Kfoury Abdallah G, Hammond M Elizabeth H, Snow Gregory L, Drakos Stavros G, Stehlik Josef, Fisher Patrick W, Reid Bruce B, Everitt Melanie D, Bader Feras M, Renlund Dale G
Intermountain Medical Center and Intermountain Healthcare, Salt Lake City, UT, USA.
J Heart Lung Transplant. 2009 Aug;28(8):781-4. doi: 10.1016/j.healun.2009.04.035.
Little has been reported on the clinical significance of asymptomatic antibody-mediated rejection (AMR) alone or mixed rejection (MR), defined as concurrent cellular rejection (CR) and AMR in heart transplantation. In this study, we examined whether a differential impact on cardiovascular mortality (CVM) existed when comparing asymptomatic AMR, to stable MR or CR.
The Utah Transplantation Affiliated Hospitals (UTAH) Cardiac Transplant Program pathology database of all heart transplant recipients between 1985 and 2004 was queried. Patients were classified as cellular, antibody-mediated, or mixed rejectors based on their predominant pattern of rejection type in the first three months post-transplant. Kaplan-Meier survival curves were fit to each of the three groups and analyses were adjusted for age at the time of transplant, gender, and underlying primary cardiac disease.
Eight hundred and sixty nine heart transplant recipients qualified for analysis. Over the study period, patients with asymptomatic AMR or stable MR patterns had significantly worse CVM when compared to patients with stable CR pattern (AMR, 21.2%; MR, 18.0%; CR, 12.6%; AMR vs. CR, p = 0.009; MR vs. CR, p = 0.001). In contrast, CVM was comparable in patients with asymptomatic AMR or stable MR patterns (p = 0.9).
Asymptomatic or subclinical AMR and MR are clinically relevant, should be recognized, and deserve consideration for therapeutic intervention in hopes of avoiding adverse outcomes.
关于无症状抗体介导排斥反应（AMR）单独存在或混合性排斥反应（MR，定义为心脏移植中同时存在细胞排斥反应（CR）和AMR）的临床意义，此前报道较少。在本研究中，我们比较了无症状AMR与稳定型MR或CR时，对心血管死亡率（CVM）的影响是否存在差异。
查询了犹他移植附属医院（UTAH）心脏移植项目1985年至2004年间所有心脏移植受者的病理数据库。根据移植后前三个月主要的排斥反应类型模式，将患者分为细胞性、抗体介导性或混合性排斥反应者。对三组分别绘制Kaplan-Meier生存曲线，并针对移植时的年龄、性别和潜在原发性心脏病进行分析调整。
869名心脏移植受者符合分析条件。在研究期间，与稳定型CR模式的患者相比，无症状AMR或稳定型MR模式的患者CVM显著更差（AMR为21.2%；MR为18.0%；CR为12.6%；AMR与CR相比，p = 0.009；MR与CR相比，p = 0.001）。相比之下，无症状AMR或稳定型MR模式的患者CVM相当（p = 0.9）。
无症状或亚临床AMR和MR具有临床相关性，应予以识别，并值得考虑进行治疗干预，以期避免不良后果。
