Risk Factor For Post-transplant Mortality Research Articles

Long-term outcomes of heart transplantation in adults with congenital heart disease: The impact of single-ventricle versus biventricular physiology

ObjectiveCongenital heart disease is a risk factor for mortality after orthotopic heart transplantation; however, the impact of preoperative circulation type and primary congenital heart disease diagnosis remains poorly delineated. MethodsWe retrospectively reviewed patients with adult congenital heart disease aged 16 years or more who underwent orthotopic heart transplantation at our institution between 2008 and 2022. Patients were categorized as having single-ventricle or biventricular circulation. The primary end point was 5-year post-transplant survival. ResultsSixty-one patients with adult congenital heart disease (single-ventricle: n = 26 [42.6%], biventricular: n = 35 [57.4%]) underwent orthotopic heart transplantation at 33.7 [interquartile range, 19.1-48.7] years. The most common congenital heart disease diagnosis was hypoplastic left heart syndrome (n = 11, 42.3%) in the single-ventricle group and congenitally corrected transposition of the great arteries (n = 7, 20.0%) in the biventricular group. Twenty-four patients previously underwent Fontan palliation. At transplant, patients in the single-ventricle group were younger (18.5 [interquartile range, 17.6-32.3] years vs 45.0 [interquartile range, 33.0-52.2] years, P < .001) and more likely to have biopsy-proven cirrhosis (46.2% vs 14.3%, P = .01) and protein-losing enteropathy (42.3% vs 2.9%, P < .001). Patients in the single-ventricle group also had longer bypass times (223.4 ± 65.3 minutes vs 187.4 ± 59.5 minutes, P = .03) and longer durations of mechanical ventilatory support (3.5 [interquartile range, 2.0-6.0] days vs 1.0 [interquartile range, 1.0-2.0] days, P < .001). Operative mortality was comparable (11.5% vs 8.6%, P = 1). Median follow-up was 6.0 [interquartile range, 2.4-10.0] years. Five-year survival was worse in the single-ventricle group (66.0% ± 10.0% vs 91.3% ± 4.8%, P = .03), as was freedom from major rejection (58.3% ± 10.2% vs 84.0% ± 6.6%, P = .02). In univariable analysis, hypoplastic left heart syndrome and Fontan circulation were risk factors for post-transplant mortality (hypoplastic left heart syndrome: hazard ratio, 5.0, P < .001; Fontan: hazard ratio, 3.5, P = .03). ConclusionsAdult patients with congenital heart disease undergoing heart transplant with single-ventricle physiology experienced a more complicated post-transplant course, with worse long-term survival and freedom from rejection. Multicenter studies are required to guide orthotopic heart transplantation decision-making in this complex cohort.

Pretransplant Functional Status Predicts Postoperative Morbidity and Mortality after Liver Transplantation in Patients with Cirrhosis.

This study aimed to investigate whether pretransplant frailty can predict postoperative morbidity and mortality after liver transplantation (LT) in patients with cirrhosis. We retrospectively reviewed 242 patients who underwent LT between 2018 and 2020 at a tertiary hospital in Korea. Among them, 189 patients (78.1%) received LT from a living donor. Physical frailty at baseline was assessed by the Short Physical Performance Battery (SPPB), by which patients were categorized into two groups: frail (SPPB <10) and non-frail (SPPB ≥10). Among the whole cohort (age, 55.0±9.2 years; male, 165 [68.2%]), 182 patients were classified as non-frail and 60 patients were classified as frail. Posttransplant survival was shorter in the frail group than the non-frail group (9.3 months vs 11.6 months). Postoperative intensive care unit stay was longer in the frail group than in the non-frail group (median, 6 days vs 4 days), and the 30-day complication rate was higher in the frail group than in the non-frail group (78.3% vs 59.3%). Frailty was an independent risk factor for posttransplant mortality (adjusted hazard ratio, 2.38; 95% confidence interval, 1.02 to 5.57). In subgroup analysis, frail patients showed lower posttransplant survival regardless of history of hepatocellular carcinoma and donor type. Assessment of pretransplant frailty, as measured by SPPB, provides important prognostic information for clinical outcomes in cirrhotic patients undergoing LT.

