Russo Mark J, Chen Jonathan M, Hong Kimberly N, Stewart Allan S, Ascheim Deborah D, Argenziano Michael, Mancini Donna M, Oz Mehmet C, Naka Yoshifumi
Division of Cardiothoracic Surgery, Department of Surgery, College of Physicians and Surgeons, Columbia University , New York, NY, USA.
Circulation. 2006 Nov 21;114(21):2280-7. doi: 10.1161/CIRCULATIONAHA.106.615708. Epub 2006 Nov 6.
This study compares posttransplantation outcomes of survival and morbidity among recipients with and without diabetes mellitus (DM).
The United Network of Organ Sharing (UNOS) provided deidentified patient-level data. Primary analysis focused on 20,412 first-time heart transplant recipients aged > or = 18 years who underwent transplantation between January 1, 1995, and December 31, 2005. To determine severity of DM, DM recipients were stratified by their aggregate number of diabetes-related complications (DRCs), including pretransplantation history of renal failure (serum creatinine = 2.5 mg/dL), peripheral vascular disease, cerebrovascular accident, and severe obesity (body mass index > or = 35 kg/m2). Kaplan-Meier analysis was performed to compare time to event. Although posttransplantation survival was significantly better (P<0.001) among patients without DM (median survival 10.1 years) than among those with DM (9.0 years), survival did not differ (P=0.08) between those without DM (10.1 years) and those with uncomplicated DM (0 DRCs; 9.3 years). Among those with DM, survival was worse with each additional DRC: 0 DRC, 9.3 years; 1 DRC, 6.7 years; and > or = 2 DRCs, 3.6 years. Although acute rejection and transplant coronary artery disease-free survival did not differ between groups, renal failure and severe infection-free survival were worse in those with DM and were inversely related to the number of DRCs.
Posttransplantation survival among patients with uncomplicated DM was not significantly different than that among nondiabetics. However, when stratified by disease severity, recipients with more severe diabetes had significantly worse survival than nondiabetics. Therefore, although DM alone should not be a contraindication to heart transplantation, given the critical shortage of transplantable organs, maximal benefit may be achieved by exploring alternative treatment options in patients with severe DM. These include use of high-risk transplant lists and destination therapy.
本研究比较了有和没有糖尿病（DM）的心脏移植受者移植后的生存和发病结局。
器官共享联合网络（UNOS）提供了经过去识别化处理的患者层面数据。主要分析聚焦于1995年1月1日至2005年12月31日期间接受移植的20412例年龄≥18岁的首次心脏移植受者。为确定DM的严重程度，将DM受者按糖尿病相关并发症（DRC）的总数进行分层，包括移植前肾衰竭病史（血清肌酐≥2.5mg/dL）、外周血管疾病、脑血管意外和严重肥胖（体重指数≥35kg/m²）。采用Kaplan-Meier分析比较事件发生时间。尽管无DM患者（中位生存期10.1年）移植后的生存率显著高于DM患者（9.0年）（P<0.001），但无DM患者（10.图1年）和无并发症DM患者（0个DRC；9.3年）之间的生存率无差异（P=0.08）。在DM患者中，每增加一个DRC，生存率就更差：0个DRC，9.3年；1个DRC，6.7年；≥2个DRC，3.6年。尽管各组之间急性排斥反应和无移植冠状动脉疾病生存率无差异，但DM患者的肾衰竭和无严重感染生存率更差，且与DRC数量呈负相关。
无并发症DM患者移植后的生存率与非糖尿病患者无显著差异。然而，按疾病严重程度分层时，糖尿病更严重的受者生存率显著低于非糖尿病患者。因此，尽管单纯DM不应成为心脏移植的禁忌证，但鉴于可移植器官严重短缺，通过探索严重DM患者的替代治疗方案可能实现最大获益。这些方案包括使用高风险移植名单和目标治疗。
