Gjertson D W, Terasaki P I, Takemoto S, Mickey M R
UCLA Tissue Typing Laboratory, 90024.
N Engl J Med. 1991 Apr 11;324(15):1032-6. doi: 10.1056/NEJM199104113241505.
Although receiving a cadaveric kidney matched at the HLA-A, B, and DR loci enhances graft survival in cyclosporine-treated patients, the value of a national system of kidney allocation based on HLA matching, with the attendant increased likelihood of better matching, is still questioned. Some fear that the costs of a national system are unjustified when only a small fraction of donors would exactly match any of the 16,000 potential recipients anyway. We estimated the effect on graft survival of the use of HLA matching for all allocations of cadaveric kidneys in the United States.
The graft-survival rates in five mutually exclusive groups of transplants with increasing numbers of HLA mismatches were estimated by partitioning the data for 22,190 first-time recipients of cadaveric kidneys. Overall graft survival was projected as a weighted average with use of the percentages of transplants in the hierarchical groups in recipient waiting pools of various sizes. We compared the benefits and costs of HLA matching in a national system with those of introducing cyclosporine, which was projected to enhance graft survival by 7 percentage points at 10 years.
Sharing kidneys nationally on the basis of hierarchical HLA matching was estimated to enhance graft survival by an additional 5 percentage points at 10 years. The anticipated five-year cost of national allocation of kidneys by HLA matching for 7000 recipients, including consideration of the costs of graft removal and dialysis after transplant rejection, would be +4F6.5 million less than the cost of using cyclosporine alone.
The use of an HLA allocation system will not add to the cost of renal transplantation, but it will improve the long-term results to the same extent as cyclosporine. We propose the initiation of a national kidney-sharing system based on hierarchical levels of HLA matches.
尽管接受在HLA - A、B和DR位点相匹配的尸体肾可提高接受环孢素治疗患者的移植肾存活率，但基于HLA匹配的全国性肾脏分配系统的价值仍受到质疑，该系统会增加更好匹配的可能性。一些人担心，当只有一小部分供体能够与16000名潜在受者中的任何一位完全匹配时，全国性系统的成本是不合理的。我们估计了在美国对所有尸体肾分配使用HLA匹配对移植肾存活率的影响。
通过对22190例首次接受尸体肾移植受者的数据进行划分，估计了HLA错配数量递增的五个相互排斥的移植组中的移植肾存活率。总体移植肾存活率通过使用不同规模受者等待池中分层组中移植的百分比作为加权平均值来预测。我们将全国性系统中HLA匹配的益处和成本与引入环孢素的益处和成本进行了比较，预计环孢素可使10年时的移植肾存活率提高7个百分点。
据估计，在全国范围内基于分层HLA匹配共享肾脏可使10年时的移植肾存活率再提高5个百分点。对7000名受者进行HLA匹配的全国性肾脏分配的预期五年成本，包括考虑移植排斥后移植肾切除和透析的成本，将比单独使用环孢素的成本少465万美元。
使用HLA分配系统不会增加肾移植的成本，但它将在与环孢素相同的程度上改善长期效果。我们建议启动基于HLA匹配分层水平的全国性肾脏共享系统。