Modern outcomes of heart-lung transplantation: assessing the impact of the updated US allocation system.

In 2018, the United Network for Organ Sharing modified their heart allocation policy to reduce waitlist mortality and prioritize patients with the greatest acuity. Considering declining rates of combined heart-lung transplantation, this study sought to investigate the impact of the new allocation system on waitlist and post-transplant outcomes of patients listed for combined heart-lung transplantation. Adult patients listed for combined heart-lung transplant between 2012 and 2021 were included. Patients were stratified according to listing era. Competing risk regression was used to assess waitlist outcomes. Cox proportional hazards regression was used to establish risk factors for post-transplant mortality. A total of 511 patients were included, of whom 295 (57.8%) were listed in era 1 and 216 (42.2%) in era 2. Era 2 was associated with increased likelihood of transplant (adjusted standard hazard ratio (aSHR): 1.60 [1.23-2.07]; P < 0.01) and decreased waitlist mortality (aSHR: 0.43 [0.25-0.73]; P < 0.01). Despite longer ischaemic times and increased use of preoperative veno-arterial extracorporeal membrane oxygenation (ECMO) in era 2, early post-transplant survival was equivalent. Predicted heart mass ratio <0.8 (Hazard ratio (HR); 3.24; P = 0.01), ventilator support (HR: 3.83; P < 0.01) and greater ischaemic times (HR: 1.80; P < 0.01) independently predicted the mortality. Procedures at high centre volumes (HR: 0.36; P = 0.04) were associated with decreased mortality. Use of ECMO was not predictive of mortality in the modern era. The allocation policy change has led to improvements in waitlist outcomes in patients listed for heart-lung transplantation. Despite increased ischaemic times and use of ECMO, early post-transplant survival was equivalent.

Extracorporeal Membrane Oxygenation Support for Interstitial Lung Disease in Idiopathic Inflammatory Myopathies: An ELSO Registry Analysis.

Extracorporeal Membrane Oxygenation Support for Interstitial Lung Disease in Idiopathic Inflammatory Myopathies: An ELSO Registry Analysis.

Mitigation of Post-Transplant Mortality Risk by Appropriate Donor-to-Recipient Size Matching Using Predicted Heart Mass

<h3>Purpose</h3> Obesity is a known risk factor for post-transplant mortality. Obesity epidemic in U.S. has led to a higher prevalence of obese patients as potential heart transplant recipients. It is unclear if appropriate size matching of donor-to-recipient using predicted heart mass (PHM) can mitigate this risk among obese recipients. <h3>Methods</h3> We selected all recipients with heart transplants performed between 1995 and 2020 (n=34,812) using the United Network for Organ Sharing database to examine the risk of death in 6 separate categories of recipient's BMI (Table) according to PHM matching. PHM-based appropriate match happened when Donor PHM/Recipient PHM x 100% was within 86% to 114% whereas under- and over-match were defined as <86% and >114%, respectively. Multivariable Cox regression models were created examining long-term risk of death in appropriately matched and over-matched categories compared to under-matched category in the overall cohort and separately within each BMI group. <h3>Results</h3> Upon follow-up (mean 5.29 years), 9,810 patients died. Recipients appropriately matched to donor hearts had an 8% lower risk of death compared to recipients matched with underweight donors by PHM (Table). Compared to those who had under-matched hearts, normal or overweight recipients who received appropriately matched donor hearts based on PHM had a 10-13% lower risk of death post-transplant (Table). In addition, morbidly obese recipients who were appropriately matched with donor hearts also had a 17% lower risk of death post-transplant (borderline statistically significant p=0.06; Table). The risk of death among obese or severely obese recipients did not differ with appropriate PHM matching or over matching compared to under-matching. <h3>Conclusion</h3> Although pretransplant obesity continues to be a risk factor for death post-transplant, appropriate size matching for donor hearts by PHM may lower the risk of death compared to under-matching specifically among normal and overweight recipients.

