Recipient-surgeon racial concordance in orthotopic heart transplantation outcomes.

BACKGROUND: Prior studies have demonstrated deleterious outcomes for physician-patient racial discordance. We explored recipient-surgeon racial concordance and short-term postoperative survival in adults undergoing orthotopic heart transplantation (OHT). METHODS: The United Network for Organ Sharing (UNOS) database was queried to identify White and Black adult (≥18 years) patients undergoing isolated OHT between 2000 and 2020. Surgeon race was obtained from publicly available images. All non-White and non-Black recipients and surgeons were excluded. Linear probability models were utilized to explore the relationship between recipient-surgeon racial concordance and 30-, 60-, and 90-day post-transplant mortality using a fixed effects approach. RESULTS: A total of 26,133 recipients were identified (mean age 52.79 years, 74.4% male) with 77.65% (n = 20,292) being White and 22.35% (n = 5841) being Black. A total of 662 White surgeons performed 25,946 (97.56%) OHTs during the study period while 17 Black surgeons performed 437 (1.67%) OHTs. Although some evidence of differences across groups was observed in cross-tabular specifications, these differences became insignificant after the inclusion of controls (i.e., comorbidities and fixed effects). This suggests that recipient race and physician race are not correlated with post-OHT survival at 30, 60, or 90 days. CONCLUSIONS: Recipient-surgeon racial concordance and discordance among adults undergoing OHT do not appear to impact post-transplant survival. Nor do we observe significant penalties accruing for Black patients overall once controls are accounted for. Given that worse outcomes have historically been demonstrated for Black patients undergoing OHT, further work will be necessary to improve understanding of racial disparities for patients with end-stage heart failure.

Pre-transplant Biomarkers of Immune Dysfunction Improve Risk Assessment of Post-transplant Mortality Compared to Conventional Clinical Risk Scores.

Introduction: There is a critical need to accurately stratify liver transplant (LT) candidates' risk of post-LT mortality prior to LT to optimize patient selection and avoid futility. Here, we compare previously described pre-LT clinical risk scores with the recently developed Liver Immune Frailty Index (LIFI) for prediction of post-LT mortality. LIFI measures immune dysregulation based on pre-LT plasma HCV IgG, MMP3 and Fractalkine. LIFI accurately predicts post-LT mortality, with LIFI-low corresponding to 1.4% 1-year post-LT mortality compared with 58.3% for LIFI-high (C-statistic=0.85). Methods: LIFI was compared to MELD, MELD-Na, MELD 3.0, D-MELD, MELD-GRAIL, MELD-GRAIL-Na, UCLA-FRS, BAR, SOFT, P-SOFT, and LDRI scores on 289 LT recipients based on waitlist data at the time of LT. Survival, hazard of early post-LT death, and discrimination power (C-statistic) were assessed. Results: LIFI showed superior discrimination (highest C-statistic) for post-LT mortality when compared to all other risk scores, irrespective of biologic MELD. On univariate analysis, the LIFI showed a significant correlation with mortality 6-months, as well as 1-, 3-, and 5-years. No other pre-LT scoring system significantly correlated with post-LT mortality. On bivariate adjusted analysis, African American race (p<0.05) and pre-LT cardiovascular disease (p=0.053) were associated with early- and long-term post-LT mortality. Patients who died within 1-yr following LT had a significantly higher incidence of infections, including 30-day and 90-day incidence of any infection, pneumonia, abdominal infections, and UTI (p<0.05). Conclusions: LIFI, which measures pre-LT biomarkers of immune dysfunction, more accurately predicts risk of post-LT futility compared with current clinical predictive models. Pre-LT assessment of immune dysregulation may be critical in predicting mortality after LT and may optimize selection of candidates with lowest risk of futile outcomes.

Validation of existing risk scores for mortality prediction after a heart transplant in a Chinese population.

