Utah Transplant Affiliated Hospitals (U.T.A.H.) Cardiac Transplant Program, University of Utah Health Center and Veterans Affairs Medical CentePlease check the following authors groups Abdallah G. Kfoury, Stavros G. Drakos, Craig H. Selzman affilation citation is missing.-->r, Intermountain Medical Center, Salt Lake City, Utah.
International Society for Heart and Lung Transplantation Registry, Dallas, Texas.
J Heart Lung Transplant. 2017 Apr;36(4):407-417. doi: 10.1016/j.healun.2016.08.008. Epub 2016 Aug 20.
Survival beyond 1 year after heart transplantation has remained without significant improvement for the last 2 decades. A more individualized approach to post-transplant care could result in a reduction of long-term mortality. Although recipient age has been associated with an increased incidence of certain post-transplant morbidities, its effect on cause-specific mortality has not been established.
We analyzed overall and cause-specific mortality of heart transplant recipients registered in the International Society for Heart and Lung Transplantation Registry between 1995 and 2011. Patients were grouped by recipient age: 18 to 29, 30 to 39, 40 to 49, 50 to 59, 60 to 69, and ≥ 70 years. Multivariable regression models were used to examine the association between recipient age and leading causes of post-transplant mortality. We also compared immunosuppression (IS) use among the different recipient age groups.
There were 52,995 recipients (78% male; median age [5th, 95th percentile]: 54 [27, 66] years). Survival through 10 years after transplant was lower in heart transplant recipients in the 2 more advanced age groups: 49% for 60 to 69 years and 36% for ≥ 70 years (p < 0.01 for pairwise comparisons with remaining groups). The risk of death caused by acute rejection (hazard ratio [HR], 4.11; p < 0.01), cardiac allograft vasculopathy (HR, 2.85; p < 0.01), and graft failure (HR, 2.29; p < 0.01) was highest in the youngest recipients (18-29 years) compared with the reference group (50-59 years). However, the risk of death caused by infection (HR, 2.10; p < 0.01) and malignancy (HR, 2.23; p < 0.01) was highest in older recipients (≥ 70 years). Similarly, the risk of death caused by renal failure was lower in younger recipients than in the reference group (HR, 0.53; p < 0.01 for 18-49 years vs 50-59 years). The use of induction IS was similar among the different recipient age groups, and differences in maintenance IS were not clinically important.
Causes of death in this large cohort of heart transplant recipients varied significantly with recipient age at the time of transplant, with cause-specific mortality profiles suggesting a possible effect of inadequate IS in younger recipients and over-IS in older recipients. Thus, a more personalized approach, possibly including different IS strategies according to recipient age, might result in improved post-transplant survival.
在过去的 20 年中，心脏移植后 1 年的生存率仍没有显著提高。对移植后护理进行更个体化的处理可能会降低长期死亡率。尽管受体年龄与某些移植后疾病的发生率增加有关，但它对特定原因死亡率的影响尚未确定。
我们分析了 1995 年至 2011 年间国际心肺移植协会注册的心脏移植受者的总死亡率和特定原因死亡率。患者按受体年龄分组：18 至 29 岁、30 至 39 岁、40 至 49 岁、50 至 59 岁、60 至 69 岁和≥70 岁。使用多变量回归模型检查受体年龄与移植后主要死亡原因之间的关系。我们还比较了不同受体年龄组之间免疫抑制（IS）的使用情况。
共有 52995 名受者（78%为男性；中位年龄[第 5 百分位数，第 95 百分位数]：54[27，66]岁）。在年龄较大的两个组中，心脏移植受者 10 年后的生存率较低：60 至 69 岁组为 49%，≥70 岁组为 36%（与其余组相比，差异具有统计学意义[两两比较，p<0.01]）。与参考组（50-59 岁）相比，急性排斥反应（危险比[HR]，4.11；p<0.01）、心脏移植物血管病（HR，2.85；p<0.01）和移植物衰竭（HR，2.29；p<0.01）导致死亡的风险在最年轻的受者（18-29 岁）中最高。然而，在年龄较大的受者（≥70 岁）中，感染（HR，2.10；p<0.01）和恶性肿瘤（HR，2.23；p<0.01）导致死亡的风险最高。同样，年轻受者（18-49 岁）发生肾衰竭导致死亡的风险低于参考组（HR，0.53；p<0.01）。不同受体年龄组之间诱导性 IS 的使用情况相似，而维持性 IS 的差异没有临床意义。
本研究中，该大型心脏移植受者队列的死亡原因与移植时受者年龄显著相关，特定原因死亡率提示年轻受者的免疫抑制不足和老年受者的免疫抑制过度可能是造成这种情况的原因。因此，采用更个体化的方法，可能包括根据受者年龄制定不同的免疫抑制策略，可能会提高移植后的生存率。