MILESTONE: More Than 1,200 Children Bridged to Heart Transplantation with Mechanical Circulatory Support.

Pediatric mechanical circulatory support (MCS) has been successfully used to bridge numerous children to transplantation who otherwise would have been unlikely to survive on the waitlist and, in many cases, make them better transplant candidates. The purpose of this study was to analyze what the pediatric heart failure community has achieved over the last 15 years in reaching 1,200 cases of bridging children to heart transplantation. The United Network for Organ Sharing database was used to identify MCS patients ages 0-18 at the time of listing for heart transplantation between 2005 and 2019, divided into three eras: first (2005-2009), second (2010-2014), and third (2015-2019). From 2005 to 2019, 1,289 pediatric cases were identified. More patients were successfully bridged to transplantation with MCS in the third-era (28%) [vs. first-era (16%), second-era (24%), p ≤ 0.004]. The proportion of discharges on ventricular assist device has increased as well from 3% to 22% (p < 0.001). Post-transplant survival was significantly better in the third era (1-year survival: 96%; 3-year survival: 89%) compared to the two previous eras (p = 0.006). On MCS, renal dysfunction, ventilator dependence, inotrope use, and functional status improved from the time of listing to transplantation (p < 0.01). Hepatic dysfunction (p < 0.001), renal dysfunction (p = 0.004), congenital heart disease (p = 0.023), and infant age (p = 0.002) were risk factors for post-transplant mortality. Over the last 15 years, pediatric MCS has become an accepted and increasingly used strategy for bridging children to transplantation. MCS therapy is associated with improved end-organ function at the time of transplantation, perhaps contributing to the increasing post-transplantation survival of patients bridged with MCS.

Systemic Immune-Inflammatory Marker of High Meld Patients Is Associated With Early Mortality After Liver Transplantation

The scarcity of deceased donor livers has led to allocation of grafts to only the most seriously ill patients with a high Model for End-Stage Liver Disease (MELD) score, which has resulted in a high mortality rate after deceased donor liver transplantation (DDLT). The aim of this study is to identify risk factors for posttransplant mortality and thereby reduce futile outcomes in DDLT. Between 2013 and 2019, 57 recipients with MELD scores ≥30 underwent DDLT in our center. We retrieved data and identified the risk factors for 90-day posttransplant mortality. The perioperative clinical and laboratory parameters of patients who did or did not survive for 90 days were subjected to logistic regression analysis. Twelve patients died within 90 days. Results of univariate analysis indicated that the differences in patient survival were determined by the amount of intraoperative platelets transfused, the presence of posttransplant septicemia, and systemic immune-inflammation index (SII) at the time of listing with MELD scores ≥30. Multivariate analysis revealed that an SII ≥870 (× 109/L) and posttransplant septicemia were independent risk factors for 90-day mortality. Twenty-two patients had SIIs ≥870, and 13 of these patients had posttransplant septicemia. Of the 13 patients, 90-day mortality occurred in 10 cases. However, in 35 patients with SIIs <870, 90-day mortality due to posttransplant septicemia was recorded only in 1 patient. In conclusion, a preoperative SII ≥870 in a patient with a high MELD score may be a significant risk factor for early posttransplant mortality. Because posttransplant septicemia in patients with high SIIs can lead to fatality, a more intensive effort to prevent infection is needed for patients undergoing DDLT carrying such risk factors to avoid futile liver transplantation.

