Department of Transplantation, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, London, UK.
King's Health Economics, Health Services and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience at King's College, London, UK.
Lancet. 2017 Feb 18;389(10070):727-734. doi: 10.1016/S0140-6736(16)31595-1. Epub 2017 Jan 6.
More than 40% of patients awaiting a kidney transplant in the UK are sensitised with human leucocyte antigen (HLA) antibodies. Median time to transplantation for such patients is double that of unsensitised patients at about 74 months. Removing antibody to perform an HLA-incompatible (HLAi) living donor transplantation is perceived to be high risk, although patient survival data are limited. We compared survival of patients opting for an HLAi kidney transplant with that of similarly sensitised patients awaiting a compatible organ.
From the UK adult kidney transplant waiting list, we selected crossmatch positive living donor HLAi kidney transplant recipients who received their transplant between Jan 1, 2007, and Dec 31, 2013, and were followed up to Dec 31, 2014 (end of study). These patients were matched in a 1:4 ratio with similarly sensitised patients cases listed for a deceased-donor transplant during that period. Data were censored both at the time of transplantation (listed only), and at the end of the study period (listed or transplant). We used Kaplan-Meier curves to compare patient survival between HLAi and the matched cohort.
Of 25 518 patient listings, 213 (1%) underwent HLAi transplantation during the study period. 852 matched controls were identified, of whom 41% (95% CI 32-50) remained without a transplant at 58 months after matching. We noted no difference in survival between patients who were in the HLAi group compared with the listed only group (log rank p=0·446), or listed or transplant group (log rank p=0·984).
Survival of sensitised patients undergoing HLAi in the UK is comparable with those on dialysis awaiting a compatible organ, many of whom are unlikely to be have a transplant. Choosing a direct HLAi transplant has no detrimental effect on survival, but offers no survival benefit, by contrast with similar patients studied in a North American multicentre cohort.
UK National Health Service Blood & Transplant and Guy's & St Thomas' National Institute for Health Research Biomedical Research Centre.
在英国，超过 40%等待肾移植的患者存在人类白细胞抗原 (HLA) 抗体。此类患者的中位移植时间是未致敏患者的两倍，约为 74 个月。尽管患者生存数据有限，但人们认为去除抗体进行 HLA 不匹配（HLAi）活体供肾移植风险较高。我们比较了选择 HLAi 肾移植的患者与等待匹配器官的类似致敏患者的生存情况。
从英国成人肾移植等待名单中，我们选择了在 2007 年 1 月 1 日至 2013 年 12 月 31 日期间接受交叉配型阳性的 HLAi 活体供肾移植且随访至 2014 年 12 月 31 日（研究结束）的患者，并按照 1:4 的比例与同期等待尸肾移植的类似致敏患者进行匹配。数据在移植时（仅列出）和研究结束时（列出或移植）进行了删失。我们使用 Kaplan-Meier 曲线比较 HLAi 组和匹配队列的患者生存情况。
在 25518 名患者名单中，213 名（1%）在研究期间接受了 HLAi 移植。确定了 852 名匹配对照，其中 41%（95%CI 32-50）在匹配后 58 个月仍未进行移植。我们发现，与仅列出组（对数秩检验 p=0.446）或列出或移植组（对数秩检验 p=0.984）相比，HLAi 组患者的生存情况没有差异。
在英国，接受 HLAi 的致敏患者的生存情况与接受透析等待匹配器官的患者相当，其中许多患者不太可能进行移植。与在北美多中心队列中研究的类似患者相比，选择直接 HLAi 移植不会对生存产生不利影响，但也没有生存获益。
英国国民保健署血液与移植和盖伊与圣托马斯国家卫生研究院生物医学研究中心。
