Pre- and early postoperative risk factors for death after cardiac transplantation: A single center analysis

A Systematic Review for Variables to Be Collected in a Transplant Database for Improving Risk Prediction

BACKGROUND

This systematic review was commissioned to identify new variables associated with transplant outcomes that are not currently collected by the Organ Procurement and Transplantation Network (OPTN).

METHODS

We identified 81 unique studies including 1 193 410 patients with median follow-up of 36 months posttransplant, reporting 108 unique risk factors.

RESULTS

Most risk factors (104) were recipient related; few (4) were donor related. Most risk factors were judged to be practical and feasible to routinely collect. Relative association measures were small to moderate for most risk factors (ranging between 1.0 and 2.0). The strongest relative association measure for a heart transplant outcome with a risk factor was 8.6 (recipient with the previous Fontan operation), for a kidney transplant 2.8 (sickle cell nephropathy as primary cause of end-stage renal disease), for a liver transplant 14.3 (recipient serum ferritin >500 µg/L), and for a lung transplant 6.3 (Burkholderia cepacia complex infection for 1 y or less). OPTN may consider some of these 108 variables for future collection to enhance transplant research and clinical care.

CONCLUSIONS

Evidence-based approaches can be used to determine variables collected in databases and registries. Several candidate variables have been identified for OPTN.

Older patients (age 65+) report better quality of life, psychological adjustment, and adherence than younger patients 5 years after heart transplant: A multisite study

BACKGROUND

Research examining age differences after heart transplant (HT) has focused primarily on morbidity and mortality outcomes, with little emphasis on potential age differences in quality of life and psychosocial outcomes. The objective of the study was to determine whether older patients have more positive adjustment and quality of life several years after HT compared with younger patients.

METHODS

The study recruited 555 patients who were at least 5 years post-HT from 4 United States medical centers. The sample included 165 older patients (≥ 60 years at HT), 300 middle-aged patients (between 45 and 59 years), and 90 younger patients (< 45 years). Of these, 78% were men, 88% were white, and most were well educated (14.04 mean years of education). Outcome measures examined quality of life, social support, mood, coping strategies, stress, health functioning, and adherence. Hypotheses regarding outcomes were derived from incidental findings from the original study.

RESULTS

Statistics included multivariate analyses of covariance, followed by univariate analyses of covariance that controlled for differences in sex, race, years of education, and marital status. Older HT patients were more satisfied with quality of life (p < 0.001) and social support (p = 0.003), had less HT-related stress (p < 0.001), negative affect (p < 0.001), depression (p < 0.001), better overall functioning (p = 0.035), less use of negative coping strategies (p = 0.006), less difficulty with adherence (p < 0.001), and better actual adherence (p < 0.001) than younger and middle-aged HT patients.

CONCLUSIONS

Older patients in this large sample had better quality of life, psychosocial adjustment, and adherence after HT than middle-aged and younger patients. If replicated, this age advantage should at least be considered when assessing age as a criterion for HT clinical decision making and organ allocation policy.

Combined heart-kidney transplantation: a review of recipient selection and patient outcomes

Elevated serum creatinine is a common finding among patients awaiting heart transplantation because of reduced renal perfusion in the setting of severe heart failure as well as overlapping risk factors for chronic kidney disease and heart disease. Patients with significant renal dysfunction preoperatively have worse outcomes with heart transplantation alone compared with those with normal renal function or those with renal dysfunction who undergo combined heart-kidney transplantation. Optimizing organ distribution and patient outcomes after cardiac transplantation requires appropriate recipient selection, including deciding which patients will benefit from combined heart-kidney transplantation. This review focuses on the evaluation of patients with chronic kidney disease awaiting heart transplantation and the outcomes of combined heart-kidney transplantation.

Predictors of rehospitalization time during the first year after heart transplant

BACKGROUND

Patient problems after heart transplant (HT) can lead to rehospitalization.

OBJECTIVE

To examine rehospitalization patterns and identify predictors of the number of days rehospitalized at the transplant site during the first year after HT surgery.

METHODS

Hierarchical regression identified predictors of greater rehospitalization time from chart data collected from two transplant sites during the first posttransplant year on 269 adult HT recipients. Variables (total = 32) were entered in six steps: clinical site, demographics, perioperative variables, cardiac function, immunosuppressant dosages, and post-HT complications.

RESULTS

The number of days rehospitalized at the transplant site during the first year after HT ranged from 0 to 142 (mean = 25, median = 16); 64% were rehospitalized; 37% were rehospitalized more than once. Main reasons were rejections, infections, cardiovascular problems, and gastrointestinal (GI) problems. The regression model explained 48.7% of the variance in rehospitalization time, with post-HT complications explaining the most variance. Ten predictors were significant: intravenously treated infections, treated acute rejections, shorter stay for HT surgery, GI complications, higher prednisone dose, female gender, coma, sex mismatch between donor and recipient, renal complications, and clinical site.

