Development and Validation of a Risk Score Predicting Death Without Transplant in Adult Heart Transplant Candidates.

Autor:	Zhang KC; Department of Medicine, University of Chicago, Chicago, Illinois., Narang N; Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois.; Department of Medicine, University of Illinois-Chicago., Jasseron C; Agence de la Biomédecine, Direction Prélèvement Greffe Organes-Tissus, Saint-Denis La Plaine, France., Dorent R; Agence de la Biomédecine, Direction Prélèvement Greffe Organes-Tissus, Saint-Denis La Plaine, France., Lazenby KA; Pritzker School of Medicine, University of Chicago, Chicago, Illinois., Belkin MN; Department of Medicine, University of Chicago, Chicago, Illinois., Grinstein J; Department of Medicine, University of Chicago, Chicago, Illinois., Mayampurath A; Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison., Churpek MM; Department of Medicine, University of Wisconsin, Madison., Khush KK; Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California., Parker WF; Department of Medicine, University of Chicago, Chicago, Illinois.; Department of Public Health Sciences, University of Chicago, Chicago, Illinois.; MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois.
Jazyk:	angličtina
Zdroj:	JAMA [JAMA] 2024 Feb 13; Vol. 331 (6), pp. 500-509.
DOI:	10.1001/jama.2023.27029
Abstrakt:	Importance: The US heart allocation system prioritizes medically urgent candidates with a high risk of dying without transplant. The current therapy-based 6-status system is susceptible to manipulation and has limited rank ordering ability. Objective: To develop and validate a candidate risk score that incorporates current clinical, laboratory, and hemodynamic data. Design, Setting, and Participants: A registry-based observational study of adult heart transplant candidates (aged ≥18 years) from the US heart allocation system listed between January 1, 2019, and December 31, 2022, split by center into training (70%) and test (30%) datasets. Adult candidates were listed between January 1, 2019, and December 31, 2022. Main Outcomes and Measures: A US candidate risk score (US-CRS) model was developed by adding a predefined set of predictors to the current French Candidate Risk Score (French-CRS) model. Sensitivity analyses were performed, which included intra-aortic balloon pumps (IABP) and percutaneous ventricular assist devices (VAD) in the definition of short-term mechanical circulatory support (MCS) for the US-CRS. Performance of the US-CRS model, French-CRS model, and 6-status model in the test dataset was evaluated by time-dependent area under the receiver operating characteristic curve (AUC) for death without transplant within 6 weeks and overall survival concordance (c-index) with integrated AUC. Results: A total of 16 905 adult heart transplant candidates were listed (mean [SD] age, 53 [13] years; 73% male; 58% White); 796 patients (4.7%) died without a transplant. The final US-CRS contained time-varying short-term MCS (ventricular assist-extracorporeal membrane oxygenation or temporary surgical VAD), the log of bilirubin, estimated glomerular filtration rate, the log of B-type natriuretic peptide, albumin, sodium, and durable left ventricular assist device. In the test dataset, the AUC for death within 6 weeks of listing for the US-CRS model was 0.79 (95% CI, 0.75-0.83), for the French-CRS model was 0.72 (95% CI, 0.67-0.76), and 6-status model was 0.68 (95% CI, 0.62-0.73). Overall c-index for the US-CRS model was 0.76 (95% CI, 0.73-0.80), for the French-CRS model was 0.69 (95% CI, 0.65-0.73), and 6-status model was 0.67 (95% CI, 0.63-0.71). Classifying IABP and percutaneous VAD as short-term MCS reduced the effect size by 54%. Conclusions and Relevance: In this registry-based study of US heart transplant candidates, a continuous multivariable allocation score outperformed the 6-status system in rank ordering heart transplant candidates by medical urgency and may be useful for the medical urgency component of heart allocation.
Databáze:	MEDLINE
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