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Ethnic Differences in the Epidemiology of Graft Failure in a Contemporary Cohort
S90
The Journal of Heart and Lung Transplantation, Vol 32, No 4S, April 2014
2( 33)
Table 1.
Univariate analysis risk factors by Cox regression test
Variable
Hazard ratio
P value
Confidence Interval
Recipient age Female donor to male recipient Recipient Donor Weight quote
1.04 2.22
0.018 0.04
1.01-1.07 1.04-4.75
3.92
0.002
1.67-9.19
2( 32) Retransplantation Versus Medical Therapy for Cardiac Allograft Vasculopathy (CAV): Analysis of the International Society for Heart and Lung Transplantation (ISHLT) Registry L. Goldraich ,1 J. Stehlik,2 A.Y. Kucheryavaya,3 L.B. Edwards,3 H.J. Ross.4 1Cardiac Transplant Program, Peter Munk Cardiac Center, University of Toronto, Toronto, ON, Canada; 2University of Utah School of Medicine, Salt Lake City, UT; 3International Society for Heart and Lung Transplantation and United Network for Organ Sharing, Richmond, VA; 4Cardiac Transplant Program, University of Toronto, Toronto, ON, Canada. Purpose: Cardiac retransplant is the accepted therapy for selected heart transplant recipients with advanced CAV. Progresses in pharmacological and percutaneous therapies have improved long-term survival of recipients with CAV. Prospective studies comparing medical management (MM) to retransplant (ReTx) as therapy for CAV are lacking. The ISHLT Registry was used to examine survival in adult heart transplant recipients with CAV. Methods: Recipients transplanted between 1995-2010 who developed CAV and were either retransplanted within 2 years of the CAV diagnosis (ReTx) or alive at ≥ 2 years after the CAV diagnosis without retransplant (MM) were included. Donor, recipient and transplant characteristics associated with increased mortality were compared between groups. In survival analysis, censoring occurred at the time of retransplant or loss to follow-up. To avoid bias, survival was computed from the date of retransplant for ReTx and starting at 2 years after CAV diagnosis for MM. Results: The study population included 4,636 patients (68 in ReTx and 4,568 in MM). Median time to CAV diagnosis was 2.9 and 2.1 years in ReTx and MM, respectively (p= 0.23). Recipient sex was comparable (79% males) in both groups. ReTx patients tended to be younger at time of ReTx compared to MM (51 vs. 55 years; p= 0.07). Median follow-up was 3.7 years for ReTx and 4.6 years for MM. There were 27 deaths in ReTx, and 1,453 in MM, and causes related to CAV or graft failure were similar between groups. There was a trend for better survival at 3 years in MM (83% vs. 74%; p= 0.051), but survival at 9 years was comparable (52% in ReTx and 50.5% in MM; p= 0.65) (Figure 1). Conclusion: Following the diagnosis of CAV, long-term survival is comparable with either MM or with ReTx. The challenges of retransplantation as well as the improved MM options underline the need for very restrictive approach to repeat transplant in recipients who develop CAV.
