Pre-Transplant C-Reactive Protein ≥ 20 mg/L Predicts Infection-Related Mortality After Heart Transplantation

Background: Patients after heart transplantation (HTX) require lifelong immunosuppressive therapy to prevent graft rejection, thereby increasing susceptibility to infections. C-reactive protein (CRP) is a recognized biochemical marker of system-wide inflammation and generally rises with increasing infection severity. As the prognostic relevance of elevated CRP (≥20 mg/L) prior to HTX has been unclear, we analyzed its effects on post-transplant outcomes. Methods: We performed a retrospective, observational, single-center study including 418 patients who received HTX at Heidelberg Heart Center between the years 2000 and 2019. HTX recipients were grouped according to pre-transplant CRP (<20 or ≥20 mg/L). We analyzed donor and recipient characteristics, post-transplant pharmacotherapy, and post-transplant mortality including causes of death. Results: Pre-transplant CRP was ≥20 mg/L in 102 of 418 HTX recipients (24.4%). These patients had a significantly higher 30-day (11.8% versus 5.1%, p = 0.019), 1-year (39.2% versus 17.4%, p < 0.001), 2-year (42.2% versus 23.1%, p < 0.001), and 5-year post-transplant mortality (47.1% versus 30.4%, p = 0.002). Infection/sepsis was more frequently the cause of death within five years after HTX among patients with a pre-transplant CRP ≥ 20 mg/L (28.4% vs. 15.8%, p = 0.005), particularly pulmonary infections (19.6% vs. 9.5%, p = 0.006). Multivariate Cox regression showed pre-transplant CRP ≥ 20 mg/L as an independent predictor of 5-year post-transplant mortality (HR: 1.630, 95% CI: 1.144-2.323, p = 0.007). Conclusions: Pre-transplant CRP ≥ 20 mg/L identifies HTX candidates at increased risk of infection-related mortality after HTX, particularly pulmonary infections. Intensified pre-transplant evaluation for occult infection and close post-transplant infectious surveillance is advisable.