Gill John S, Abichandani Rekha, Kausz Annamaria T, Pereira Brian J G
Department of Nephrology, Tufts-New England Medical Center, Boston, Massachusetts, USA.
Kidney Int. 2002 Nov;62(5):1875-83. doi: 10.1046/j.1523-1755.2002.00640.x.
One third of cadaveric kidney transplant recipients suffer graft loss within five years of transplantation. Non-immunologic factors that predict mortality among non-transplant patients also may be potentially modifiable risk factors for mortality among patients with transplant failure.
Applying multivariate survival analysis to data from the United States Renal Data System, we determined the effect of immunologic or transplant related factors and non-immunologic factors on mortality in patients who initiated dialysis after kidney transplant failure in the United States between April 1995 and September 1998.
A total of 4741 patients were followed for a median +/- standard deviation of 15 +/- 11 months after initiation of dialysis after transplant failure. The majority of the 1016 (21%) deaths were due to cardiac (36%) or infectious (17%) causes. Patients in the following groups had an increased risk for all-cause mortality: older patients [hazard ratio (HR) = 1.04 per year, 95% confidence interval (95% CI) 1.03-1.04], women (HR = 1.31, 95% CI 1.10-1.56), patients of white race (HR = 1.94, 95% CI 1.32-2.84), patients with diabetes (HR = 1.76, 95% CI 1.43-2.16), peripheral vascular disease (HR = 1.94, 95% CI 1.54-2.43), congestive heart failure (HR = 1.26, 95% CI 1.05-1.53), drug use (HR = 2.23; 95% CI 1.08-4.60), smokers (HR = 1.35, 95% CI 1.01-1.81), first transplant recipients (HR = 1.32, 95% CI 1.02-1.69), and patients with a higher glomerular filtration rate (GFR) at dialysis initiation (HR = 1.04 per mL/min higher, 95% CI 1.02-1.06). Those with private insurance (HR = 0.67, 95% CI 0.49-0.93) and higher serum albumin (HR = 0.73 per g/dL higher, 95% CI 0.64-0.83) had a decreased risk for all-cause mortality. Acute rejection, antibody induction, donor source, duration of graft survival and the maximum attained GFR during transplantation did not predict all-cause mortality.
Non-immunologic factors predicted mortality among patients with transplant failure but immunologic and transplant related factors did not. Prevention, early diagnosis and treatment of co-morbid conditions and the complications of chronic kidney disease may improve the survival of patients with transplant failure.
三分之一的尸体肾移植受者在移植后五年内出现移植肾失功。在非移植患者中预测死亡率的非免疫因素也可能是移植失败患者死亡的潜在可改变风险因素。
应用多变量生存分析对美国肾脏数据系统的数据进行分析，我们确定了免疫或移植相关因素以及非免疫因素对1995年4月至1998年9月在美国肾移植失败后开始透析的患者死亡率的影响。
在移植失败后开始透析后，共对4741例患者进行了中位±标准差为15±11个月的随访。1016例（21%）死亡患者中，大多数死于心脏原因（36%）或感染原因（17%）。以下几组患者全因死亡风险增加：老年患者[风险比（HR）=每年1.04，95%置信区间（95%CI）1.03 - 1.04]、女性（HR = 1.31，95%CI 1.10 - 1.56）、白人患者（HR = 1.94，95%CI 1.32 - 2.84）、糖尿病患者（HR = 1.76，95%CI 1.43 - 2.16）、外周血管疾病患者（HR = 1.94，95%CI 1.54 - 2.43）、充血性心力衰竭患者（HR = 1.26，95%CI 1.05 - 1.53）、药物使用者（HR = 2.23；95%CI 1.08 - 4.60）、吸烟者（HR = 1.35，95%CI 1.01 - 1.81）、首次移植受者（HR = 1.32，95%CI 1.02 - 1.69）以及透析开始时肾小球滤过率（GFR）较高的患者（每高1 mL/min，HR = 1.04，95%CI 1.02 - 1.06）。拥有私人保险的患者（HR = 0.67，95%CI 0.49 - 0.93）和血清白蛋白较高的患者（每高1 g/dL，HR = 0.73，95%CI 0.64 - 0.83）全因死亡风险降低。急性排斥反应、抗体诱导、供体来源、移植肾存活时间以及移植期间达到的最高GFR均不能预测全因死亡。
非免疫因素可预测移植失败患者的死亡率，但免疫和移植相关因素不能。预防、早期诊断和治疗合并症以及慢性肾病的并发症可能会提高移植失败患者的生存率。