Race/Ethnic Differences in the Epidemiology of Graft Failure in a Contemporary Cohort A.A. Morris ,1 A. Kalogeropoulos,1 E. Kransdorf,2 M. Owen,3 R.T. Cole,1 J. Brown,1 D. Gupta,1 S.R. Laskar,1 A. Smith,1 J. Butler.1 1Emory University School of Medicine, Atlanta, GA; 2Mayo Clinic Arizona, Scottsdale, AZ; 3Emory University School of Nursing, Atlanta, GA. Purpose: Race/ethnic disparities in survival after heart transplantation (HT) have been well described, with Blacks having a higher incidence of graft failure (GF) after HT. However, the race-specific differences in the epidemiology of GF remain poorly understood. Methods: We studied 15,255 patients (mean age 52±12 years; 76% men) who underwent primary HT from 2000 to 2012. We assessed the likelihood of GF, and population-attributable risk (PAR) of independent risk factors for GF. Results: Over a median follow-up of 4.7 years, 2926 (19.2%) patients developed GF. Blacks were more likely to develop GF than Hispanics or Whites (23.6% vs. 19.2% vs. 18.2%, p< 0.001). Blacks were more likely to have risk factors for GF, including rejection requiring hospitalization, nonadherence, human leukocyte antigen (HLA) mismatch at ≥ 5 loci, and panel reactive antibody (PRA) ≥ 10% (Table 1, all p< 0.001). After adjustment for all risk factors in Table 1, Black race was associated with a higher risk of GF (hazard ratio [HR] 1.4; 95% confidence interval [CI] 1.2-1.6, p< 0.001). Rejection requiring hospitalization carried the highest PAR in all groups. Younger age at transplant and PRA ≥ 10% carried a high PAR in Blacks, while donor age carried a high PAR in Whites and Hispanics. Immunologic factors accounted for the highest overall proportion of GF in all groups, while sociodemographic and donor factors accounted for relatively less. Conclusion: GF is common after HT, however only a small proportion of GF risk can be attributed to modifiable risk factors. Racial differences in risk factors for GF after HT need to be considered in prevention and treatment efforts. Table 1.
Race-stratified adjusted HR and PAR of risk factors for graft failure Whites (N= 11,465)
Blacks (N= 2653)
Hispanics (N= 1137) HR (95% CI); PAR %
Risk Factor
N (%)
HR (95% CI); PAR % N (%)
HR (95% CI); PAR % N (%)
Age, yrs•4059•18-39•60+
6090 (53)1549 (14)3826 (33)
Reference1.1 (0.9-1.3); ---1.2 (1.11.4); 6.9
Reference1.5 646 (57)251 Reference1.4 (1.2-1.9); (22)240 (21) (0.9-2.1); ---1.2 11.61.1 (0.8(0.8-2.0); --1.5); ---
Creatinine ≥ 2 mg/dL
759 (7)
1.2 (0.9-1.4); 234 (9) ---
1524 (57)682 (26)447 (17)
1.1 (0.8-1.5); 58 (5) ---
0.7 (0.3-1.8); ---
Less than College 4208 (45) 1.2 (1.1-1.3); 1230 (56) 1.1 (0.9-1.3); 597 (67) Education 7.7 ---
0.9 (0.6-1.4); ---
Public Insurance 4247 (37) 1.1 (1.0-1.3); 1407 (53) 0.9 (0.8-1.2); 678 (60) 5.0 ---
0.9 (0.6-1.3); ---
PRA ≥ 10%
1998 (19) 1.2 (1.0-1.4); 645 (26) 3.8
1.3 (1.0-1.6); 190 (18) 6.6
1.4 (0.8-2.2); ---
HLA mismatch ≥ 5 loci
5500 (57) 1.2 (1.1-1.3); 1542 (68) 0.9 (0.7-1.1); 610 (61) 10.0 ---
1.0 (0.7-1.5); ---
Medication nonadherence
330 (3)
1.7 (1.3-2.3); 44 (4) 4.3
2.1 (1.2-3.7); 4.1
Rejection requiring hospitalization
1643 (14) 2.5 (2.2-2.8); 644 (24) 17.4
2.3 (1.8-2.8); 217 (19) 23.3
1.8 (1.2-2.7); 13.1
Cardiac allograft 3169 (28) 0.8 (0.7-0.9); 678 (26) vasculopathy ---
0.7 (0.6-0.9); 283 (25) ---
0.8 (0.5-1.2); ---
Ischemic Time ≥ 4 hrs
2280 (21) 1.0 (0.9-1.1); 459 (18) ---
1.2 (0.9-1.5); 247 (22) ---
1.1 (0.7-1.7); ---
Donor age ≥ 29 yrs
5852 (51) 1.3 (1.1-1.4); 1339 (51) 1.2 (0.9-1.5); 516 (45) 11.5 ---
1.4 (1.0-2.1); 16.9
1.8 (1.5-2.3); 163 (6) 2.4
The Journal of Heart and Lung Transplantation, Vol 32, No 4S, April 2014
2( 33)
Table 1.