Postoperative Outcomes in Infants Undergoing ABO-incompatible Heart Transplantation in the United States

BackgroundABO-incompatible heart transplant is a method to increase the infant donor pool. However data on long-term survival and rejection after ABO-incompatible heart transplant in recent era are limited. MethodsThe United Network for Organ Sharing database was queried for infant heart transplants performed from January 2008 to March 2020. Patient demographics and known risk factors for posttransplant mortality were collected. Statistical analysis using Bayesian additive regression trees was performed to evaluate the association of ABO incompatibility and overall survival, graft survival, acute rejection episodes, and length of stay. ResultsOf 1368 included infants (age < 1 year), 280 (20.47%) were ABO incompatible. ABO incompatibility was not associated with increased all-cause mortality, acute rejection episodes, or length of stay, whereas extracorporeal membrane oxygenation and intubation status of the recipient at the time of transplantation were associated with increased all-cause mortality and graft failure. Idiopathic cardiomyopathy was associated with a decreased likelihood of posttransplant all-cause mortality. One-, 5-, and 10-year survival rates among compatible vs incompatible transplants were estimated to be 90% vs 88%, 82% vs 79%, and 77% vs 73%, respectively. ConclusionsABO-incompatible infant heart transplant does not affect posttransplant survival, incidence of rejection, or postoperative length of stay. Therefore it remains a viable and important strategy to increase the infant donor pool.

Center Experience Affects Liver Transplant Outcomes in Patients with Hilar Cholangiocarcinoma.

Based on favorable outcomes reported by experienced centers, perihilar cholangiocarcinoma (Ph-CCA) has become an accepted indication for liver transplantation (LT). What is less clear is if the reported outcomes have been reproduced nationwide in the US. The aim of this study was to evaluate post-transplant outcomes in patients with Ph-CCA and to determine prognostic factors. Patients who underwent LT with Model for End-stage Liver Disease exception scores for Ph-CCA between 2010 and 2017 were evaluated. Transplant centers were classified into well- and less-experienced groups: Group 1 [well-experienced (≥ 6 LTs), 7 centers]; Group 2 [less-experienced (< 6 LTs), 23 centers]. Post-transplant mortality due to all-cause and recurrence of Ph-CCA were set as endpoints. Post-transplant outcomes were significantly better in Group 1 than in Group 2, with 1-, 3-, and 5-year patient survival rates of 91.8%, 56.9%, and 45.8%, versus 65.6%, 48.8%, and 26.0%, respectively. Group 2 showed a significantly higher risk of 1-, 3-, and 5-year all-cause mortality and 1-year mortality associated with Ph-CCA recurrence. Center experience was an independent risk factor for post-transplant mortality. In intention-to-treat analysis, a positive prognostic effect of LT was significant and LT decreased the mortality risk by 86% in the well-experienced group [hazard ratio (HR) 0.14, p < 0.001], whereas this effect was not observed in the less-experienced group (HR 1.35, p = 0.47). Risk of recurrence of malignancy and mortality was significantly higher in the less-experienced center group. Center effects on post-transplant outcomes in patients with Ph-CCA should be recognized, and the introduction of center approval for LT for Ph-CCA may be justified to achieve comparable outcomes between centers.

Heart Transplantation - Part II: Aspects of Procedure and Medical Management

Ischemic time, defined as the period from donor procurement to surgical implantation and restoration of intrinsic allograft function, is an independent risk factor for post-transplant mortality. In general, the ischemic time should be less than 4 hours. Most programs will accept donor hearts from within their own UNOS region or within a radius of 500 to 1000 miles to minimize ischemic time. Given the prevalent use of ventricular assist devices (VAD) as bridge to transplant and the increased time required to explant both the native heart and VAD hardware, patients must live within 2-3 hours (by car or air) of the transplant center. Coordinating the donor harvest and recipient preparation requires close collaboration between multiple surgeons, surgical teams and coordinators. This review contains 11 figures, 7 tables, and 52 references. Key words: heart transplant, immunosuppression, allograft rejection, infection, hypertension, hyperlipidemia, diabetes, malignancy, cardiac allograft vasculopathy, survival

