Impact of antibodies against human leukocyte antigens on long-term outcome in pediatric heart transplant patients: an analysis of the United Network for Organ Sharing database.

OBJECTIVES

Controversy exists regarding the importance of circulating antibodies as determined by panel-reactive antibody screening as a risk factor for graft failure in pediatric patients undergoing heart transplantation. This study sought to determine the association of elevated anti-human leukocyte antibodies with long-term survival in pediatric heart transplant patients.

METHODS

The United Network for Organ Sharing registry was queried for pediatric patients (aged < 18 years at listing) with panel-reactive antibody levels obtained before heart transplantation from 1987 through 2004. Survival analysis methods were used to assess the association of elevated panel-reactive antibodies with long-term graft and patient survival.

RESULTS

Panel-reactive antibodies were obtained before transplantation from 3534 patients, median age 4 years (interquartile range 0-12 years). Most, 2711 (77%), had no detectable panel-reactive antibodies, 436 (12%) had panel-reactive antibodies of 1% to 10%, and 387 (11%) had panel-reactive antibodies greater than 10%. Patients with panel-reactive antibodies greater than 10% were more likely to be older (P = .04), have congenital heart disease (P < .001), and have a longer wait list time (P = .006). Patients with panel-reactive antibodies greater than 10% had significantly worse graft survival and patient survival than did patients with undetectable panel-reactive antibodies and panel-reactive antibodies of 1% to 10% (P < .05 for all). Controlling for confounding variables, elevated panel-reactive antibodies as a continuous variable and panel-reactive antibodies greater than 10% as a categorical variable were independently associated with decreased graft survival (P = .04 and P = .02, respectively).

CONCLUSIONS

Elevated panel-reactive antibodies are independently associated with worse long-term graft survival in pediatric patients undergoing heart transplantation. Further study is needed to determine the optimal management of this high-risk population.