Ethnic disparity in Israel impacts long-term results after heart transplantation

Abstract

BackgroundEthnicity may affect graft longevity and recipient mortality after heart transplantation (HTx). We hypothesized that differences in ethnic origin between Arabs and Jews undergoing HTx in Israel may contribute to differences in long-term outcomes.MethodsThe study population comprised all 254 patients who underwent HTx between 1991 and 2017 in a tertiary medical center located in the center of Israel. Patients were categorized as either Jews (226 patients, 89%) or Arabs (28 patients, 11%). The primary end point was cardiac allograft vasculopathy (CAV), secondary end points were cardiovascular (CV) mortality and the combined end point of CAV/CV mortality.ResultsIn comparison with Jews, Arab patients were significantly younger (ave. age 42 vs. 50) and had shorter in-hospital stay (45 vs. 80 days). However, Kaplan-Meier survival analysis showed that at 10 years of follow-up CAV rates were significantly higher among Arabs (58%) compared with Jews (23%; log-rank P = 0.01) for the overall difference during follow-up. Similar results were shown for the separate end point of CV mortality and the combined end point of CAV/CV mortality. Multivariate analysis, which controlled for age, gender, statin treatment, and other potential confounders, showed that Arab recipient ethnic origin was associated with a significant > 2.5-fold (p = 0.01) increase in the risk for CAV; a > 4-fold increase in the risk for CV mortality (p = 0.001); and approximately 4-fold increase in the risk for the combined end point (p = 0.001). These findings were validated by propensity score analysis.ConclusionsOur data suggest that Arab ethnic origin is associated with a significantly increased risk for CAV and mortality following HTx. Suggested explanations contributing to ethnic disparities in Israel include socioeconomic, environmental and genetic factors. Further studies are required to evaluate whether more aggressive risk factor management in the Israeli Arab population following HTx would reduce CAV and CV mortality in this high-risk population. Increased awareness and early intervention of the Israeli healthcare system and cooperation with the Arab community is of paramount importance.

Donor‐recipient ethnic mismatching impacts short‐ and long‐term results of heart transplantation

“…In a previous study assessing the influence of Jewish and Arab ethnicity and HT outcomes, no differences were found in the rejection rates solely according to the patient's ethnic group, or in the time to first major rejection . However, in the present study, we demonstrated that donor‐recipient ethnic mismatch was associated with a higher rejection rate.…”

“…The effect of donor‐recipient ethnic mismatching was already evident in the immediate post‐transplant period, with >8‐fold increased risk for PGD and >7‐fold increased risk for in‐hospital mortality. In a previous study, we showed that the ethnic origin of Arabs is associated with a significantly increased risk for CAV and mortality following HT . Based on these findings, our current study results have been adjusted to Arab ethnic origin.…”

“…The Kaplan‐Meier estimator was used to assess the time to the first occurrence of each endpoint by the recipient's ethnic origin, and groups were compared using the log‐rank test. Multivariable Cox proportional hazard regression analysis was used to evaluate the association between the recipient's ethnic origin and the first occurrence of endpoints during follow‐up by producing hazard ratios (HR), after adjustment for Arab ethnicity, based on our previous observations . To predict probability for dichotomic outcome, logistic regressions were conducted assessing odds ratios (OR).…”

“…Both groups are heterogenous and have different important social and demographic characteristics . Although both Jews and Arabs are of Semite origin, we have previously shown that Arab ethnic origin is associated with a significantly increased risk for cardiac allograft vasculopathy (CAV) and mortality following HT …”