Donor History of Drug Use and Graft Survival in Pediatric Heart Transplant Recipients.

Importance: Older children awaiting a heart transplant (HT) sometimes receive a heart offer from a donor with a history of drug use (HDU). The effect of using such donor hearts on posttransplant survival in pediatric recipients is unclear. Objective: To assess the association of using hearts from donors with HDU on posttransplant graft survival in pediatric HT recipients. Design, Setting, and Participants: For this retrospective cohort study, all pediatric HT recipients (aged <18 years) in the Organ Procurement and Transplantation Network database during January 1, 2000, to December 31, 2020, were identified. Among the recipients who received a heart from a donor with HDU, nearly all donors were aged 11 years or older. A propensity score (PS) model was developed to assess the probability of receiving a heart from a donor with HDU using baseline recipient and donor variables, limiting the study cohort to donors aged 11 years or older. Data were analyzed from October 2023 to November 2024. Exposure: HT using a heart from a donor with HDU (exposure group) vs from a donor without HDU (control group). Main Outcomes and Measures: The main outcome was graft loss (death or retransplant) assessed at 90 days after transplant and long term among 90-day survivors. Kaplan-Meier survival curves and a Cox proportional hazards regression model that accounted for matching of exposure and control groups were used to compare risk of graft loss. Results: This study included 2730 pediatric HT recipients. Their median age at HT was 14 years (IQR, 11-16 years), and most (1642 [60.1%]) were male. Overall, the exposure group comprised 822 children who received a heart from a donor with HDU; of these, 765 (93.1%) were PS matched to the control group. There was no difference in risk of graft loss within 90 days (hazard ratio [HR], 0.93 [95% CI, 0.55-1.57]; P = .78) or at long-term follow-up (HR, 1.04 [95% CI, 0.87-1.25]; P = .68) between PS-matched groups. Risk of graft loss within 90 days was not significantly different in children who received a heart from a donor with a history of cocaine use (157 pairs) vs children in the control group (HR, 0.55 [95% CI, 0.19-1.54]; P = .25); however, the risk of long-term graft loss among 90-day survivors was significantly higher (HR, 2.03 [95% CI, 1.35-3.06]; P = .001). Conclusions and Relevance: In this cohort study of pediatric HT recipients, there was no association of 90-day graft survival with donor HDU; however, donor history of cocaine use was associated with a higher risk of long-term graft loss. These findings may be important when considering a donor with HDU for pediatric HT candidates.