CONCLUSION

Sixty-four percent of the patients were rehospitalized at the transplant site during the first year after HT surgery (with a median of 16 hospital days); 37% were rehospitalized more than once. Significant predictors of the amount of time rehospitalized pertained to five types of complications (rejections, infections, GI, renal, coma), shorter HT surgical stay, female gender, higher prednisone dose, sex-mismatched donor, and clinical site. The study identifies who uses the most hospital resources during the first year after HT.

[Major complications in the recovery unit following heart transplant: incidence and risk factors]

OBJECTIVE

To assess the incidence of major complications in the postoperative recovery unit and to analyze the associated recipient, donor, and surgical risk factors.

MATERIAL AND METHODS

We studied a series of consecutive orthotopic heart transplants carried out in our hospital from 2001 through 2007. Patients who experienced major complications during their stay in the recovery ward were compared with those who did not. Exitus, primary graft failure, severe infection, and need for hemodialysis were considered major complications.

RESULTS

One hundred fifty-two patients were enrolled. The mean stay in the recovery unit was 3 days (range, 225-5 days). Thirty-nine patients (26%) developed major complications in the recovery unit and 113 did not. The complications were primary graft failure (20%), infection (12%), and acute renal failure (53%). Patients with and without major complications were significantly different with respect to mean (SD) age (55 [6] vs 50 [12] years, respectively; P=.001), presence of diabetes mellitus (41% vs 14%, P=.0001), classification in New York Heart Association functional class IV/IV status (54% vs 34%, P=.05), emergency transplantation (46% vs 18%, P=.001), mean cardiopulmonary bypass time (145 [66] vs 119 [35], P=.03), pretransplant use of an intra-aortic balloon pump (15% vs 6%, P=.04). Multivariate analysis demonstrated an association between major complications and emergency transplantation (OR, 5.67; P=.001), recipient age over 55 years (OR, 2.99; P=.027), and diabetes mellitus (OR, 2.86; P=.048).

CONCLUSIONS

The incidence of major complications in our postoperative recovery unit was 26%. The most common complications were primary graft failure, infection, and acute renal failure. Emergency transplantation, older age, and a diagnosis of diabetes mellitus in the recipient were predictors of complication.

Differential White Cell Count Relationships With Human Cardiac Allograft Rejection

The focus of research in allograft rejection has targeted the lymphocyte, with little attention given to the neutrophil. Recent data indicate that a perioperative neutrophil influx into the cardiac allograft influences early rejection. Factors that influence neutrophil transendothelial migration might offer predictive markers of rejection. We explored the relationship between the number of circulating neutrophils in heart transplant recipients and the development of rejection. Differential white cell counts were obtained prior to transplantation and concurrently with subsequent endomyocardial rejection surveillance biopsies for 53 heart transplant recipients undergoing 410 biopsies. Preoperative differential white cell counts had no relationship with rejection. In the first 3 months after transplantation, no relationship was found between contemporary differential white cell counts and rejection. However, more than 3 months following surgery, rejection grade positively correlated on univariate analysis with neutrophil counts and the usage of cyclosporine, prednisolone, and mycophenolate. There was no relationship with eosinophils or lymphocytes. Multivariate analysis demonstrated a persistent relationship among rejection severity, neutrophil count, and prednisolone usage. A significant positive association of higher steroid usage with higher rejection grades must reflect efforts to treat patients with rejection. The significant association of higher neutrophil counts with higher rejection severity might suggest a pathological contribution to rejection. However, given the neutrophilia response to acute steroid administration, we must conclude that the neutrophil association was related to steroid administration. The absence of a relationship between white cell counts and rejection suggests that functional rather than antiproliferative strategies may offer the greatest therapeutic potential.

Risk Factors Affecting Survival in Heart Transplant Patients

BACKGROUND

Certain cardiovascular risk factors have been linked to morbidity and mortality in heart transplant (HT) patients. The sum of various risk factors may have a large cumulative negative effect, leading to a substantially worse prognosis and the need to consider whether HT is contraindicated. The objective of this study was to determine whether the risk factors usually available prior to HT result in an excess mortality in our setting that contraindicates transplantation.

MATERIALS AND METHODS

Consecutive patients who underwent heart transplantation from November 1987 to January 2004 were included. Heart-lung transplants, retransplants, and pediatric transplants were excluded. Of the 384 patients, 89% were men. Mean age was 52 years (range, 12 to 67). Underlying disease included ischemic heart disease (52%), idiopathic dilated cardiomyopathy (36%), valvular disease (8%), and other (4%). Variables considered risk factors were obesity (BMI >25), dyslipidemia, hypertension, prior thoracic surgery, diabetes, and history of ischemic heart disease. Survival curves by number of risk factors using Kaplan-Meier and log-rank for comparison of curves.

RESULTS

Overall patient survival at 1, 5, 10, and 13 years was 76%, 68%, 54%, and 47%, respectively. Survival at 10 years, if fewer than two risk factors were present, was 69%; 59% if two or three factors were present; and 37% if more than three associated risk factors were present (P = .04).

CONCLUSIONS

The presence of certain risk factors in patients undergoing HT resulted in lower survival rates. The combination of various risk factors clearly worsened outcomes. However, we do not believe this should be an absolute contraindication for transplantation.

