比较伴有和不伴有早期急性排斥反应的肺移植受者支气管狭窄。
A comparative analysis of bronchial stricture after lung transplantation in recipients with and without early acute rejection.
机构信息
Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA.
出版信息
Ann Thorac Surg. 2013 Sep;96(3):1008-17; discussion 1017-8. doi: 10.1016/j.athoracsur.2013.01.104. Epub 2013 Jul 18.
BACKGROUND
Risk factors and outcomes of bronchial stricture after lung transplantation are not well defined. An association between acute rejection and development of stricture has been suggested in small case series. We evaluated this relationship using a large national registry.
METHODS
All lung transplantations between April 1994 and December 2008 per the United Network for Organ Sharing (UNOS) database were analyzed. Generalized linear models were used to determine the association between early rejection and development of stricture after adjusting for potential confounders. The association of stricture with postoperative lung function and overall survival was also evaluated.
RESULTS
Nine thousand three hundred thirty-five patients were included for analysis. The incidence of stricture was 11.5% (1,077/9,335), with no significant change in incidence during the study period (P=0.13). Early rejection was associated with a significantly greater incidence of stricture (adjusted odds ratio [AOR], 1.40; 95% confidence interval [CI], 1.22-1.61; p<0.0001). Male sex, restrictive lung disease, and pretransplantation requirement for hospitalization were also associated with stricture. Those who experienced stricture had a lower postoperative peak percent predicted forced expiratory volume at 1 second (FEV1) (median 74% versus 86% for bilateral transplants only; p<0.0001), shorter unadjusted survival (median 6.09 versus 6.82 years; p<0.001) and increased risk of death after adjusting for potential confounders (adjusted hazard ratio 1.13; 95% CI, 1.03-1.23; p=0.007).
CONCLUSIONS
Early rejection is associated with an increased incidence of stricture. Recipients with stricture demonstrate worse postoperative lung function and survival. Prospective studies may be warranted to further assess causality and the potential for coordinated rejection and stricture surveillance strategies to improve postoperative outcomes.
背景
肺移植后支气管狭窄的风险因素和结果尚不清楚。小病例系列研究提示急性排斥反应与狭窄的发生有关。我们使用一个大型国家登记处评估了这种关系。
方法
根据美国器官共享网络（UNOS）数据库，分析了 1994 年 4 月至 2008 年 12 月期间的所有肺移植。使用广义线性模型，在校正潜在混杂因素后，确定早期排斥与狭窄发生之间的关系。还评估了狭窄与术后肺功能和总生存率的关系。
结果
共纳入 9335 例患者进行分析。狭窄的发生率为 11.5%（1077/9335），研究期间发生率无显著变化（P=0.13）。早期排斥与狭窄的发生率显著增加相关（调整优势比[OR]，1.40；95%置信区间[CI]，1.22-1.61；p<0.0001）。男性、限制性肺疾病和移植前住院需求也是狭窄的相关因素。发生狭窄的患者术后最大预计用力呼气量的 1 秒峰值百分比（FEV1）较低（仅双侧移植者的中位数为 74%，而非狭窄者的中位数为 86%；p<0.0001），未经调整的生存率较短（中位数为 6.09 年，而非狭窄者的中位数为 6.82 年；p<0.001），并且在校正潜在混杂因素后，死亡风险增加（调整后的危险比为 1.13；95%CI，1.03-1.23；p=0.007）。
结论
早期排斥与狭窄发生率增加有关。发生狭窄的受者术后肺功能和生存率较差。可能需要前瞻性研究进一步评估因果关系和协调排斥与狭窄监测策略以改善术后结果的潜力。
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