-matched comparison, the two groups had similar 1-year survival (90.0% vs. 90.4%, p = 0.656). Multivariable analysis identified ECMO, Impella, and pretransplant dialysis as strong predictors of waitlist transfusion. In a sub-analysis, the odds of waitlist transfusion increased nonlinearly with longer waitlist time.
Conclusion:
There is a lower incidence of waitlist transfusion among transplant recipients under the 2018 allocation system. Waitlist transfusion is not an independent predictor of adverse posttransplant outcomes but rather a marker of the patient's clinical condition. ECMO, Impella, and pretransplant dialysis are strong predictors of waitlist transfusion.
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