[Analysis of factors that can influence the appearance of acute heart transplant failure]

INTRODUCTION AND OBJECTIVE

Acute graft failure (AGF) is defined as significant failure of myocardial function in a newly implanted heart. The aim of the present study was to investigate a series of factors related to heart transplantation (HT) in relation to AGF.

MATERIAL AND METHOD

In a study of 287 consecutive HTs performed over a 14-year period, AGF was defined when: a) the surgeon observed ventricular dysfunction before closing the sternotomy; b) various inotropic drugs were required at high doses in the first days after surgery, or c) ventricular dysfunction was identified by routine echocardiography in the immediate postoperative period. Statistical analysis comprised a descriptive and univariate comparative study, followed by multivariate analysis based on application of a logistical regression model.

RESULTS

The incidence of AGF was 22%. Predictors of AGF were female donor status (OR = 2.2; 95% CI, 1.2-4.4; p = 0.02), a disproportion of more than 20% in donor-recipient body weight (OR = 2.2; 95% CI, 1.1-4.3; p = 0.02), and background ischemic heart disease (OR = 2.5; 95% CI, 5.5-1.1; p = 0.03) or valve pathology (OR = 5.0; 95% CI, 7.0-1.5; p = 0.01).

CONCLUSIONS

AGF is a frequent pathology, which was present in 22% of our heart transplantation patients. Among the modifiable factors related to AGF was a clear disproportion in body weight and the size of grafts from female donors. Unmodifiable factors related to AGF were ischemic heart disease and valvular heart disease as a cause of heart transplantation.

Recent trends in early outcome of adult patients after heart transplantation: a single-institution review of 251 transplants using standard donor organs

Older age, prior transplantation, pulmonary hypertension, and mechanical support are commonly seen in current potential cardiac transplant recipients. Transplants in 436 consecutive adult patients from 1994 to 1999 were reviewed. There were 251 using standard donors in 243 patients (age range 18-69 years). To emphasize recipient risk, 185 patients who received a nonstandard donor were excluded from analysis. The indications for transplant were ischemic heart disease (n = 123, 47%), dilated cardiomyopathy (n = 82, 32%), and others (n=56, 21%). One hundred and forty-nine (57%) recipients were listed as status I; 5 and 6% were supported with an intra-aortic balloon and an assist device, respectively. The 30-d survival and survival to discharge were 94.7 and 92.7%, respectively; 1-year survival was 89.1%. Causes of early death were graft failure (n = 6), infection (n = 4), stroke (n = 4), multiorgan failure (n = 3) and rejection (n = 2). Predictors were balloon pump use alone (OR= 11.4, p =0.002), pulmonary vascular resistance > 4 Wood units (OR = 5.7, p = 0.007), pretransplant creatinine > 2.0 mg/dL (OR = 6.9, p = 0.004) and female donor (OR = 8.3, p = 0.002). Recipient age and previous surgery did not affect short-term survival. Heart transplantation in the current era consistently offers excellent early and 1-year survival for well-selected recipients receiving standard donors. Early mortality tends to reflect graft failure while hospital mortality may be more indicative of recipient selection.

Long-term outcomes after cardiac transplantation: an experience based on different eras of immunosuppressive therapy

BACKGROUND

Constantly changing practices in heart transplantation have improved posttransplant survival in patients with end-stage heart disease. The objective of this study was to evaluate long-term outcomes in different eras of immunosuppressive therapy after cardiac transplantation at a single center during a two-decade period.

METHODS

A retrospective review of 1,086 consecutive cardiac allograft recipients who underwent transplantation between 1977 to 1999 was performed. Patients were divided into four eras based on type of immunosuppressive therapy: era 1 = steroids, azathioprine (n = 26, February 1977 to March 1983), era II = steroids, cyclosporine (n = 43, April 1983 to April 1985), era III = cyclosporine, steroids, azathioprine (n = 752, April 1985 to December 1995), era IV = cyclosporine, steroids, mycophenolate mofetil (n = 315, January 1996 to October 1999).

RESULTS

The actuarial survival of the entire cohort of 1,086 patients undergoing cardiac transplantation was 79%, 66%, and 49% at 1, 5, and 10 years, respectively. There were significant trends in recipient age and gender distribution among the four eras with increasing proportion of older age (> 60 years) and female recipients in eras III and IV (p = 0.001 and 0.02). Early mortality and long-term survival improved significantly over all eras (p < 0.001). Rejection as a cause of death decreased over time (era I, 24%; era II, 21%; era III, 15%; era IV, 9%; p = 0.02), whereas the contribution of transplant coronary artery disease as a cause of death remained unchanged.

CONCLUSIONS

Cardiac transplantation provides satisfactory long-term survival for patients with end-stage heart failure. The improving outcomes in survival correlate with improved immunosuppressive therapy in each era. Although the reasons for improvement in survival over time are multifactorial, we believe that changes in immunosuppressive therapy have had a major impact on survival as evidenced by the decreasing number of deaths due to rejection.