Abstract
BackgroundEthnicity may affect graft longevity and recipient mortality after heart transplantation (HTx). We hypothesized that differences in ethnic origin between Arabs and Jews undergoing HTx in Israel may contribute to differences in long-term outcomes.MethodsThe study population comprised all 254 patients who underwent HTx between 1991 and 2017 in a tertiary medical center located in the center of Israel. Patients were categorized as either Jews (226 patients, 89%) or Arabs (28 patients, 11%). The primary end point was cardiac allograft vasculopathy (CAV), secondary end points were cardiovascular (CV) mortality and the combined end point of CAV/CV mortality.ResultsIn comparison with Jews, Arab patients were significantly younger (ave. age 42 vs. 50) and had shorter in-hospital stay (45 vs. 80 days). However, Kaplan-Meier survival analysis showed that at 10 years of follow-up CAV rates were significantly higher among Arabs (58%) compared with Jews (23%; log-rank P = 0.01) for the overall difference during follow-up. Similar results were shown for the separate end point of CV mortality and the combined end point of CAV/CV mortality. Multivariate analysis, which controlled for age, gender, statin treatment, and other potential confounders, showed that Arab recipient ethnic origin was associated with a significant > 2.5-fold (p = 0.01) increase in the risk for CAV; a > 4-fold increase in the risk for CV mortality (p = 0.001); and approximately 4-fold increase in the risk for the combined end point (p = 0.001). These findings were validated by propensity score analysis.ConclusionsOur data suggest that Arab ethnic origin is associated with a significantly increased risk for CAV and mortality following HTx. Suggested explanations contributing to ethnic disparities in Israel include socioeconomic, environmental and genetic factors. Further studies are required to evaluate whether more aggressive risk factor management in the Israeli Arab population following HTx would reduce CAV and CV mortality in this high-risk population. Increased awareness and early intervention of the Israeli healthcare system and cooperation with the Arab community is of paramount importance.
Highlights
Ethnicity may affect graft longevity and recipient mortality after heart transplantation (HTx)
Definitions and endpoints Ethnic groups Ethnic groups were categorized according to the Statistical Abstract of Israel [9]: Jews; Arab Moslems, Arab Christians, and Druze; others: non-Arab Christians, members of other religions, and those not classified by religion in the Population Registry
We have shown that: 1) Arab recipient origin is associated with significant and independent increased risk for cardiac allograft vasculopathy (CAV); 2) Cardiovascular mortality and the combined end point of CAV/CV mortality are significantly higher in the Arab recipients; and 3) There were no significant differences in rejection rates between the two groups
Summary
Ethnicity may affect graft longevity and recipient mortality after heart transplantation (HTx). Since the first HTx in 1967 [1], survival and outcomes have improved considerably. Multiple factors have been identified that contribute to improved outcomes [2]. Several studies have reported ethnicity as a predictor of graft longevity and recipient mortality in HTx [3,4,5]. Available evidence suggests that the survival of African American patients after HTx is lower compared with other ethnic groups [6]. Long-term survival after HTx has improved across eras in Caucasian recipients but not in their African American or Hispanic-Latino counterparts, suggesting that racial/ethnic disparities in long-term survival after HTx have worsened over time [4]. Contributing factors are socioeconomic, immunologic, and pharmacogenetic [7]
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