OBJECTIVES: The objectives of this study were to validate 3 existing heart transplant risk scores with a single-centre cohort in China and evaluate the efficacy of the 3 systems in predicting mortality. METHODS: We retrospectively studied 428 patients from a single centre who underwent heart transplants from January 2015 to December 2019. All patients were scored using the Index for Mortality Prediction After Cardiac Transplantation (IMPACT) and the United Network for Organ Sharing (UNOS) and risk stratification scores (RSSs). We assessed the efficacy of the risk scores by comparing the observed and the predicted 1-year mortality. Binary logistic regression was used to evaluate the predictive accuracy of the 3 risk scores. Model discrimination was assessed by measuring the area under the receiver operating curves. Kaplan-Meier survival analyses were performed after the patients were divided into different risk groups. RESULTS: Based on our cohort, the observed mortality was 6.54%, whereas the predicted mortality of the IMPACT and UNOS scores and the RSSs was 10.59%, 10.74% and 12.89%, respectively. Logistic regression analysis showed that the IMPACT [odds ratio (OR), 1.25; 95% confidence interval (CI), 1.15-1.36; P < 0.001], UNOS (OR, 1.68; 95% CI, 1.37-2.07; P < 0.001) and risk stratification (OR, 1.61; 95% CI, 1.30-2.00; P < 0.001) scores were predictive of 1-year mortality. The discriminative power was numerically higher for the IMPACT score [area under the curve (AUC) of 0.691)] than for the UNOS score (AUC 0.685) and the RSS (AUC 0.648). CONCLUSIONS: We validated the IMPACT and UNOS scores and the RSSs as predictors of 1-year mortality after a heart transplant, but all 3 risk scores had unsatisfactory discriminative powers that overestimated the observed mortality for the Chinese cohort.

[Early central neurologic complications after heart transplantation are associated with higher intra-hospital mortality]. / Las complicaciones neurológicas centrales tempranas post-trasplante cardíaco se asocian a mayor mortalidad intrahospitalaria.

Neurological complications in orthotopic heart transplantation represent a major cause of morbidity and mortality despite successful transplantation. The aim of our study was to evaluate neurological complications on the outcome of patients with heart transplantation. We retrospectively studied 193 adult patients (aged = 18 years) who underwent heart transplant at Hospital Italiano in Buenos Aires from November 2014 to August 2018. We evaluated demographic and clinical vari ables and outcome of patients with and without neurological complications. We included 193 patients with a mean age of 51 ± 12 years of which 74% (n = 143) were men. The two most frequent causes that led to heart transplantation were idiopathic cardiomyopathy in 34% (n = 65) and ischemic cardiomyopathy in 29% (n = 56). Hemodynamic instability was present at the moment of transplant in 92% (n = 176) of the cases. Central neurological complications in the first week post-transplant occurred in 12% (n = 23). The most frequent were: encephalopathy (5%), subdural hematoma (2%), subarachnoid hemorrhage (2%), seizures (2%) and ischemic stroke (1%). Peripheral neuropathy was observed in 4% of cases. Hospital mortality was 11% (n = 22) and 88% (n = 170) was discharged at home. Those who presented central neurological complications had higher in-hospital mortality compared to those who did not (32% vs. 9%, p = 0.002).

Las complicaciones neurológicas posteriores al trasplante cardíaco representan una causa importante de morbimortalidad. La meta del presente estudio fue evaluar las complicaciones neurológicas (CN) en la evolución clínica de pacientes sometidos a trasplante cardíaco. Se evaluaron retrospectivamente todos los trasplantados cardíacos en el Hospital Italiano de Buenos Aires de noviembre del 2014 hasta agosto del 2018. Se evaluaron variables demográficas y clínicas, y se compararon entre los pacientes con y sin CN. Se incluyeron 193 adultos (edad = 18 años). La edad media fue de 51 ± 12 años, y 74% (n = 143) fueron varones. Las dos causas más frecuentes que llevaron a la indicación de trasplante fueron la miocardiopatía idiopática en 34% (n = 65) y la isquémica en 29% (n = 56). El 92% (n = 176) presentó inestabilidad hemodinámica al momento del trasplante. El 12% (n = 23) presentó CN centrales en la primer semana post-trasplante. Las más frecuentes fueron encefalopatía (5%), hematoma subdural (2%), hemorragia subaracnoidea (2%), convulsiones (2%), y accidente cerebrovascular isquémico (1%). En 4% se observó neuropatía periférica. La mortalidad hospitalaria fue del 11%, y 88% de los pacientes fueron dados de alta a domicilio. Los que presentaron CN centrales tuvieron mayor mortalidad intrahospitalaria en comparación a quienes no las presentaron (32% vs. 9%, p = 0.002).

Trends in Usage and Outcomes for Expanded Criteria Donor Kidney Transplantation in the United States Characterized by Kidney Donor Profile Index.

