Persistent racial disparities in survival after heart transplantation

Abstract

Background: Racial and ethnic disparities are well documented in many areas of health care, but have not been comprehensively evaluated among recipients of heart transplants.

Methods and results: We performed a retrospective cohort study of 39075 adult primary heart transplant recipients from 1987 to 2009 using national data from the United Network of Organ Sharing and compared mortality for nonwhite and white patients using the Cox proportional hazards model. During the study period, 8082 nonwhite and 30 993 white patients underwent heart transplantation. Nonwhite heart transplant recipients increased over time, comprising nearly 30% of transplantations since 2005. Nonwhite recipients had a higher clinical risk profile than white recipients at the time of transplantation, but had significantly higher posttransplantation mortality even after adjustment for baseline risk. Among the nonwhite group, only black recipients had an increased risk of death compared with white recipients after multivariable adjustment for recipient, transplant, and socioeconomic factors (hazard ratio, 1.34; 95% confidence interval, 1.21 to 1.47; P<0.001). Five-year mortality was 35.7% (95% confidence interval, 35.2 to 38.3) among black and 26.5% (95% confidence interval, 26.0 to 27.0) among white recipients. Black patients were more likely to die of graft failure or a cardiovascular cause than white patients, but less likely to die of infection or malignancy. Although mortality decreased over time for all transplant recipients, the disparity in mortality between blacks and whites remained essentially unchanged.

Conclusions: Black heart transplant recipients have had persistently higher mortality than whites recipients over the past 2 decades, perhaps because of a higher rate of graft failure.

Figure 1

Number of non-white and white patients placed on the heart transplantation waiting list and undergoing heart transplantation by year.

Figure 2

Unadjusted Kaplan-Meier survival curve for heart transplant recipients by racial or ethnic subgroup. Log-rank p-value < 0.0001

Figure 3

One- and five-year mortality estimates for black and white heart transplant recipients by 3-year increments adjusted for recipient age, gender, and diagnosis; donor age; and medical condition. Lines represent weighted linear regression fitted values of one-year mortality among blacks(—) and whites( ) and five-year mortality estimates among blacks(---) and whites( ).