Heart Transplantation - Part II: Aspects of Procedure and Medical Management

Ischemic time, defined as the period from donor procurement to surgical implantation and restoration of intrinsic allograft function, is an independent risk factor for post-transplant mortality. In general, the ischemic time should be less than 4 hours. Most programs will accept donor hearts from within their own UNOS region or within a radius of 500 to 1000 miles to minimize ischemic time. Given the prevalent use of ventricular assist devices (VAD) as bridge to transplant and the increased time required to explant both the native heart and VAD hardware, patients must live within 2-3 hours (by car or air) of the transplant center. Coordinating the donor harvest and recipient preparation requires close collaboration between multiple surgeons, surgical teams and coordinators. This review contains 11 figures, 7 tables, and 52 references. Key words: heart transplant, immunosuppression, allograft rejection, infection, hypertension, hyperlipidemia, diabetes, malignancy, cardiac allograft vasculopathy, survival

Pediatric heart-lung transplantation: A contemporary analysis of outcomes.

Pediatric heart-lung transplantation (HLT) is rare, and no report has analyzed patient outcomes since time of listing. We analyzed pediatric HLTs to understand risk factors for waitlist and post-HLT mortality. All pediatric (<18year old) HLT candidates were identified within the UNOS database (n=573) and grouped by age, era, and by diagnosis. Logistical regression and Cox proportional hazard modeling identified risk factors for 6-month WL and overall post-transplant mortality. 209/573 (37%) HLT candidates were transplanted, 7% recovered, 42% died waiting, and 15% were removed for another/unknown reason. Diagnoses were primary pulmonary hypertension(n=130), congenital heart disease(CHD) without Eisenmenger's syndrome (ES) (n=65), CHD with ES (n=73), and other (n=305). Patients with a diagnosis other than CHD with ES (OR: 7.55, P=.001), on IV inotropic support (OR: 2.79, P<.001), and infants (OR: 2.20, P=.004) were associated with waitlist mortality. There has been a 56% reduction in HLTs across eras (Era 1:10.8/yr vs Era 2:4.7/yr). Risk factors for post-transplant mortality were ECMO (HR: 4.1, P=.016), and being infant (HR: 2.2, P=.04) or 1-11years old (HR: 1.78, P=.015). ECMO patients have an 87% 2-year mortality rate with a median post-transplant survival of 64days. Overall, post-transplant survival was unchanged (log-rank P=.067) between eras. Excluding ECMO patients, in the recent era 29 non-infant patients with primary pulmonary hypertension had 93% 1-year survival and 67% 5-year survival. Nearly 600 pediatric patients have been listed for HLT in UNOS, although numbers are decreasing in the current era. HLT for a patient on ECMO appears to be an ineffective strategy; however, in well-selected cohorts, HLT can provide considerable post-transplant survival.

