Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland.
Division of Pulmonary and Critical Care, Department of Medicine, Johns Hopkins University, Baltimore, Maryland.
JAMA Surg. 2015 Jun;150(6):547-53. doi: 10.1001/jamasurg.2015.12.
The effect of prolonged graft ischemia (≥6 hours) on outcomes following lung transplantation is controversial.
To evaluate the effect of prolonged total graft ischemia times on long-term survival rates and the development of primary graft failure (PGF) following lung transplantation.
DESIGN, SETTING, AND PARTICIPANTS: In this retrospective study, the United Network for Organ Sharing database was queried for adult patients who underwent lung transplantation from May 1, 2005, through December 31, 2011. Primary stratification by the presence of prolonged graft ischemia was performed. Kaplan-Meier estimates at 1 and 5 years were used to compare survival in the 2 cohorts. A multivariable Cox proportional hazards regression model was constructed to identify predictors of 1- and 5-year mortality. A risk-adjusted predictive model for the development of PGF was formulated in a similar fashion.
The primary outcome of interest was 1- and 5-year survival. Secondary outcomes included PGF and other postoperative events, such as renal failure, biopsy-proven rejection, and stroke.
Of the 10,225 patients who underwent lung transplantation, 3127 (30.6%) had allografts exposed to prolonged ischemia. There was no difference in survival at 1 (83.6% [95% CI, 82.3%-84.9%] vs 84.1% [95% CI, 83.3%-85.0%]; P = .41) or 5 (52.5% [95% CI, 51.0%-54.0%] vs 53.5% [95% CI, 51.3%-55.6%]; P = .82) years between patients who received grafts that were or were not exposed to ischemia that lasted 6 hours or more, respectively. Prolonged graft ischemia did not independently predict 1- or 5-year mortality or the development of PGF (odds ratio, 1.11; 95% CI, 0.88-1.39; P = .37). Furthermore, prolonged ischemia did not independently predict 1-year (hazard ratio, 1.09; 95% CI, 0.97-1.22; P =.15) or 5-year (hazard ratio, 1.05; 95% CI, 0.98-1.14; P =.18) mortality or the development of PGF (odds ratio, 1.11; 95% CI, 0.88-1.39; P =.37).
No association was found between prolonged total graft ischemia times and primary graft failure or survival following lung transplantation. Given the scarcity of organs and the paucity of suitable recipients, prolonged ischemia time should not preclude transplantation. It is, therefore, reasonable to consider extending the accepted period of ischemia to more than 6 hours in certain patient populations to improve organ use.
肺移植后长时间供体器官缺血（≥6 小时）对结局的影响存在争议。
评估长时间总供体器官缺血时间对肺移植后长期生存率和原发性移植物衰竭（PGF）发展的影响。
设计、设置和参与者：在这项回顾性研究中，查询了 2005 年 5 月 1 日至 2011 年 12 月 31 日期间接受肺移植的成年患者的美国器官共享网络数据库。首先按供体器官长时间缺血的存在情况进行分层。使用 Kaplan-Meier 估计值在 1 年和 5 年时比较两组的生存率。构建了多变量 Cox 比例风险回归模型，以确定 1 年和 5 年死亡率的预测因素。以类似的方式制定了预测 PGF 发展的风险调整预测模型。
主要结局是 1 年和 5 年的生存率。次要结局包括 PGF 和其他术后事件，如肾衰竭、活检证实的排斥反应和中风。
在 10225 名接受肺移植的患者中，有 3127 名（30.6%）的同种异体移植物经历了长时间缺血。在 1 年（83.6%[95%CI，82.3%-84.9%]与 84.1%[95%CI，83.3%-85.0%]；P=0.41）或 5 年（52.5%[95%CI，51.0%-54.0%]与 53.5%[95%CI，51.3%-55.6%]）生存率方面，接受供体器官缺血时间为 6 小时或以上的患者之间没有差异。长时间供体器官缺血并不能独立预测 1 年或 5 年死亡率或 PGF 的发展（比值比，1.11；95%CI，0.88-1.39；P=0.37）。此外，长时间供体器官缺血也不能独立预测 1 年（风险比，1.09；95%CI，0.97-1.22；P=0.15）或 5 年（风险比，1.05；95%CI，0.98-1.14；P=0.18）死亡率或 PGF 的发展（比值比，1.11；95%CI，0.88-1.39；P=0.37）。
长时间总供体器官缺血时间与肺移植后原发性移植物衰竭或生存率之间未发现关联。鉴于器官的稀缺性和合适受者的缺乏，延长缺血时间不应排除移植。因此，在某些患者群体中，将可接受的缺血时间延长至 6 小时以上以提高器官利用率是合理的。