Univariate analysis risk factors by Cox regression test
Variable
Hazard ratio
P value
Confidence Interval
Recipient age Female donor to male recipient Recipient Donor Weight quote
1.04 2.22
0.018 0.04
1.01-1.07 1.04-4.75
3.92
0.002
1.67-9.19
2( 32) Retransplantation Versus Medical Therapy for Cardiac Allograft Vasculopathy (CAV): Analysis of the International Society for Heart and Lung Transplantation (ISHLT) Registry L. Goldraich ,1 J. Stehlik,2 A.Y. Kucheryavaya,3 L.B. Edwards,3 H.J. Ross.4 1Cardiac Transplant Program, Peter Munk Cardiac Center, University of Toronto, Toronto, ON, Canada; 2University of Utah School of Medicine, Salt Lake City, UT; 3International Society for Heart and Lung Transplantation and United Network for Organ Sharing, Richmond, VA; 4Cardiac Transplant Program, University of Toronto, Toronto, ON, Canada. Purpose: Cardiac retransplant is the accepted therapy for selected heart transplant recipients with advanced CAV. Progresses in pharmacological and percutaneous therapies have improved long-term survival of recipients with CAV. Prospective studies comparing medical management (MM) to retransplant (ReTx) as therapy for CAV are lacking. The ISHLT Registry was used to examine survival in adult heart transplant recipients with CAV. Methods: Recipients transplanted between 1995-2010 who developed CAV and were either retransplanted within 2 years of the CAV diagnosis (ReTx) or alive at ≥ 2 years after the CAV diagnosis without retransplant (MM) were included. Donor, recipient and transplant characteristics associated with increased mortality were compared between groups. In survival analysis, censoring occurred at the time of retransplant or loss to follow-up. To avoid bias, survival was computed from the date of retransplant for ReTx and starting at 2 years after CAV diagnosis for MM. Results: The study population included 4,636 patients (68 in ReTx and 4,568 in MM). Median time to CAV diagnosis was 2.9 and 2.1 years in ReTx and MM, respectively (p= 0.23). Recipient sex was comparable (79% males) in both groups. ReTx patients tended to be younger at time of ReTx compared to MM (51 vs. 55 years; p= 0.07). Median follow-up was 3.7 years for ReTx and 4.6 years for MM. There were 27 deaths in ReTx, and 1,453 in MM, and causes related to CAV or graft failure were similar between groups. There was a trend for better survival at 3 years in MM (83% vs. 74%; p= 0.051), but survival at 9 years was comparable (52% in ReTx and 50.5% in MM; p= 0.65) (Figure 1). Conclusion: Following the diagnosis of CAV, long-term survival is comparable with either MM or with ReTx. The challenges of retransplantation as well as the improved MM options underline the need for very restrictive approach to repeat transplant in recipients who develop CAV.
