The Benefit of Donor-Recipient Matching for Patients Undergoing Heart Transplantation

Background: Heart transplant volumes are not matching growing demand, and donor heart use may be decreasing.

Objectives: This study sought to investigate the benefit of heart transplantation compared with waiting while accounting for the estimated risk of a given donor-recipient match.

Methods: This study identified 28,548 heart transplant candidates in the Organ Procurement and Transplant Network between July 2006 and December 2015. Donor-recipient match quality was estimated from the donor risk index. A time-dependent covariate Cox model was used to determine the effect of donor-recipient match quality on the likelihood of a composite outcome while waiting for a transplant or after transplantation. The composite outcome was death or delisting as too ill.

Results: Donor and recipient risk estimates were inversely related to the candidate urgency. Net benefit from heart transplantation was evident across all estimates of donor-recipient status 1A and 1B candidates: status 1A (lowest-risk quartile hazard ratio [HR]: 0.37; 95% confidence interval [CI]: 0.31 to 0.43; highest-risk quartile HR: 0.52; 95% CI: 0.44 to 0.61) and status 1B candidates (lowest-risk quartile HR: 0.41; 95% CI: 0.36 to 0.47; highest-risk quartile HR: 0.66; 95% CI: 0.58 to 0.74). Status 2 candidates showed a benefit from heart transplantation; however, survival benefit was delayed. For the highest-risk donor-recipient matches, a net benefit of transplantation occurred immediately for status 1A candidates, after 12 months for status 1B candidates, and after 3 years for status 2 candidates.

Conclusions: This study demonstrated a survival benefit of heart transplantation across all ranges of estimated donor-recipient match risk for status 1A and status 1B candidates. Donor heart acceptance should be the favored strategy for these candidates. The benefit of transplantation for status 2 candidates was less apparent and dependent on estimated donor-recipient match risk, suggesting that a measure of donor-recipient match quality may be useful when considering the immediate benefit of heart transplantation for status 2 candidates in stable condition.