Donor hearts labeled at-risk underused in pediatric vs. adult transplants
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Donor hearts that meet U.S. Public Health Services increased risk criteria are used much more frequently in adults than in children despite similar posttransplant patient survival and an ongoing organ donor shortage, researchers reported.
The high discard rate of pediatric donor hearts presents a “major challenge” for children awaiting heart transplant, with 44% of available pediatric donor hearts being discarded in the U.S., Danielle S. Burstein, MD, a pediatric cardiologist with Children’s Hospital of Philadelphia, and colleagues wrote in JAMA Cardiology. A recent survey conducted as part of the International Society for Heart and Lung Transplantation donor consensus statement demonstrated significant variation in willingness to accept heart offers from U.S. Public Health Services (PHS) risk criteria in children.
“Use of donor grafts with PHS-specific risk criteria are lower compared with standard-risk donors without PHS risk criteria but may represent an opportunity to increase graft use and reduce waitlist times,” Burstein and colleagues wrote. “However, recent data on outcomes in PHS criteria-risk heart transplant recipients are limited, and differences between adult and pediatric use of PHS-risk criteria grafts may exist.”
Greater use among adults
Burstein and colleagues compared the use and outcomes of graft from donors with PHS risk-criteria vs. those with a standard-risk donor in 5,115 children vs. 30,289 adults who received a heart transplant from 2010 to 2021, using the United Network for Organ Sharing database.
“The primary outcome was whether differences in freedom from death after heart transplant occurred based on donor-risk status among pediatric and adult heart transplant recipients,” the researchers wrote. “The secondary objective was to determine whether a significant change in PHS risk criteria has occurred over the past decade among pediatric and adult heart transplant recipients.”
Researchers also assessed outcomes among adults who received a PHS risk criteria graft that was previously declined for pediatric recipients.
Within the cohort, 8.3% of children and 25.2% of adults received a heart from a PHS risk-criteria donor.
Researchers found that PHS criteria were increasingly used during the past decade, with the proportion of recipients transplanted with PHS risk-criteria donors approximately three times greater among adult recipients than children recipients.
Pediatric recipients of a PHS risk-criteria donor had greater pretransplant ventilatory support, whereas adult recipients of a PHS risk-criteria donor had greater pretransplant extracorporeal membrane oxygenation use. Patient survival was similar between pediatric recipients of PHS risk-criteria grafts vs. standard-risk donor criteria grafts and slightly higher among adult recipients of PHS risk-criteria grafts vs. standard-risk donor criteria grafts.
“Among children, Kaplan-Meier curves and log-rank analyses demonstrated no significant difference in patient survival between the two groups over the 10-year study period,” the researchers wrote. “The 1-year, 3-year and 5-year survival among PHS risk criteria vs. standard-risk donor criteria in children was 92% vs. 93%, 86% vs. 88%, and 80% vs. 84%, respectively.”
The 1,778 adult recipients who received a PHS criteria-risk donor that was previously declined for pediatric recipients had similar patient survival recipients compared with standard-risk donor criteria donors (HR = 0.92; 95% CI, 0.81-1.03; P = .18).
“The ongoing organ donor shortage underscores the need for further consideration of PHS risk criteria to decrease waitlist mortality, particularly among children where PHS risk criteria seems to be underused,” the researchers wrote.
Reconsidering risk
In a related editorial, Amanda R. Vest, MBBS, MPH, of the division of cardiology at the CardioVascular Center at Tufts Medical Center, Boston, and Elizabeth D. Blume, MD, of the department of cardiology at Boston Children’s Hospital, wrote that the findings should prompt consideration of whether the risk-benefit equation when using a donor heart designated as at increased risk for viral transmission should be different for pediatric recipients than for adults.
“Despite the extremely small absolute risk of viral transmission, the clinical implications of an unintended viral transmission may be greater for a pediatric heart transplant recipient compared with an adult,” Vest and Blume wrote. “A child with donor-derived HIV, hepatitis B virus or hepatitis C virus may have many more years of post-heart transplant survival during which the virus could become clinically consequential, for example with cirrhosis development, than an adult.”
Vest and Blume noted that HCV therapies are not yet approved for use in the youngest pediatric recipients.
“These concerns could contribute to the differential frequency of PHS risk-criteria donors among pediatric and adult recipients and may merit further investigation,” they wrote. “However, there is clearly also an imperative for children awaiting heart transplant to receive timely and high-quality organs.”
Reference:
Vest AR, et al. JAMA Cardiol. 2022;doi:10.1001/jamacardio.2022.3077.
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