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Donor Drug Use and Heart Transplant Outcomes
Quick Takes
- The number and proportion of heart donors with positive toxicology for recreational substances increased significantly between 2007 and 2017.
- Donor toxicology was not associated with lower survival, regardless of type of drug or use of multiple drugs.
- History of recreational drug use correlates weakly with drug toxicology, and therefore, may not be an indication to decline a heart offer.
Study Questions:
Does history of heart donor drug use or positive toxicology impact post-transplant survival?
Methods:
Using United Network for Organ Sharing (UNOS) data, 23,748 heart donors were identified between 2007 and 2017. Drug use was assessed by the following: 1) Measured Toxicology Score (MTS), which attributed a point for each positive result; and 2) UNOS Toxicology Score (UTS), which attributed a point for history of drug use and for current use. Kaplan-Meier survival analysis was performed to estimate survival stratified by level of drug use or history. Cox proportional hazards models were constructed to analyze survival and covariates, including donor and recipient sex, donor and recipient age, ischemic time, and specific drugs.
Results:
While most heart donors had a UTS of 0 (no history of drug use), there was a significant increase in the proportion of donors with a UTS ≥1 between 2007 and 2017 (41.3%, 54.3%, 63.4% for years 2007, 2012, and 2017, respectively; χ2 test, p < 0.0001). Similarly, there was an increase in MTS ≥1 during this period (23.0%, 37.7%, 46.1% for years 2007, 2012, and 2017, respectively; χ2 test, p < 0.0001). Linear regression demonstrated significant correlation between MTS and UTS (R2 = 0.18, p < 0.0001); however, among patients with current history of cocaine use, only 49.4% had positive toxicology. Positive alcohol toxicology decreased over time, while positive toxicology for cocaine, tetrahydrocannabinol, and benzodiazepines doubled and amphetamines increased >5-fold. On univariate analysis, MTS positive for cannabis, benzodiazepines, and amphetamines were associated with significantly higher survival. UTS (current use other than cocaine and prior use) was also associated with higher survival, while heavy alcohol was associated with lower survival. Kaplan-Meier analysis demonstrated no significant difference in survival based on MTS (p = 0.09) or UTS (p = 0.27).
Conclusions:
Among heart donors accepted for transplant, neither history of recreational drug use nor positive drug toxicology was associated with reduced survival. History of drug use may not be an adequate indicator of ongoing drug use or post-transplant risk.
Perspective:
The use of heart donors with a history of drug use has been controversial due to the potential cardiotoxic effects of agents such as cocaine, alcohol, and methamphetamines. In this large retrospective analysis, neither history of drug use nor positive toxicology was associated with a difference in survival when compared to no drug use. The reported history of drug use did not correspond well to toxicology results, and therefore, may not represent an accurate metric for donor evaluation. This analysis was performed before the new heart allocation policy was implemented, and the impact of recreational substance use in the setting of potentially different recipient profiles and peri-transplant characteristics as a result of the policy is unknown. Furthermore, although multi-drug use did not appear to affect survival, the relationship with drug level is unknown. Finally, this analysis only includes donors that were used, and it is likely that higher-risk donors were already excluded.
Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Novel Agents, Acute Heart Failure, Heart Transplant
Keywords: Alcohol Drinking, Benzodiazepines, Cannabis, Cocaine, Graft Survival, Heart Failure, Heart Transplantation, Methamphetamine, Risk Factors, Substance-Related Disorders, Secondary Prevention, Survival, Tissue Donors, Toxicology, Transplants
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