Kasiske Bertram L, Snyder Jon J, Matas Arthur J, Ellison Mary D, Gill John S, Kausz Annamaria T
The United States Renal Data System Coordinating Center, Minneapolis, Minnesota 55414, USA.
J Am Soc Nephrol. 2002 May;13(5):1358-64. doi: 10.1097/01.asn.0000013295.11876.c9.
It remains unclear whether preemptive transplantation is beneficial, and if so, who benefits. A total of 38,836 first, kidney-only transplants between 1995 and 1998 were retrospectively studied. A surprising 39% of preemptive transplants were from cadaver donors, and the proportions of cadaver donor transplants that were preemptive changed little, from 7.3% in 1995 to 7.7% in 1998. Preemptive transplants using cadaver donors were more likely among recipients aged 0 to 17 yr versus 18 to 29 yr (odds ratio [OR], 2.48; 95% confidence interval [CI], 1.94 to 3.17), white versus black (OR, 2.33; 95% CI, 2.03 to 2.68), able to work versus unable to work (OR, 1.42; 95% CI, 1.26 to 1.61), covered by private insurance versus Medicare (OR, 4.77; 95% CI, 4.26 to 5.32), or recipients with a college degree versus no college degree (OR, 1.34; 95% CI, 1.17 to 1.54). Preemptive transplants were less likely for Hispanics versus non-Hispanics (OR, 0.57; 95% CI, 0.50 to 0.67), patients with type 2 versus type 1 diabetes (OR, 0.76; 95% CI, 0.61 to 0.96), and for 2 to 5 HLA mismatches compared with 0 HLA mismatches (OR range, 0.77 to 0.82). In adjusted Cox proportional hazards analysis, the relative risk of graft failure for preemptive transplantation was 0.75 (0.67 to 0.84) among 25,758 cadaver donor transplants and 0.73 (0.64 to 0.83) among 13,078 living donor transplants, compared with patients who received a transplant after already being on dialysis. Preemptive transplantation was associated with a reduced risk of death: 0.84 (0.72 to 0.99) for cadaver donor transplants and 0.69 (0.56 to 0.85) for living donor transplants. Thus, preemptive transplantation, which is associated with improved patient and graft survival, is less common among racial minorities, those who have less education, and those who must rely on Medicare for primary payment. Alterations in the payment system, emphasis on early referral, and changes in cadaver kidney allocation could increase the number of patients who benefit from preemptive transplantation.
预先移植是否有益，若有益，哪些人会从中受益，目前仍不明确。对1995年至1998年间的38836例首次单纯肾移植进行了回顾性研究。令人惊讶的是，39%的预先移植来自尸体供体，尸体供体预先移植的比例变化不大，从1995年的7.3%升至1998年的7.7%。0至17岁的受者相比18至29岁的受者，接受尸体供体预先移植的可能性更大（优势比[OR]为2.48；95%置信区间[CI]为1.94至3.17）；白人相比黑人（OR为2.33；95%CI为2.03至2.68）；能够工作的相比无法工作的（OR为1.42；95%CI为1.26至1.61）；有私人保险的相比有医疗保险的（OR为4.77；95%CI为4.26至5.32）；有大学学位的受者相比无大学学位的（OR为1.34；95%CI为1.17至1.54）。西班牙裔相比非西班牙裔接受预先移植的可能性较小（OR为0.57；95%CI为0.50至0.67）；2型糖尿病患者相比1型糖尿病患者（OR为0.76；95%CI为0.61至0.96）；与0个HLA错配相比，2至5个HLA错配时（OR范围为0.77至0.82）。在调整后的Cox比例风险分析中，与已接受透析后才进行移植的患者相比，25758例尸体供体移植中预先移植的移植物失败相对风险为0.75（0.67至0.84），13078例活体供体移植中为0.73（0.64至0.83）。预先移植与死亡风险降低相关：尸体供体移植为0.84（0.72至0.99），活体供体移植为0.69（0.56至0.85）。因此，与改善患者及移植物存活相关的预先移植，在少数种族、受教育程度较低以及主要依靠医疗保险支付费用的人群中不太常见。支付系统的改变、对早期转诊的重视以及尸体肾分配的变化，可能会增加从预先移植中受益的患者数量。
