Statistical performance of 16 posttransplant risk scores in a contemporary cohort of heart transplant recipients

Am J Transplant. 2021 Feb;21(2):645-656. doi: 10.1111/ajt.16217. Epub 2020 Sep 5.


Accurate risk stratification of early heart transplant failure is required to avoid futile transplants and rationalize donor selection. We aimed to evaluate the statistical performance of existing risk scores on a contemporary cohort of heart transplant recipients. After an exhaustive search, we identified 16 relevant risk scores. From the UNOS database, we selected all first noncombined adult heart transplants performed between 2014 and 2017 for validation. The primary endpoint was death or retransplant during the first year posttransplant. For all scores, we analyzed their association with outcomes, sensitivity, specificity, likelihood ratios, and discrimination (concordance index and overlap of individual scores). The cohort included 9396 patients. All scores were significantly associated with the primary outcome (P < .001 for all scores). Their likelihood ratios, both negative and positive, were poor. The discriminative performance of all scores was limited, with concordance index ranging from 0.544 to 0.646 (median 0.594) and an important overlap of individual scores between patients with or without the primary endpoint. Subgroup analyses revealed important variation in discrimination according to donor age, recipient age, and the type of assist device used at transplant. Our findings raise concerns about the use of currently available scores in the clinical field.

Keywords: United Network for Organ Sharing (UNOS); clinical decision-making; clinical research/practice; heart failure/injury; heart transplantation/cardiology; organ allocation.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Cohort Studies
  • Heart Transplantation* / adverse effects
  • Humans
  • Risk Factors
  • Tissue Donors*
  • Transplant Recipients
  • Treatment Outcome