ABO 血型不相容心脏移植：儿科心脏移植研究（PHTS）数据库分析。
ABO-incompatible heart transplantation: analysis of the Pediatric Heart Transplant Study (PHTS) database.
机构信息
Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA.
出版信息
J Heart Lung Transplant. 2012 Feb;31(2):173-9. doi: 10.1016/j.healun.2011.11.013.
BACKGROUND
ABO incompatible (ABOi) heart transplantation is an accepted approach to increasing organ availability for young patients. Previous studies have suggested that early survival for ABOi transplants is similar to ABO compatible (ABOc) transplants. We analyzed the Pediatric Heart Transplant Study (PHTS) database from 1/96 to 12/08 to further assess this strategy.
METHODS
We analyzed the numbers of ABOi and ABOc done at the PHTS centers. We then compared the clinical characteristics, and short-term freedom from death, rejection and infection in the ABOi patients with the patients that had an ABOc heart transplant during the same period. All patients were less than or equal to 15 months of age at listing (the age of the oldest ABOi patient). We adjusted for co-variates shown to increase risk for mortality (age less than 1 month, extracorporeal membrane oxygenation (ECMO), ventilator, previous sternotomy, and congenital heart disease).
RESULTS
There were 931 total transplants done at 34 PHTS centers during the 12 year time period in patients ≤15 months of age. Of these, 502 transplants were performed at 20 PHTS centers that did at least one ABOi heart transplant. Eighty-five of the 502 (17%) were ABOi. At time of transplant, ABOi recipients compared with ABOc were more likely to be on a ventilator (49.4% vs 36.5%, p=0.025), and more often supported with ECMO (23.5% vs 13.4%, p=0.018). There was similar survival at 12 months (82% vs 84%, p=0.7). In risk adjusted analysis ABOi status was not associated with 1 year mortality (HR 0.85, 95% CI 0.45-1.6, p=0.61). The ABOi patients had greater freedom from rejection when compared with ABOc patients for all 34 centers (75% vs 62%, p=0.016), but the difference was not significant when limited only to the 20 centers doing ABOi transplants (75% vs 69%, p=0.4). The ABOi cohort had lower infection rates (23.5% vs 37.9%, p = 0.013). This difference remained after adjusting for center and other covariates.
CONCLUSIONS
In center and risk adjusted analysis, young children who received an ABOi transplant had equivalent one-year survival and freedom from rejection compared with those who received an ABOc transplant. In spite of the favorable outcome for ABOi recipients, many centers appear to reserve ABOi transplantation for sicker patients. These data mandate reexamination of the current United Network for Organ Sharing (UNOS) policy that gives priority to ABOc over ABOi transplantation in the United States.
背景
ABO 不相容（ABOi）心脏移植是增加年轻患者器官可用性的一种被接受的方法。先前的研究表明，ABOi 移植的早期存活率与 ABO 相容（ABOc）移植相似。我们分析了 1/96 至 12/08 期间的儿科心脏移植研究（PHTS）数据库，以进一步评估该策略。
方法
我们分析了 PHTS 中心进行的 ABOi 和 ABOc 的数量。然后，我们比较了 ABOi 患者和同期接受 ABOc 心脏移植患者的临床特征以及短期内的死亡率、排斥率和感染率。所有患者在入组时均小于或等于 15 个月龄（年龄最大的 ABOi 患者）。我们调整了已知增加死亡率风险的协变量（年龄小于 1 个月、体外膜氧合（ECMO）、呼吸机、先前的胸骨切开术和先天性心脏病）。
结果
在 12 年期间，34 个 PHTS 中心对 15 个月龄以下的患者进行了 931 次总移植。其中，20 个 PHTS 中心进行了 502 次 ABOi 心脏移植。502 例中有 85 例（17%）为 ABOi。在移植时，与 ABOc 相比，ABOi 受体更有可能使用呼吸机（49.4% vs 36.5%，p=0.025），并且更常需要 ECMO 支持（23.5% vs 13.4%，p=0.018）。12 个月时的生存率相似（82% vs 84%，p=0.7）。在风险调整分析中，ABOi 状态与 1 年死亡率无关（HR 0.85，95%CI 0.45-1.6，p=0.61）。与 ABOc 患者相比，ABOi 患者在所有 34 个中心的排斥反应发生率均较低（75% vs 62%，p=0.016），但仅在进行 ABOi 移植的 20 个中心中差异不显著（75% vs 69%，p=0.4）。ABOi 组的感染率较低（23.5% vs 37.9%，p=0.013）。在调整中心和其他协变量后，这种差异仍然存在。
结论
在中心和风险调整分析中，接受 ABOi 移植的幼儿与接受 ABOc 移植的幼儿相比，一年生存率和排斥反应发生率无差异。尽管 ABOi 受者的结果有利，但许多中心似乎将 ABOi 移植保留给病情更严重的患者。这些数据要求重新审查目前美国联合器官共享网络（UNOS）的政策，该政策将 ABOc 置于 ABOi 移植之前。
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