There has been increasing concern in the kidney transplant community about the declining use of expanded criteria donors (ECD) despite improvement in survival and quality of life. The recent introduction of the Kidney Donor Profile Index (KDPI), which provides a more granular characterization of donor quality, was expected to increase utilization of marginal kidneys and decrease the discard rates. However, trends and practice patterns of ECD kidney utilization on a national level based on donor organ quality as per KDPI are not well known. We, therefore, performed a trend analysis of all ECD recipients in the United Network for Organ Sharing (UNOS) registry between 2002 and 2012, after calculating the corresponding KDPI, to enable understanding the trends of usage and outcomes based on the KDPI characterization. High-risk recipient characteristics (diabetes, body mass index ≥30 kg/m2, hypertension, and age ≥60 years) increased over the period of the study (trend test p<0.001 for all). The proportion of ECD transplants increased from 18% in 2003 to a peak of 20.4% in 2008 and then declined thereafter to 17.3% in 2012. Using the KDPI >85% definition, the proportion increased from 9.4% in 2003 to a peak of 12.1% in 2008 and declined to 9.7% in 2012. Overall, although this represents a significant utilization of kidneys with KDPI >85% over time (p<0.001), recent years have seen a decline in usage, probably related to regulations imposed by Centers for Medicare & Medicaid Services (CMS). When comparing the hazards of graft failure by KDPI, ECD kidneys with KDPI >85% have a slightly lower risk of graft failure compared to standard criteria donor (SCD) kidneys with KDPI >85%, with a hazard ratio (HR) of 0.95, a confidence interval (CI) of 0.94-0.96, and statistical significance of p<0.001. This indicates that some SCD kidneys may actually have a lower estimated quality, with a higher Kidney Donor Risk Index (KDRI), than some ECDs. The incidence of delayed graft function (DGF) in ECD recipients has significantly decreased over time from 35.2% in 2003 to 29.6% in 2011 (p=0.007), probably related to better understanding of the donor risk profile along with increased use of hypothermic machine perfusion and pretransplant biopsy to aid in optimal allograft selection. The recent decline in transplantation of KDPI >85% kidneys probably reflects risk-averse transplant center behavior. Whether discard of discordant SCD kidneys with KDPI >85% has contributed to this decline remains to be studied.

Las complicaciones neurológicas centrales tempranas post-trasplante cardíaco se asocian a mayor mortalidad intrahospitalaria / Early central neurologic complications after heart transplantation are associated with higher intra-hospital mortality

Resumen Las complicaciones neurológicas posteriores al trasplante cardíaco representan una causa importante de morbimortalidad. La meta del presente estudio fue evaluar las complicaciones neurológicas (CN) en la evolución clínica de pacientes sometidos a trasplante cardíaco. Se evaluaron retrospectivamente todos los trasplantados cardíacos en el Hospital Italiano de Buenos Aires de noviembre del 2014 hasta agosto del 2018. Se evaluaron variables demográficas y clínicas, y se compararon entre los pacientes con y sin CN. Se incluyeron 193 adultos (edad ≥ 18 años). La edad media fue de 51±12 años, y 74% (n = 143) fueron varones. Las dos causas más frecuentes que llevaron a la indicación de trasplante fueron la miocardiopatía idiopática en 34% (n = 65) y la isquémica en 29% (n = 56). El 92% (n = 176) presentó inestabilidad hemodinámica al momento del trasplante. El 12% (n = 23) presentó CN centrales en la primer semana post-trasplante. Las más frecuentes fueron encefalopatía (5%), hematoma subdural (2%), hemorragia subaracnoidea (2%), convulsiones (2%), y accidente cerebrovascular isquémico (1%). En 4% se observó neuropatía periférica. La mortalidad hospitalaria fue del 11%, y 88% de los pacientes fueron dados de alta a domicilio. Los que presentaron CN centrales tuvieron mayor mortalidad intrahospitalaria en comparación a quienes no las presentaron (32% vs. 9%, p = 0.002).

Abstract Neurological complications in orthotopic heart transplantation represent amajor cause of morbidity and mortality despite successful transplantation. The aim of our study was to evaluate neurological complications on the outcome of patients with heart transplantation. We retrospectively studied 193 adult patients (aged ≥ 18 years) who underwent heart transplant at Hospital Italiano in Buenos Aires from November 2014 to August 2018. We evaluated demographic and clinical variables and outcome of patients with and without neurological complications. We included 193 patients with a mean age of 51 ± 12 years of which 74% (n = 143) were men. The two most frequent causes that led to heart transplantation were idiopathic cardiomyopathy in 34% (n = 65) and ischemic cardiomyopathy in 29% (n = 56). Hemodynamic instability was present at the moment of transplant in 92% (n = 176) of the cases. Central neurological complications in the first week post-transplant occurred in 12% (n = 23). The most frequent were: encephalopathy (5%), subdural hematoma (2%), subarachnoid hemorrhage (2%), seizures (2%) and ischemic stroke (1%). Peripheral neuropathy was observed in 4% of cases. Hospital mortality was 11% (n = 22) and 88% (n = 170) was discharged at home. Those who presented central neurological complications had higher in-hospital mortality compared to those who did not (32% vs. 9%, p = 0.002).