Sharples L D, Caine N, Mullins P, Scott J P, Solis E, English T A, Large S R, Schofield P M, Wallwork J
MRC Biostatistics Unit, Cambridge, UK.
Transplantation. 1991 Aug;52(2):244-52. doi: 10.1097/00007890-199108000-00012.
This study demonstrates the importance of analyzing survival by cause of death in order to achieve a better understanding of the prognostic indicators involved. It further emphasizes the need for analysis of risk factors in both univariate and multivariate models, and the danger of making judgements based on premature analysis of data on follow-up after heart transplantation. Survival following transplantation is characterized by the major hazards of early death due to infection and rejection and late graft loss due to coronary occlusive disease (COD). This study summarizes the first-graft survival experience for 323 transplant patients at Papworth Hospital, and assesses a number of potential risk factors for (1) early mortality, (2) late mortality from COD, and (3) development of COD. The potential risk factors considered for all hazards are donor and recipient age, sex, blood group, and matching of these factors; donor cause of death and recipient immunosuppression; inotropic support; waiting time; preoperative diagnosis and previous cardiac surgery; ischemic time; and extubation time. In addition, for development of, and graft loss from, COD, perioperative rejection and cytomegalovirus infection; hypertension at discharge; and cholesterol, triglycerides, and lipids at two years were assessed as risk factors. Advances in immunosuppression were observed to have increased overall survival rates and decreased mortality from infection, rejection, and COD, as well as decreasing morbidity from COD. Fatal rejection was found to be more likely in female recipients, recipients over 40 years, recipients of grafts from donors over 30 years old, patients who were transplanted for valvular heart disease, and patients who waited less than three months for their transplant. Male recipients of female donor organs were more likely to lose their grafts as a result of COD. Patients older than 50 and hearts from donors older than 40 conferred a high risk of development of and loss from COD. Patients transplanted for ischemic heart disease were more likely to develop COD. High cholesterol, low HDL, high LDL, and high triglycerides at two years after transplant showed some evidence of high risk for the subsequent development of COD, although these relationships are not statistically significant at this stage. Contrary to other recent studies, cytomegalovirus infection was not found to be a risk factor for the development of COD.
本研究表明，按死因分析生存率对于更好地理解所涉及的预后指标至关重要。它进一步强调了在单变量和多变量模型中分析风险因素的必要性，以及基于心脏移植后随访数据的过早分析做出判断的危险性。移植后的生存情况特点是存在因感染和排斥导致的早期死亡以及因冠状动脉闭塞性疾病（COD）导致的晚期移植物丧失等主要风险。本研究总结了帕普沃思医院323例移植患者的首次移植物生存经验，并评估了一些针对以下方面的潜在风险因素：（1）早期死亡率；（2）因COD导致的晚期死亡率；（3）COD的发生。针对所有风险考虑的潜在风险因素包括供体和受体的年龄、性别、血型以及这些因素的匹配情况；供体死因和受体免疫抑制情况；正性肌力支持；等待时间；术前诊断和既往心脏手术史；缺血时间；以及拔管时间。此外，对于COD的发生和移植物丧失，围手术期排斥反应和巨细胞病毒感染；出院时的高血压；以及两年时的胆固醇、甘油三酯和血脂水平被评估为风险因素。观察到免疫抑制方面的进展提高了总体生存率，降低了因感染、排斥和COD导致的死亡率，以及降低了因COD导致的发病率。发现女性受体、40岁以上的受体、接受30岁以上供体移植物的受体、因瓣膜性心脏病接受移植的患者以及移植等待时间少于三个月的患者发生致命排斥反应的可能性更大。接受女性供体器官的男性受体因COD更有可能失去移植物。50岁以上的患者以及来自40岁以上供体的心脏发生COD及其导致移植物丧失的风险较高。因缺血性心脏病接受移植的患者更有可能发生COD。移植后两年时高胆固醇、低高密度脂蛋白、高低密度脂蛋白和高甘油三酯水平显示出后续发生COD的一些高风险迹象，尽管目前这些关系在统计学上并不显著。与其他近期研究相反，未发现巨细胞病毒感染是COD发生的风险因素。
