Sex Differences in Utilization of Donation After Circulatory Death Donors for Heart Transplantation and Associated Outcomes

Abstract

Background: The use of donation after circulatory death (DCD) donors for heart transplantation (HT) is increasing in the United States. Whether sex differences exist in DCD HT utilization and outcomes is unknown.

Methods: Adults listed for HT at DCD centers between January 1, 2019 (first US DCD HT) and September 15, 2023, in the Organ Procurement and Transplantation Network Registry were included. Differences in listing for DCD HT by sex were investigated using multivariable logistic regression. The impact of listing for DCD HT (modeled as a time-varying covariate) on waitlist outcomes including the rate of HT waitlist removal for death or clinical deterioration was assessed using multivariable competing risk analyses. Annual trends in DCD HT and 2-year survival after DCD HT by sex were also investigated.

Results: A total of 9807 individuals were listed at DCD centers during the study period. Listing for DCD HT was less common among women after multivariable adjustment (odds ratio, 0.84 [95% CI, 0.76-0.92]; P<0.001). Listing for DCD HT was associated with an adjusted increased rate of HT (hazard ratio, 1.85 [95% CI, 1.75-1.95]; P<0.001) and a lower risk of waitlist removal for death or clinical deterioration (hazard ratio, 0.57 [95% CI, 0.45-0.73]; P<0.001) for both men and women; these protective effects were not different between sexes (interaction terms: transplant, P=0.55; delisting, P=0.91). During the study period, women made up 26% to 29% of donation after brain death transplants, but only 18% to 20% of DCD transplants. Survival at 2 years after DCD HT was similar between sexes (87% for women and 88% for men; log-rank P=0.37).

Conclusions: Women were less likely to be listed for DCD HT and makeup proportionally less DCD transplants compared with men. Being listed for DCD HT improved waitlist outcomes in both sexes. One-year survival after DCD HT was similar by sex. As DCD HT expands, additional measures to ensure equitable access are imperative.

Keywords: brain death; heart transplantation; sex; tissue and organ procurement.