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Peer-reviewedCC BY-NC-ND 4.0JHLT Open

Sex-specific association between body mass index and mortality after heart transplantation: A nationwide KOTRY Cohort Study1

  • Yoseb Lee1
  • Kitae Kim1
  • Ah Ram Kim2
  • Jung Ae Hong1
  • Junho Hyun2
  • Sang Eun Lee2
  • Min-Seok Kim2
  • Eun-Seok Jeon3
  • Jin-Oh Choi3
  • Jaewon Oh4
  • Seok-Min Kang4
  • Myoung Soo Kim5
4 more authors
  • Jae-Joong Kim2
  • Hae-Young Lee6
  • Sung-Ho Jung1
  • The KOTRY Study Group
6 affiliations
  1. 1Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
  2. 2Division of Cardiology, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
  3. 3Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, Republic of Korea
  4. 4Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
  5. 5Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
  6. 6Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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Abstract

Background: Body mass index has paradoxical associations with outcomes in advanced heart failure, but whether its relationship with survival after heart transplantation differs by sex remains uncertain.

Methods: We analyzed 1059 adult heart transplant recipients enrolled in the Korean Organ Transplantation Registry from 2014 through 2023. Body mass index was assessed using Asian-specific BMI categories and 3-knot restricted cubic splines. The primary outcome was all-cause mortality. Multivariable Cox models adjusted for prespecified clinical characteristics and pretransplant support. Sex differences in the body mass index–mortality association were evaluated using restricted cubic spline modeling.

Results: The cohort included 304 female patients, and 217 deaths occurred during a median follow-up of 3.6 years. The body mass index–mortality association differed by sex in the pooled spline model (P for interaction=0.041). In male patients, the association was nonlinear and U-shaped (P for overall association=0.031; P for nonlinearity=0.017). Underweight was associated with higher mortality than normal weight (adjusted hazard ratio, 1.97; 95% confidence interval, 1.17–3.33). In female patients, the fitted association was inverse, without evidence of nonlinearity (P for overall association=0.030; P for nonlinearity=0.302). Obesity class I was associated with lower mortality than normal weight (adjusted hazard ratio, 0.24; 95% confidence interval, 0.08–0.73), although this estimate was based on few events.

Conclusions: The association between body mass index and mortality after heart transplantation may differ by sex. The apparent lower mortality among female patients with obesity class I is hypothesis-generating and requires external validation.

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Cite

BibTeXRIS
BibTeX
@article{lee2026sexspecific,
  title = {{Sex-specific association between body mass index and mortality after heart transplantation: A nationwide KOTRY Cohort Study1}},
  author = {Yoseb Lee and Kitae Kim and Ah Ram Kim and Jung Ae Hong and Junho Hyun and Sang Eun Lee and Min-Seok Kim and Eun-Seok Jeon and Jin-Oh Choi and Jaewon Oh and Seok-Min Kang and Myoung Soo Kim and Jae-Joong Kim and Hae-Young Lee and Sung-Ho Jung and The KOTRY Study Group},
  journal = {JHLT Open},
  year = {2026},
  month = oct,
  doi = {10.1016/j.jhlto.2026.100703},
  url = {https://doi.org/10.1016/j.jhlto.2026.100703},
  note = {CC BY-NC-ND 4.0},
}
RIS
TY  - JOUR
TI  - Sex-specific association between body mass index and mortality after heart transplantation: A nationwide KOTRY Cohort Study1
AU  - Yoseb Lee
AU  - Kitae Kim
AU  - Ah Ram Kim
AU  - Jung Ae Hong
AU  - Junho Hyun
AU  - Sang Eun Lee
AU  - Min-Seok Kim
AU  - Eun-Seok Jeon
AU  - Jin-Oh Choi
AU  - Jaewon Oh
AU  - Seok-Min Kang
AU  - Myoung Soo Kim
AU  - Jae-Joong Kim
AU  - Hae-Young Lee
AU  - Sung-Ho Jung
AU  - The KOTRY Study Group
PY  - 2026
DA  - 2026/10/05
JO  - JHLT Open
DO  - 10.1016/j.jhlto.2026.100703
UR  - https://doi.org/10.1016/j.jhlto.2026.100703
AB  - Background: Body mass index has paradoxical associations with outcomes in advanced heart failure, but whether its relationship with survival after heart transplantation differs by sex remains uncertain.  Methods: We analyzed 1059 adult heart transplant recipients enrolled in the Korean Organ Transplantation Registry from 2014 through 2023. Body mass index was assessed using Asian-specific BMI categories and 3-knot restricted cubic splines. The primary outcome was all-cause mortality. Multivariable Cox models adjusted for prespecified clinical characteristics and pretransplant support. Sex differences in the body mass index–mortality association were evaluated using restricted cubic spline modeling.  Results: The cohort included 304 female patients, and 217 deaths occurred during a median follow-up of 3.6 years. The body mass index–mortality association differed by sex in the pooled spline model (P for interaction=0.041). In male patients, the association was nonlinear and U-shaped (P for overall association=0.031; P for nonlinearity=0.017). Underweight was associated with higher mortality than normal weight (adjusted hazard ratio, 1.97; 95% confidence interval, 1.17–3.33). In female patients, the fitted association was inverse, without evidence of nonlinearity (P for overall association=0.030; P for nonlinearity=0.302). Obesity class I was associated with lower mortality than normal weight (adjusted hazard ratio, 0.24; 95% confidence interval, 0.08–0.73), although this estimate was based on few events.  Conclusions: The association between body mass index and mortality after heart transplantation may differ by sex. The apparent lower mortality among female patients with obesity class I is hypothesis-generating and requires external validation.
SN  - 2950-1334
ER  -