title: Who is the high-risk recipient? Predicting mortality after heart transplant using pretransplant donor and recipient risk factors.
abstract: BACKGROUND
  In this study we sought the following: (1) To objectively assess the risk related to various pretransplant recipient and donor characteristics; (2) to devise a preoperative risk stratification score (RSS) based on pretransplant recipient and donor characteristics predicting graft loss at 1 year; and (3) to define different risk strata based on RSS.
  
  
  METHODS
  The United Network for Organ Sharing provided de-identified patient-level data. Analysis included 11,703 orthotopic heart transplant recipients aged 18 years or greater and transplanted between January 1, 2001 and December 31, 2007. The primary outcome was 1-year graft failure. Multivariable logistic regression analysis (backward p value<0.20) was used to determine the relationship between pretransplant characteristics and 1-year graft failure. Using the odds ratio for each identified variable, an RSS was devised. The RSS strata were defined by calculating receiver operating characteristic curves and stratum specific likelihood ratios.
  
  
  RESULTS
  The strongest negative predictors of 1-year graft failure included the following: right ventricular assist device only, extracorporeal membrane oxygenation, renal failure, extracorporeal left ventricular assist device, total artificial heart, and advanced age. Threshold analysis identified 5 discrete RSS strata: low risk (LR, RSS: <2.55; n=3242, 27.7%), intermediate risk (IR, RSS: 2.55-5.72; n=6,347, 54.2%), moderate risk (MR, RSS: 5.73-8.13; n=1,543, 13.2%), elevated risk (ER, RSS: 8.14-9.48; n=310, 2.6%), and high risk (HR, RSS: >9.48; n=261, 2.2%). The 1-year actuarial survival (%) in the LR, IR, MR, ER, and HR groups were 93.8, 89.2, 81.3, 67.0, and 47.0, respectively.
  
  
  CONCLUSIONS
  Pretransplant recipient variables significantly influence early and late graft failure after heart transplantation. The RSS may improve organ allocation strategies by reducing the potential negative impact of transplanting candidates who are at a high risk for poor postoperative outcomes.
authors.affiliation: Division of Cardiothoracic Surgery, Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, New York, USA.
authors.forename: Kimberly N
authors.initials: KN
authors.lastname: Hong
authors.forename: Alexander
authors.initials: A
authors.lastname: Iribarne
authors.forename: Berhane
authors.initials: B
authors.lastname: Worku
authors.forename: Hiroo
authors.initials: H
authors.lastname: Takayama
authors.forename: Annetine C
authors.initials: AC
authors.lastname: Gelijns
authors.forename: Yoshifumi
authors.initials: Y
authors.lastname: Naka
authors.forename: Val
authors.initials: V
authors.lastname: Jeevanandam
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Russo
mesh_terms: D000206:Actuarial Analysis; D000293:Adolescent; D000328:Adult; D000368:Aged; D015897:Comorbidity; D005260:Female; D006084:Graft Rejection / Q000401:mortality*; D006305:Health Status Indicators; D006333:Heart Failure / Q000401:mortality*; D016027:Heart Transplantation / Q000401:mortality*; D006801:Humans; D053208:Kaplan-Meier Estimate; D016013:Likelihood Functions; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011183:Postoperative Complications / Q000401:mortality*; D012372:ROC Curve; D012189:Retrospective Studies; D012307:Risk Factors; D014019:Tissue Donors / Q000706:statistics & numerical data*; D014481:United States; D055815:Young Adult