Risk Stratification to Improve Transplant Benefit in Older Candidates: Are All Comorbidities Created Equal?

Patient (pts) selection is crucial to keep equity and acceptable prognosis after heart transplant (HT). Several factors are known to influence post-HT outcome, but their interplay with recipient age is poorly explored. Aiming to optimize older patients profiling, we designed this study to weigh risk factors for post-HT outcome across recipient age strata. We analyzed the association among pre-HTx clinical and laboratory data of pts receiving HT in our Center in 1999-2013 and post-HT survival. Risk factors were stratified according to recipient age older or younger than 60, deriving two age-specific risk scores, calculated on the basis of adjusted odds ratios (OR). 418 pts (age: 52±12, 32%>60 yrs, 80% males, 20% diabetes (DM), 42% with ischemic cardiomyopathy (CAD) and 63% with GFR <60 ml/min) were analyzed. During a 17y follow-up, 273 patients died accounting for a 66.7±2.6% 10y survival. Multivariate analysis revealed different weight of comorbidities in influencing outcome across the two age strata: GFR <60 ml/min (OR: 1.9), UNOS-1A status (OR: 2.2), sensitization (OR: 2.2), and donor age <40y (OR: 1.8) in young pt, while in old pt, PVR>3(OR:2.4), CAD (OR:1.9), and status 1A (OR:4.9; all p≤0.05). We then calculated age-specific derived risk scores defining high-risk patients those with a score >2 (median). Young low risk pts had the best estimated 10-yrs survival, while old low risk pts had a better outcome than the young high risk (60.0±5.2% vs 40.9±12.1%, p=0.001). High-risk pts (young and old) had similar outcomes, even after conditioning survival >1 year. Risk factors for post-HT outcome weigh differently according to age strata. HT may be considered as first choice strategy in selected older pts with low risk profile, in whom may provide better outcomes than younger with high-risk profile (i.e. sensitized with GFR<60 ml/min). Strategies different from HT in patients >60y with high-risk profile may improve equity in resources allocation.