The Impact of Donor Gender on Heart Transplantation Outcomes - A Study of over 60,000 Patients in the United States

Purpose The objective of this study was to evaluate the impact of donor gender on heart transplantation outcomes in the United States. Methods From 1987 to March 2019, 63,775 adult patients underwent heart transplantation in the United States, and their data were prospectively collected by the United Network for Organ Sharing (UNOS). Patients without missing data were stratified by donor gender (female, N = 11,474; male, N = 27,509) and donor menopause status (pre-menopause, ages 35-40 years old, N = 1,783; post-menopause, ages 50-55 years old, N = 1,105). The groups were propensity matched 1:1 based on year of surgery, pre-transplant status, wait list time, human leukocyte antigen matching, donor demographics, and allograft ischemic time. Paired t-test, McNemor's tests and Kaplan-Meier survival analyses were performed. The primary endpoint was all cause mortality, and secondary endpoints were postoperative complications. Results Propensity matching generated 15,506 patients based on donor gender and 1,094 patients based on donor menopause status. Recipients who received female donor hearts were more likely to have acute rejection episodes (630/11.9% vs. 545/10.1%, p = .007) and require post-transplant dialysis (837/10.9% vs. 719/9.3%, p = .001) than those who received male donor hearts. No difference was observed between using female or male donor hearts in the rates of graft failure (551/8.2% vs. 641/9.5%) or stroke (179/2.4% vs. 199/2.6%) (p ≥ .34). Median survival using female vs. male donor hearts was 11.6 vs. 12.1 years (p = .34) with ten-year survival of 56.5% vs. 57.1%, respectively. Recipients who received pre- vs. post-menopausal female donor hearts had similar rates of acute rejection episodes (39/11% vs. 45/12.5%), graft failure (37/7.9% vs. 46/9.9%), stroke (10/1.8% vs. 15/2.8%), or requiring dialysis (67/12.3% vs. 81/14.9%) (p ≥ .09). Median survival using pre- vs. post-menopausal female donor hearts was 11.5 vs. 10.4 years (p = .23) with ten-year survival of 56.7% vs. 51.2%, respectively. Conclusion Analysis of the UNOS database showed similar median survival using female vs. male donor hearts in adult heart transplantation, irrespective of donor menopause status. Currently, female donor hearts are used far less frequently, thus these results represent an opportunity to maximize usage by better utilization of suitable female donor organs.