Donor History of Drug Use and Graft Survival in Pediatric Heart Transplant Recipients

Older children awaiting a heart transplant (HT) sometimes receive a heart offer from a donor with a history of drug use (HDU). The effect of using such donor hearts on posttransplant survival in pediatric recipients is unclear.

To assess the association of using hearts from donors with HDU on posttransplant graft survival in pediatric HT recipients.

For this retrospective cohort study, all pediatric HT recipients (aged <18 years) in the Organ Procurement and Transplantation Network database during January 1, 2000, to December 31, 2020, were identified. Among the recipients who received a heart from a donor with HDU, nearly all donors were aged 11 years or older. A propensity score (PS) model was developed to assess the probability of receiving a heart from a donor with HDU using baseline recipient and donor variables, limiting the study cohort to donors aged 11 years or older. Data were analyzed from October 2023 to November 2024.

HT using a heart from a donor with HDU (exposure group) vs from a donor without HDU (control group).

The main outcome was graft loss (death or retransplant) assessed at 90 days after transplant and long term among 90-day survivors. Kaplan-Meier survival curves and a Cox proportional hazards regression model that accounted for matching of exposure and control groups were used to compare risk of graft loss.

This study included 2730 pediatric HT recipients. Their median age at HT was 14 years (IQR, 11-16 years), and most (1642 [60.1%]) were male. Overall, the exposure group comprised 822 children who received a heart from a donor with HDU; of these, 765 (93.1%) were PS matched to the control group. There was no difference in risk of graft loss within 90 days (hazard ratio [HR], 0.93 [95% CI, 0.55-1.57]; P = .78) or at long-term follow-up (HR, 1.04 [95% CI, 0.87-1.25]; P = .68) between PS-matched groups. Risk of graft loss within 90 days was not significantly different in children who received a heart from a donor with a history of cocaine use (157 pairs) vs children in the control group (HR, 0.55 [95% CI, 0.19-1.54]; P = .25); however, the risk of long-term graft loss among 90-day survivors was significantly higher (HR, 2.03 [95% CI, 1.35-3.06]; P = .001).

In this cohort study of pediatric HT recipients, there was no association of 90-day graft survival with donor HDU; however, donor history of cocaine use was associated with a higher risk of long-term graft loss. These findings may be important when considering a donor with HDU for pediatric HT candidates.