Survival in allosensitized children after listing for cardiac transplantation

Background: Little is known about the effect of pre-transplant alloantibody in the pediatric cardiac transplant population. Methods: All cardiac listings (n =. 298) at Children's Hospital of Pittsburgh from January 1990 through February 2006 were reviewed to determine the impact of allosensitization on transplantation outcomes. Analysis focused on: (1) wait list outcomes; (2) survival from the time of listing, regardless of subsequent transplantation; (3) post-transplant graft and patient survival; and (4) post-transplant freedom from graft vasculopathy. Institutional policy required a negative, prospective crossmatch for candidates with panel-reactive antibody >20%. Results: Alloantibody data were available for 252 (85%) listings. Median time to transplantation was greater for sensitized vs non-sensitized subjects (2.7 months vs 1.3 months; p = 0.02). At 1 year after listing, sensitized subjects had a higher incidence of death (22% vs 8.4%; p = 0.055). Survival at all time-points after listing (regardless of transplantation) was worse for sensitized subjects (p = 0.04). Although no statistically significant differences in post-transplant graft or patient survival were noted, pre-transplant allosensitization was associated with decreased freedom from graft vasculopathy (hazard ratio [HR1 2.76, 95% confidence interval [CI] 1. 18 to 6.45; p = 0.019). Conclusions: A policy requiring a negative, prospective crossmatch for highly sensitized candidates is associated with longer wait list time and higher mortality after listing. The development of graft vasculopathy appears to be influenced by the presence of pre-transplant alloantibody.