45. Liver Transplant in Acute Liver Failure – Looking Back

Background and Aims: Acute liver failure (ALF) although relatively uncommon, tends to affect young individuals and is the leading cause for emergency liver transplantation (LT) the world over. We carried out this study to look at the disease spectrum and to identify the possible predictors of poor outcomes after LT. Methods: We analyzed retrospectively data of 70 cases (median age 24yrs, M:F 1:2) of LT performed for ALF at our institution from April 2007 to April 2017 (out of total of 560 (12%)). Results: The etiology was identified in 53 cases [HAV (n = 15), HBV(n = 5), HEV (n = 1), ATT induced n= (6), Acute Wilson's (n = 3), Autoimmune (n = 5) and Yellow Phosphorous (YP), rodenticide poisoning (n = 16)] and remaining 17 cases were of indeterminate etiology. Etiology differed between adults (>12 years, n = 61) and children (n = 9). Whilst the most common etiology in adults were indeterminate followed by HAV and YP poisoning, equal incidence of indeterminate, acute Wilson's and ATT induced liver failure were seen among children. Upon meeting King's College criteria, 69 had live donor LT (55 Right lobe grafts, 3 left lobe grafts, 4 lefts lateral segment grafts and 5 cases were APOLT) and 1 deceased donor LT. Post-operative morbidity seen were bile leak (23%), sepsis (17.3%), ACR (14.4%), AKI (13%), graft dysfunction (5%), HAT (2.8%) and PVT (1.4%). Overall mortality was 36% (50% in the pediatric and 34% in adults), vast majority of which (92%) occurred within 30 days of transplant. The major cause of mortality was sepsis with MODS. Risk factors for mortality on univariate analysis included donor age >35yrs, pre-transplant renal dysfunction, Grade 4 encephalopathy and hepatitis A, YP poisoning and seronegative etiology. However, on multivariate analysis, only grade IV HE was a significant risk factor for post-transplant mortality. Over a median follow up of 6.17yrs, 60.2% of perioperative survivors are leading a normal life. Most of these mortalities (81.2%) occurred in the immediate post-operative period (within 30 days). Conclusions: LT for ALF carry high mortality (36%) in those presenting with Grade 4 encephalopathy. Nevertheless, if they survive the perioperative period, long term survival is excellent. The authors have none to declare.

Cardiac Transplantation in Fontan Patients Has Equally Excellent Results as Biventricular Congenital Heart Disease Patients

Purpose Failing Fontan circulation patients are one of the fastest growing cohorts with heart failure presenting to congenital programs. We sought to describe their outcomes by combining two databases. Methods The UNOS database and the Pediatric Hospital Information System (PHIS) database identified Fontan patients undergoing transplantation at a PHIS hospital from 2006-2018. Kaplan-Meier analysis and multivariate logistic regression to identify risk factors for mortality were performed. Results 130 patients underwent cardiac transplantation after the Fontan operation. Age ranged from 1-35 year old (6 [4-9]) with 1-year survival of 85%. Only 5/130 were > 17 years old. Overall survival(Figure 1A) was similar to biventricular congenital heart transplant recipients(log-rank p-value=0.623). Patients transplanted within 1 year of Fontan operation (n=22) have worse survival than those transplanted >1 year after Fontan (n=108) (log-rank p-value=0.021)(Figure 1B). On multivariate analysis, only GFR Conclusion Pediatric patients undergoing cardiac transplantation with a Fontan circulation have surprisingly good transplantation survival, equivalent to biventricular congenital heart disease patients. However, if transplantation is within a year from the Fontan operation, outcomes are significantly worse. As noted in many other patient cohorts, end-organ (i.e., renal) dysfunction is a significant risk factor for post-transplant mortality in Fontan patients as well.

Benefits of kidney transplantation for a national cohort of patients aged 70 years and older starting renal replacement therapy.

Our objectives were to evaluate kidney transplantation survival benefit in people aged ≥70 who were receiving renal replacement therapy (RRT) and to identify their risk factors for posttransplant mortality. This study included all patients in the national French Renal Epidemiology and Information Network registry who started RRT between 2002 and 2013 at age ≥70. Mortality risk was compared between patients with transplants; on the waiting list; and on dialysis matched for age, gender, comorbidities, and time on dialysis. Of the 41 716 elderly patients starting RRT, 1219 (2.9%) were on the waiting list and 877 (2.1%) underwent transplantation during the follow-up. Until month 3, transplant patients had a risk of death triple that of the wait-listed group. Although the risk was halved at month 9, the perioperative risk was still not offset by month 36. Compared with matched dialysis patients (n=2183), transplant patients were not at significantly increased perioperative risk and had a lower mortality risk starting at month 3. Risk factors for posttransplant mortality were diabetes, cardiovascular comorbidities, and dialysis duration >2years. Among older dialysis patients, 20% had neither cardiovascular comorbidity nor diabetes. Systematic early assessment of the eligibility of elderly patients for kidney transplantation is recommended to expand registration to patients with poor survival on dialysis and no cardiovascular comorbidity.

