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Sex-Based Disparities in Waitlist and Posttransplant Outcomes Under the Previous and Revised United States Heart
Anjali Purohit1, Dana Marsy2, Nabin K Shrestha1,3,2
1Michigan State University College of Human Medicine, Grand Rapids, Michigan, USA.
Insights
The revised heart transplant (HT) allocation system improved transplant access for women. However, women still face worse posttransplant survival rates compared to men, indicating persistent sex-based disparities.
Area of Science:
- Cardiology
- Transplantation Medicine
- Health Equity
Background:
- The US heart transplant (HT) allocation system was revised in October 2018 to improve equity.
- Previous system limitations included narrow patient stratifications and limited geographic scope.
- The impact of the revised system on sex-based disparities in HT waitlist and posttransplant outcomes remains understudied.
Purpose of the Study:
- To evaluate the effect of the revised HT allocation system on sex-based differences in waitlist and posttransplant outcomes.
- To identify persistent disparities in heart transplantation access and survival based on sex.
Main Methods:
- Retrospective analysis of adult HT candidates from the Organ Procurement and Transplantation Network (OPTN) database (January 2014 - December 2021).
- Patients stratified by sex and allocation system era (pre- and post-October 2018).
- Waitlist outcomes analyzed using competing risks; posttransplant outcomes analyzed using Kaplan-Meier and Cox models.
Main Results:
- Women showed higher 1-year transplant incidence in both allocation systems (old: 60.4% vs. 54.1%; new: 72.4% vs. 66.6%).
- Adjusted 1-year posttransplant survival was lower for women than men in both systems (old: 91.2% vs. 93.3%; new: 89.7% vs. 91.4%).
- Female sex remained an independent predictor of lower adjusted survival despite improved transplant access.
Conclusions:
- The updated HT allocation system enhanced transplant access for women without increasing waitlist mortality.
- Significant sex-based disparities in adjusted posttransplant survival persist.
- Addressing immunological, clinical, and system-level sex-based factors is crucial for improving transplant equity.
Background:
In October 2018, the heart transplant (HT) allocation system in the United States was revised to address limitations of the prior model. Changes included more granular patient population stratifications and expansion of geographic boundaries. While the revised allocation system has improved transplant access for critically ill patients, limited data exist regarding its impact on sex-based disparities in waitlist and posttransplant outcomes.
Objective:
To evaluate the impact of the revised HT allocation system on sex-based differences on waitlist and posttransplant outcomes.
Methods:
We conducted a retrospective study of adult patients listed for HT in the Organ Procurement and Transplantation Network database between January 1, 2014 and December 31, 2021. Patients were stratified by sex and allocation system era. Waitlist outcomes were analyzed using competing risks methodology. Posttransplant outcomes were analyzed using Kaplan-Meier and Cox proportional hazards models.
Results:
Of 26,876 patients, 16,053 (59.7%) were listed under the previous system and 10,823 (40.3%) under the current system. A total of 4,216 (26.2%) were women in the previous system and 2,882 (26.6%) were women in the current system. In both allocation systems, women had a significantly higher cumulative incidence of transplantation at 1 year compared with men (old: 60.4% versus 54.1%; new: 72.4% versus 66.6%, p < 0.001). Among 18,725 transplant recipients, adjusted 1-year posttransplant survival was significantly lower for women compared with men in both systems (old: 91.2% versus 93.3%, p < 0.001; new: 89.7% versus 91.4%, p = 0.036). Female sex remained an independent predictor of lower adjusted survival despite increased access to transplantation.
Conclusion:
The updated allocation system has improved transplant access for women without increasing waitlist mortality. However, women continue to experience worse adjusted posttransplant survival compared with men. These disparities likely reflect a combination of immunological, clinical, and system sex-based factors. Ongoing investigation is needed to address sex-based inequities in transplant outcomes.
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