Osho Asishana A, Castleberry Anthony W, Snyder Laurie D, Ganapathi Asvin M, Speicher Paul J, Hirji Sameer A, Stafford-Smith Mark, Daneshmand Mani A, Duane Davis R, Hartwig Matthew G
School of Medicine; and the Departments of.
Surgery.
J Heart Lung Transplant. 2015 Apr;34(4):571-9. doi: 10.1016/j.healun.2014.09.035. Epub 2014 Oct 2.
Historical concerns about lung transplantation in patients with a glomerular filtration rate (GFR) ≤ 50 ml/min/1.73 m(2) have not been validated. We hypothesize that a pre-transplant GFR ≤ 50 ml/min/1.73 m(2) represents a high mortality risk, especially in the setting of acute GFR decline. In addition, we explore the potential for improved risk stratification using a statistically derivable alternative cutoff.
Adult, primary, lung recipients in the United Network for Organ Sharing database were analyzed (October 1987 to December 2011). Recursive partitioning identified the GFR value that provides maximal separation in 1-year mortality. Survival over/under the cutoffs was compared using stratified log-rank, Cox, and Kaplan-Meier methods, before and after 1:2 propensity score matching.
Median GFR at time of transplant for 19,425 study patients was 94.2 ml/min/1.73 m(2) (quartile 1-quartile, 2 76.9-105.9 ml/min/1.73 m(2)). Recursive partitioning identified a GFR of 40.2 ml/min/1.73 m(2) as the ideal inflection point for predicting 1-year survival. Cutoffs demonstrated statistically significant effects on survival after 840 patients with a GFR ≤ 50 ml/min/1.73 m(2) (hazard ratio, 1.28; 95% confidence interval, 1.15-1.43) and 401 patients with a GFR ≤ 40.2 ml/min/1.73 m(2) (hazard ratio, 1.57; 95% confidence interval, 1.36-1.83) were matched with high GFR controls (p < 0.001). In 13,509 patients with available GFR at the time of listing and transplant, a pre-transplant GFR decline of ≥ 50% from baseline was associated with worse survival (p < 0.001).
A pre-transplant GFR ≤ 50 ml/min/1.73 m(2) is associated with decreased survival. However, patients with GFR between 40 and 50 ml/min/1.73 m(2) do not suffer excessive post-transplant mortality and should not be automatically excluded from listing. Notably, outcomes are worse in patients with poor renal function and concomitant pre-transplant GFR decline. Strategies should be devised to detect and manage interval renal deterioration before lung transplantation.
既往对于肾小球滤过率（GFR）≤50 ml/min/1.73 m² 的患者进行肺移植的担忧尚未得到证实。我们假设移植前 GFR≤50 ml/min/1.73 m² 代表高死亡风险，尤其是在急性 GFR 下降的情况下。此外，我们探索使用统计学推导的替代临界值来改善风险分层的可能性。
对器官共享联合网络数据库中的成年原发性肺移植受者进行分析（1987 年 10 月至 2011 年 12 月）。递归划分确定了在 1 年死亡率方面提供最大区分度的 GFR 值。在 1:2 倾向评分匹配前后，使用分层对数秩检验、Cox 检验和 Kaplan-Meier 方法比较临界值上下的生存率。
19425 例研究患者移植时的 GFR 中位数为 94.2 ml/min/1.73 m²（四分位数间距，2 76.9 - 105.9 ml/min/1.73 m²）。递归划分确定 GFR 为 40.2 ml/min/1.73 m² 是预测 1 年生存率的理想转折点。对于 840 例 GFR≤50 ml/min/1.73 m² 的患者（风险比，1.28；95%置信区间，1.15 - 1.43）和 401 例 GFR≤40.2 ml/min/1.73 m² 的患者（风险比，1.57；置信区间，1.36 - 1.83）与高 GFR 对照组进行匹配后，临界值对生存率有统计学显著影响（p < 0.001）。在 13509 例登记和移植时具有可用 GFR 的患者中，移植前 GFR 较基线下降≥50%与较差的生存率相关（p < 0.001）。
移植前 GFR≤50 ml/min/1.73 m² 与生存率降低相关。然而，GFR 在 40 至 50 ml/min/1.73 m² 之间的患者移植后不会遭受过高的死亡率，不应自动被排除在登记之外。值得注意的是，肾功能差且伴有移植前 GFR 下降的患者预后更差。应制定策略在肺移植前检测和管理间歇性肾功能恶化。