Invited Commentary

Models of posttransplant mortality are common. They are used frequently: for prognostic information for providers and families, benchmarking of individual center results, and public reporting of those results. Each model or score has strengths and weaknesses that are predominantly determined by the data source and the methodology. The score presented in this issue of The Annals of Thoracic Surgery by O’Connor and colleagues [1O'Connor M.J. Glatz A.C. Rossano J.W. et al.Cumulative effect of preoperative risk factors on mortality after pediatric heart transplantation.Ann Thorac Surg. 2018; 106: 561-567Abstract Full Text Full Text PDF Scopus (6) Google Scholar] is paradigmatic of both the potential and the limitations of a single-center retrospective study. By identifying a series of risk factors unavailable to larger datasets, it demonstrates how the use of large dataset models of posttransplant mortality has the potential to dissuade centers from transplanting high-risk pediatric patients. Most prior models and scores predicting posttransplant mortality in children have been developed using large datasets, commonly either the Pediatric Heart Transplant Study or the Organ Procurement and Transplantation Network/United Network for Organ Sharing data [2Almond C.S. Gauvreau K. Canter C.E. Rajagopal S.K. Piercey G.E. Singh T.P. A risk-prediction model for in-hospital mortality after heart transplantation in US children.Am J Transplant. 2012; 12: 1240-1248Crossref PubMed Scopus (66) Google Scholar, 3Schumacher K.R. Almond C. Singh T.P. et al.Predicting graft loss by 1 year in pediatric heart transplantation candidates: an analysis of the Pediatric Heart Transplant Study database.Circulation. 2015; 131: 890-898Crossref PubMed Scopus (49) Google Scholar, 4Davies R.R. Russo M.J. Mital S. et al.Predicting survival among high-risk pediatric cardiac transplant recipients: an analysis of the United Network for Organ Sharing database.J Thorac Cardiovasc Surg. 2008; 135 (155.e1–2): 147-155Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar]. Organ Procurement and Transplantation Network/United Network for Organ Sharing data underlie the risk prediction models utilized by the Scientific Registry of Transplant Recipients to develop the publicly available program-specific reports (PSRs) evaluating individual center performance. These large-dataset models have the advantage of large sample sizes from multiple centers, but often lack relevant clinical information. Using a single-center retrospective analysis, O’Connor and colleagues [1O'Connor M.J. Glatz A.C. Rossano J.W. et al.Cumulative effect of preoperative risk factors on mortality after pediatric heart transplantation.Ann Thorac Surg. 2018; 106: 561-567Abstract Full Text Full Text PDF Scopus (6) Google Scholar] have identified several risk factors for posttransplant mortality that are not available in larger datasets, including single ventricle congenital heart disease, pulmonary vein stenosis, a history of greater than or equal to 4 prior sternotomies, and referral from another cardiac surgical center. Unfortunately, the methodology limits the practical applicability of the resultant score: the score is unvalidated, it suffers from the biases of the center (eg, there was only a single patient with renal insufficiency), and the increase in mortality occurred predominantly among patients with 4 or 5 risk factors (78% versus 7% to 14% in those with 0 to 3 risk factors). As the authors note, further study and validation of the score is required. However, the inclusion of these granular and specific clinical risk factors does point to the limitations of the current system of public reporting and program monitoring. Accurate models require accounting for all relevant risk models. The Scientific Registry of Transplant Recipients models used in generating PSRs fail to account for many factors that this study and others suggest are associated with high post-transplant mortality: pulmonary vein stenosis, specific congenital diagnoses, a high number of prior sternotomies, and other anatomic abnormalities. When PSRs and similar modeling are used for public reporting, regulatory oversight, and insurance contracting, centers become incentivized to avoid transplanting candidates whose risk factors are not accounted for in the modeling. Thus, while the specific score developed by O’Connor and colleagues [1O'Connor M.J. Glatz A.C. Rossano J.W. et al.Cumulative effect of preoperative risk factors on mortality after pediatric heart transplantation.Ann Thorac Surg. 2018; 106: 561-567Abstract Full Text Full Text PDF Scopus (6) Google Scholar] may have limited wider applicability, the identification of these granular risk factors and their inclusion in modeling is critical both to maximizing individual outcomes and to maintaining access to transplantation among high-risk patients. Cumulative Effect of Preoperative Risk Factors on Mortality After Pediatric Heart TransplantationThe Annals of Thoracic SurgeryVol. 106Issue 2PreviewRisk assessment in heart transplantation is critical for candidate selection, but current models inadequately assess individual risk of postoperative mortality. We sought to identify risk factors and develop a scoring system to predict mortality after heart transplantation in children. Full-Text PDF

