Post-transplant mortality and graft failure after induction immunosuppression among Black heart transplant recipients in the United States

Abstract

Black heart transplant recipients are more likely to receive induction immunosuppression compared to other races because of higher rates of acute rejection, graft failure, and mortality. However, it is not known whether contemporary induction immunosuppression improves their post-transplant outcomes. To evaluate whether Black patients who were prescribed induction immunosuppression therapy have lower all-cause mortality or graft-failure rates compared to those who were not, we studied Black U.S. adult heart transplant recipients in the Scientific Registry of Transplant Recipients database (2008-2018). We used multivariable Cox proportional hazards regression analysis to compare the hazards of all-cause mortality or graft failure as a composite, for patients who were prescribed induction immunosuppression and those who were not. Among 5160 recipients, 2787 (54.0%) were prescribed induction immunosuppression and 2373 (46.0%) were not. There was no evidence of survival differences according to induction immunosuppression for the composite of all-cause mortality or graft failure (aHR = 1.13, 95% CI 0.96-1.32), mortality (aHR = 1.14, 95% CI 0.97-1.34), graft failure (aHR = 1.05, 95% CI 0.82-1.34) and acute rejection (aHR = 1.00, 95% CI 0.89-1.12). Given the side effects of treatment, future guidelines should reconsider the recommendation for induction immunosuppression among Black patients.

Fig 1:

Unadjusted Kaplan-Meier Survival Curves stratified by prescription of induction immunosuppression among Black heart transplant recipients, Scientific Registry of Transplant Recipients, 2008-2018. a. Composite of all-cause mortality or graft failure b. All-cause mortality only c. Graft failure only d. Acute rejection

Fig 1:

Unadjusted Kaplan-Meier Survival Curves stratified by prescription of induction immunosuppression among Black heart transplant recipients, Scientific Registry of Transplant Recipients, 2008-2018. a. Composite of all-cause mortality or graft failure b. All-cause mortality only c. Graft failure only d. Acute rejection

Fig 2:

Survival curve from adjusted* Cox proportional hazards regression model for the Composite of all-cause mortality stratified by prescription of induction immunosuppression among Black heart transplant recipients, Scientific Registry of Transplant Recipients, 2008-2018. *Adjusted for donor age, gender and race, donor-recipient race mismatch, donor-recipient gender mismatch, ischemic time (in minutes), year of transplant (2008-2010, 2011-2013, 2014-2018), recipient age, gender, level of education (2), normal (18-24.9 kg/m²), overweight (25-29.9 kg/m²), obese (>30 kg/m²)], estimated glomerular filtration rate (MDRD equation), dialysis, total bilirubin(mg/dL), diagnosis of diabetes mellitus, hypertension, hepatitis C virus infection, cytomegalovirus infection, etiology of heart disease (ischemic, non-ischemic dilated cardiomyopathy, other), prior non-transplant heart surgery, history of chronic steroid use, smoking status (none, past or current), history of malignancy, IV antibiotics-treated infection during hospitalization for the transplant, peri-transplant steroid use, any ventricular assist device (VAD) use, extra corporeal membrane oxygenation(ECMO), panel reactive antibodies (≥ 10%, <10%), waiting list status (status 1A, others), life support status before transplant, mean pulmonary arterial pressure (mmHg), hospitalization status (intensive care unit [ICU], non-ICU hospitalization, not hospitalized), number of HLA mismatches, maintenance immunosuppression agents (tacrolimus, mycophenolate mofetil, cyclosporin, mTOR [mechanistic target of rapamycin] inhibitors, others) and transplant center.