Accumulating Multiple High-Risk Criteria Incrementally Decreases Survival After Pediatric Heart Transplantation
R. R. Davies1, M. J. Russo2, S. Mital1, T. M. Martens1, R. A. Sorabella1, K. N. Hong1, A. C. Gelijns1, A. J. Moskovitz2, J. M. Quaegebeur1, R. S. Mosca1, J. M. Chen1. 1College of Physicians and Surgeons, Columbia University, New York, NY, 2International Center for Health Outcomes and Innovation Research, Columbia University, New York, NY,
BACKGROUND: A number of centers have reported success with cardiac transplant using alternate-list strategies in the adult population. However, similar studies of high-risk pediatric recipients are lacking. The purpose of this study is to evaluate long-term post-transplant survival in high-risk pediatric recipients.
METHODS: UNOS provided de-identified patient-level data. The study population included 3,529 recipients aged < 21 years transplanted 1/1/95-12/31/05. Recipients were stratified based on the presence or absence of high-risk criteria (HRC): pulmonary vascular resistance > 6 woods units (n=237, 6.8%), creatinine clearance (CrCl) < 40 ml/min (311, 8.8%), hepatitis C positivity (33, 0.9%), donor:recipient weight ratio < 0.7 (80, 2.3%), panel reactive antibody (PRA) > 40% (235, 6.7%), retransplantation (235, 6.7%), age < 1 year old (1092, 31.2%).
RESULTS: Overall 1,751 (50%) patients met at least one HRC, and 1,751 (50.0%) had no HRC. Among all patients 1-, 5-, and 10-year mortality was 85.2%, 71.0%, and 57.0% respectively. One-year mortality for each HRC is given in Table 1. Proportional hazards regression demonstrated that only CrCl < 40 (hazard ratio 1.79, 95% confidence interval 1.16-2.74) and PRA > 40% (1.76, 1.22-2.52) predicted poor survival. Higher numbers of HRC in a patient were correlated with increased 1-year mortality (p < 0.0001, Table 2) and poor long-term survival (Figure, p < 0.0001).
CONCLUSIONS: Individually the effect of HRC on post-transplant survival varied; however increasing numbers of HRC in a patient resulted in a cumulative increase in mortality. These findings suggest that recipient criteria for transplantation should focus on the number of HRC rather than the presence or absence of a single risk factor.
| High Risk Criterion | 1-year mortality# | Odds ratio (95%CI) |
| PVR > 6 woods units | 30/201 (14.9%) | 0.87 (0.59-1.31) |
| CrCl < 40 ml/min | 87/262 (33.2%) | 2.84 (2.15-3.74)* |
| Hepatitis C | 9/28 (32.1%) | 2.42 (1.08-5.28)* |
| Weight Ratio < 0.70 | 18/73 (24.7%) | 1.68 (0.98-2.88) |
| Elevated PRA > 40% | 41/223 (18.4%) | 1.15 (0.81-1.64) |
| Retransplantation | 34/193 (17.6%) | 1.09 (0.74-1.59) |
| Infant (age < 1 year) | 199/937 (31.8%) | 1.61 (1.32-1.96)* |
| * p < 0.05 | ||
| # patients lost to follow-up before 1 year were censored | ||
| Number of High Risk Criteria | 1-year mortality# | Odds ratio (95%CI) |
| 0 | 188/1446 (13.0%) | 0.60 (0.49-0.73) |
| 1 | 199/1141 (17.4%) | 1.11 (0.91-1.36) |
| 2 | 85/321 (26.5%) | 1.99 (1.52-2.61)* |
| 3 or more | 16/44 (36.4%) | 2.95 (1.58-5.49)* |
| * p < 0.05 | ||
| # patients lost to follow-up before 1 year were censored | ||
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