Poor Out-patient Clinic Appointment Compliance is a Predictor of Post-Heart Transplant Mortality in Children

Patient behavioral characteristics such as medication non-adherence are associated with increased risk for rejection and poor post-transplant outcomes. It remains unknown if poor compliance with scheduled outpatient clinic appointments is a risk factor for post-transplant mortality in pediatric heart transplant recipients.

FRI-500 - Acute rise in delta model for end-stage liver disease as a prognostic risk factor for post-transplant mortality: an analysis of a national registry

FRI-500 - Acute rise in delta model for end-stage liver disease as a prognostic risk factor for post-transplant mortality: an analysis of a national registry

Survival Outcomes Following Pediatric Liver Transplantation (Pedi-SOFT) Score: A Novel Predictive Index

A prognostic index to predict survival after liver transplantation could address several clinical needs. Here, we devised a scoring system that predicts recipient survival after pediatric liver transplantation. We used univariate and multivariate analysis on 4565 pediatric liver transplant recipients data and identified independent recipient and donor risk factors for posttransplant mortality at 3 months. Multiple imputation was used to account for missing variables. We identified five factors as significant predictors of recipient mortality after pediatric liver transplantation: two previous transplants (OR 5.88, CI 2.88-12.01), one previous transplant (OR 2.54, CI 1.75-3.68), life support (OR 3.68, CI 2.39-5.67), renal insufficiency (OR 2.66, CI 1.84-3.84), recipient weight under 6 kilograms (OR 1.67, CI 1.12-2.36) and cadaveric technical variant allograft (OR 1.38, CI 1.03-1.83). The Survival Outcomes Following Pediatric Liver Transplant score assigns weighted risk points to each of these factors in a scoring system to predict 3-month recipient survival after liver transplantation with a C-statistic of 0.74. Although quite accurate when compared with other posttransplant survival models, we would not advocate individual clinical application of the index.

The Munich‐LTX‐Score: predictor for survival after lung transplantation

The purpose of this study was to create a prognostic score calculated one yr after LTX based on post-transplant factors inclusive of donor and recipient characteristics that could be used to predict long-term survival in patients after lung transplantation (LTX). Uni- and multivariate analysis in 206 consecutive LTX patients identified independent risk factors for post-transplant mortality and onset of bronchiolitis obliterans syndrome. Munich-LTX-Score is devised by summing up each identified risk factor. Multivariate analyses revealed acute rejection, lymphocytic bronchiolitis, donor age ≥ 55 yr, and HLA-A ≥ 2-/DR ≥ 2 mismatch and single LTX to be independent negative predictors for long-term survival (p < 0.05). Munich-LTX-Score identified three discrete groups: low-, moderate-, and high risk. The actuarial five-yr survival after score calculation one yr after LTX of the entire cohort was 58%, compared with 91% in low-, 54% in moderate-, and 0% in the high-risk group (p < 0.001). Within our cohort of patients calculation of the Munich-LTX-Score, consisting of donor-, recipient-, and post-transplant characteristics, one yr after LTX allowed to predict long-term survival of lung transplant recipients. After prospective validation, this score could identify patients who may benefit from intensified surveillance after LTX.