Sex Differences in Simultaneous Heart-Kidney Transplantation: A 25-Year United Network for Organ Sharing Analysis.
Sex differences after cardiac transplantation are well described; whether similar sex differences exist after simultaneous heart-kidney transplantation (SHKT) remains unknown.
Adults (≥18 years) undergoing first-time SHKT between January 1, 1999, and September 30, 2024, were identified in the United Network for Organ Sharing registry. Rates of SHKT by sex were examined across allocation-policy eras. Post-transplant survival was compared by sex using multivariable Cox regression. Among 3068 recipients (19.7% women), women were more likely to have nonischemic cardiomyopathy and a higher pulmonary vascular resistance and less likely to have durable left ventricular assist device support at the time of transplant. Unadjusted survival did not differ by sex at 1 or 5 years (log-rank P = .236 and P = .593, respectively). After multivariable adjustment, as sex violated proportional hazards, a piecewise constant Cox model showed a numerically higher perioperative than postperioperative sex hazard, neither significant in the full cohort (adjusted hazard ratio [aHR] 1.38 [P = .061] and aHR 1.19 [P = .473]). The perioperative disparity was significant in the prespecified 90-day landmark analysis (days 0-90, aHR 1.58, 95% confidence interval 1.12-2.22 [P = .009]; days 91-365, aHR 0.91 [P = .729]) and in the contemporary allocation era (aHR 1.78, 95% confidence interval 1.19-2.65, P = .005). No sex differences were observed at 5 years and no significant sex interactions were identified across 10 prespecified effect modifiers (all P > .005).
Women demonstrated an early post-transplant mortality signal concentrated within the first 90 days after SHKT, without excess long-term risk. These findings underscore the need for earlier referral and perioperative optimization of high-risk women to improve equity in SHKT outcomes.
Adults (≥18 years) undergoing first-time SHKT between January 1, 1999, and September 30, 2024, were identified in the United Network for Organ Sharing registry. Rates of SHKT by sex were examined across allocation-policy eras. Post-transplant survival was compared by sex using multivariable Cox regression. Among 3068 recipients (19.7% women), women were more likely to have nonischemic cardiomyopathy and a higher pulmonary vascular resistance and less likely to have durable left ventricular assist device support at the time of transplant. Unadjusted survival did not differ by sex at 1 or 5 years (log-rank P = .236 and P = .593, respectively). After multivariable adjustment, as sex violated proportional hazards, a piecewise constant Cox model showed a numerically higher perioperative than postperioperative sex hazard, neither significant in the full cohort (adjusted hazard ratio [aHR] 1.38 [P = .061] and aHR 1.19 [P = .473]). The perioperative disparity was significant in the prespecified 90-day landmark analysis (days 0-90, aHR 1.58, 95% confidence interval 1.12-2.22 [P = .009]; days 91-365, aHR 0.91 [P = .729]) and in the contemporary allocation era (aHR 1.78, 95% confidence interval 1.19-2.65, P = .005). No sex differences were observed at 5 years and no significant sex interactions were identified across 10 prespecified effect modifiers (all P > .005).
Women demonstrated an early post-transplant mortality signal concentrated within the first 90 days after SHKT, without excess long-term risk. These findings underscore the need for earlier referral and perioperative optimization of high-risk women to improve equity in SHKT outcomes.
Authors
Ramu Ramu, Shabbir Shabbir, Masotti Masotti, Schultz Schultz, Maharaj Maharaj, Alexy Alexy, Fraser Fraser, Watt Watt, Wong Wong, Mulvihill Mulvihill, Shaffer Shaffer, John John, Cogswell Cogswell
View on Pubmed