Race/Ethnic Differences in the Epidemiology of Graft Failure in a Contemporary Cohort A.A. Morris ,1 A. Kalogeropoulos,1 E. Kransdorf,2 M. Owen,3 R.T. Cole,1 J. Brown,1 D. Gupta,1 S.R. Laskar,1 A. Smith,1 J. Butler.1 1Emory University School of Medicine, Atlanta, GA; 2Mayo Clinic Arizona, Scottsdale, AZ; 3Emory University School of Nursing, Atlanta, GA. Purpose: Race/ethnic disparities in survival after heart transplantation (HT) have been well described, with Blacks having a higher incidence of graft failure (GF) after HT. However, the race-specific differences in the epidemiology of GF remain poorly understood. Methods: We studied 15,255 patients (mean age 52±12 years; 76% men) who underwent primary HT from 2000 to 2012. We assessed the likelihood of GF, and population-attributable risk (PAR) of independent risk factors for GF. Results: Over a median follow-up of 4.7 years, 2926 (19.2%) patients developed GF. Blacks were more likely to develop GF than Hispanics or Whites (23.6% vs. 19.2% vs. 18.2%, p< 0.001). Blacks were more likely to have risk factors for GF, including rejection requiring hospitalization, nonadherence, human leukocyte antigen (HLA) mismatch at ≥ 5 loci, and panel reactive antibody (PRA) ≥ 10% (Table 1, all p< 0.001). After adjustment for all risk factors in Table 1, Black race was associated with a higher risk of GF (hazard ratio [HR] 1.4; 95% confidence interval [CI] 1.2-1.6, p< 0.001). Rejection requiring hospitalization carried the highest PAR in all groups. Younger age at transplant and PRA ≥ 10% carried a high PAR in Blacks, while donor age carried a high PAR in Whites and Hispanics. Immunologic factors accounted for the highest overall proportion of GF in all groups, while sociodemographic and donor factors accounted for relatively less. Conclusion: GF is common after HT, however only a small proportion of GF risk can be attributed to modifiable risk factors. Racial differences in risk factors for GF after HT need to be considered in prevention and treatment efforts. Table 1.
Race-stratified adjusted HR and PAR of risk factors for graft failure Whites (N= 11,465)
Blacks (N= 2653)
Hispanics (N= 1137) HR (95% CI); PAR %
Risk Factor
N (%)
HR (95% CI); PAR % N (%)
HR (95% CI); PAR % N (%)
Age, yrs•4059•18-39•60+
6090 (53)1549 (14)3826 (33)
Reference1.1 (0.9-1.3); ---1.2 (1.11.4); 6.9
Reference1.5 646 (57)251 Reference1.4 (1.2-1.9); (22)240 (21) (0.9-2.1); ---1.2 11.61.1 (0.8(0.8-2.0); --1.5); ---
Creatinine ≥ 2 mg/dL
759 (7)
1.2 (0.9-1.4); 234 (9) ---
1524 (57)682 (26)447 (17)
1.1 (0.8-1.5); 58 (5) ---
0.7 (0.3-1.8); ---
Less than College 4208 (45) 1.2 (1.1-1.3); 1230 (56) 1.1 (0.9-1.3); 597 (67) Education 7.7 ---
0.9 (0.6-1.4); ---
Public Insurance 4247 (37) 1.1 (1.0-1.3); 1407 (53) 0.9 (0.8-1.2); 678 (60) 5.0 ---
0.9 (0.6-1.3); ---
PRA ≥ 10%
1998 (19) 1.2 (1.0-1.4); 645 (26) 3.8
1.3 (1.0-1.6); 190 (18) 6.6
1.4 (0.8-2.2); ---
HLA mismatch ≥ 5 loci
5500 (57) 1.2 (1.1-1.3); 1542 (68) 0.9 (0.7-1.1); 610 (61) 10.0 ---
1.0 (0.7-1.5); ---
Medication nonadherence
330 (3)
1.7 (1.3-2.3); 44 (4) 4.3
2.1 (1.2-3.7); 4.1
Rejection requiring hospitalization
1643 (14) 2.5 (2.2-2.8); 644 (24) 17.4
2.3 (1.8-2.8); 217 (19) 23.3
1.8 (1.2-2.7); 13.1
Cardiac allograft 3169 (28) 0.8 (0.7-0.9); 678 (26) vasculopathy ---
0.7 (0.6-0.9); 283 (25) ---
0.8 (0.5-1.2); ---
Ischemic Time ≥ 4 hrs
2280 (21) 1.0 (0.9-1.1); 459 (18) ---
1.2 (0.9-1.5); 247 (22) ---
1.1 (0.7-1.7); ---
Donor age ≥ 29 yrs
5852 (51) 1.3 (1.1-1.4); 1339 (51) 1.2 (0.9-1.5); 516 (45) 11.5 ---
1.4 (1.0-2.1); 16.9
1.8 (1.5-2.3); 163 (6) 2.4