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Published on: June 6, 2025
Sex Differences in Utilization of Donation After Circulatory Death Donors for Heart Transplantation and Associated
Ersilia M DeFilippis1, Maria Masotti2, Elena M Donald1
1Division of Cardiology (E.M. DeFilippis, E.M. Donald, J.E., N.U.), Columbia University Irving Medical Center, New York, NY.
Insights
Women are less likely to receive heart transplants from donation after circulatory death (DCD) donors, despite similar survival rates. Equitable access to DCD heart transplantation is crucial as its use expands.
Area of Science:
- Cardiology
- Transplantation Medicine
- Organ Donation
Background:
- Donation after circulatory death (DCD) heart transplantation (HT) is increasingly utilized in the US.
- Existing data do not clarify sex-based disparities in DCD HT utilization or outcomes.
Purpose of the Study:
- To investigate sex differences in DCD HT utilization among adults listed for HT.
- To analyze the impact of DCD HT listing on waitlist outcomes and survival by sex.
Main Methods:
- Analysis of adult HT candidates listed at DCD centers (Jan 2019–Sep 2023) using the OPTN Registry.
- Multivariable logistic regression for listing disparities; competing risk analyses for waitlist outcomes.
- Examination of annual DCD HT trends and 2-year post-transplant survival by sex.
Main Results:
- Women were less likely to be listed for DCD HT (OR 0.84, P<0.001) and represented a smaller proportion of DCD transplants (18-20%) compared to brain death donors (26-29%).
- DCD HT listing improved HT rates (HR 1.85, P<0.001) and reduced waitlist mortality (HR 0.57, P<0.001) for both sexes, with no significant sex interaction.
- Two-year post-DCD HT survival was comparable between women (87%) and men (88%) (P=0.37).
Conclusions:
- Women face underutilization in DCD heart transplantation compared to men.
- Listing for DCD HT offers significant survival benefits for both sexes.
- Ensuring equitable access to DCD HT is imperative as the procedure becomes more widespread.
Background:
The use of donation after circulatory death (DCD) donors for heart transplantation (HT) is increasing in the United States. Whether sex differences exist in DCD HT utilization and outcomes is unknown.
Methods:
Adults listed for HT at DCD centers between January 1, 2019 (first US DCD HT) and September 15, 2023, in the Organ Procurement and Transplantation Network Registry were included. Differences in listing for DCD HT by sex were investigated using multivariable logistic regression. The impact of listing for DCD HT (modeled as a time-varying covariate) on waitlist outcomes including the rate of HT waitlist removal for death or clinical deterioration was assessed using multivariable competing risk analyses. Annual trends in DCD HT and 2-year survival after DCD HT by sex were also investigated.
Results:
A total of 9807 individuals were listed at DCD centers during the study period. Listing for DCD HT was less common among women after multivariable adjustment (odds ratio, 0.84 [95% CI, 0.76-0.92]; P<0.001). Listing for DCD HT was associated with an adjusted increased rate of HT (hazard ratio, 1.85 [95% CI, 1.75-1.95]; P<0.001) and a lower risk of waitlist removal for death or clinical deterioration (hazard ratio, 0.57 [95% CI, 0.45-0.73]; P<0.001) for both men and women; these protective effects were not different between sexes (interaction terms: transplant, P=0.55; delisting, P=0.91). During the study period, women made up 26% to 29% of donation after brain death transplants, but only 18% to 20% of DCD transplants. Survival at 2 years after DCD HT was similar between sexes (87% for women and 88% for men; log-rank P=0.37).
Conclusions:
Women were less likely to be listed for DCD HT and makeup proportionally less DCD transplants compared with men. Being listed for DCD HT improved waitlist outcomes in both sexes. One-year survival after DCD HT was similar by sex. As DCD HT expands, additional measures to ensure equitable access are imperative.
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