Pondering Higher-Risk Pediatric Heart Donors: Can We Use More?

Pediatric heart transplantation is challenged with long waiting list times and high waiting list mortality, mostly due to a continuing organ shortage and high rates of nonuse. This analysis was conducted to determine the outcomes associated with high-risk donors when recipient variability is neutralized. The United Network for Organ Sharing (UNOS) thoracic organ transplant database was searched for pediatric heart transplant recipients (≤17 years old at time of listing) between January 2006 and December 2015. High-risk donors were identified using 2 previously published methods based on donor utilization (DUB) and recipient survival (RSB). Within each of the populations, which were not mutually exclusive, low- and high-risk donor cohorts were propensity matched on recipient characteristics, and outcomes (graft survival) were analyzed using Kaplan-Meier methods. When recipient variability was harmonized, the DUB population (n = 3048) did not have different graft survival times between the high-risk graft recipients (n = 1016) and low-risk graft recipients (n = 2032; P = .713). Likewise, the RSB population (n = 1053) also did not have different graft survival times between the high-risk graft recipients (n = 351) and low-risk graft recipients (n = 702; P = .706). Cardiac allografts deemed high risk by use- and survival-based methods led to equivalent posttransplant survival as matched recipients with low-risk donors. This study demonstrates that traditionally high-risk donors may have been associated with worst posttransplant survival because of the recipients that used them. Therefore, accepting these “high-risk” donor grafts should be considered as a potential approach to reduce waiting list times and mortality while maintaining comparable posttransplant survival.