Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Transplant Center, Vanderbilt University Medical Center, Nashville, Tennessee; Veterans Affairs Hospital, Tennessee Valley Healthcare System, Nashville, Tennessee.
Ann Thorac Surg. 2018 Dec;106(6):1633-1639. doi: 10.1016/j.athoracsur.2018.06.072. Epub 2018 Aug 16.
Single lung transplantation (SLT) and double lung transplantation (DLT) are associated with differences in morbidity and mortality, although the effects of transplant type on patient-reported outcomes are not widely reported and conclusions have differed. Previous studies compared mean health-related quality of life (HRQOL) scores but did not evaluate potentially different temporal trajectories in the context of longitudinal follow-up. To address this uncertainty, this study was designed to evaluate longitudinal HRQOL after SLT and DLT with the hypothesis that temporal trajectories differ between SLT and DLT.
Patients transplanted at a single institution were eligible to be surveyed at 1 month, 3 months, 6 months, and then annually after transplant using the Short Form 36 Health Survey, with longitudinal physical component summary (PCS) and mental component summary (MCS) scores as the primary outcomes. Multivariable mixed-effects models were used to evaluate the effects of transplant type and time posttransplant on longitudinal PCS and MCS after adjusting age, diagnosis, rejection, Lung Allocation Score quartile, and intubation duration. Time by transplant type interaction effects were used to test whether the temporal trajectories of HRQOL differ between SLT and DLT recipients. HRQOL scores were referenced to general population norms (range, 40 to 60; mean, 50 ± 10) using accepted standards for a minimally important difference (½ SD, 5 points).
Postoperative surveys (n = 345) were analyzed for 136 patients (52% male, 23% SLT, age 52 ± 13 years, LAS 42 ± 12, follow-up 37 ± 29 months [range, 0.6 to 133]) who underwent lung transplantation between 2005 and 2016. After adjusting for model covariates, overall posttransplant PCS scores have a significant downward trajectory (p = 0.015) whereas MCS scores remain stable (p = 0.593), with both averaging within general population norms. The time by transplant type interaction effect (p = 0.002), however, indicate that posttransplant PCS scores of SLT recipients decline at a rate of 2.4 points per year over the total observation period compared to DLT. At approximately 60 months, the PCS scores of SLT recipients, but not DLT recipients, fall below general population norms.
The trajectory of physical HRQOL in patients receiving SLT declines over time compared with DLT, indicating that, in the longer term, SLT recipients are more likely to have physical HRQOL scores that fall substantively below general population norms. Physical HRQOL after 5 years may be a consideration for lung allocation and patient counseling regarding expectations when recommending SLT or DLT.
单肺移植（SLT）和双肺移植（DLT）在发病率和死亡率方面存在差异，尽管移植类型对患者报告的结果的影响尚未广泛报道，且结论也存在差异。既往研究比较了平均健康相关生活质量（HRQOL）评分，但并未在纵向随访中评估潜在的不同时间轨迹。为了解决这一不确定性，本研究旨在评估 SLT 和 DLT 后的纵向 HRQOL，并假设 SLT 和 DLT 之间的时间轨迹存在差异。
在单中心接受移植的患者有资格在移植后 1 个月、3 个月、6 个月以及随后每年使用短格式 36 健康调查（SF-36）进行调查，主要结局为纵向物理成分综合评分（PCS）和心理成分综合评分（MCS）。采用多变量混合效应模型，在调整年龄、诊断、排斥反应、肺分配评分四分位数和插管时间后，评估移植类型和移植后时间对 PCS 和 MCS 的纵向影响。通过移植类型与时间的交互作用来检验 SLT 和 DLT 受者的 HRQOL 时间轨迹是否存在差异。采用公认的最小有意义差异（½ SD，5 分）标准，将 HRQOL 评分与一般人群的参考值（范围 40 至 60；平均 50 ± 10）进行比较。
对 2005 年至 2016 年间接受肺移植的 136 例患者（52%为男性，23%为 SLT，年龄 52 ± 13 岁，LAS 42 ± 12，随访 37 ± 29 个月[范围 0.6 至 133]）的术后调查（n=345）进行了分析。经模型协变量调整后，整体移植后 PCS 评分呈显著下降趋势（p=0.015），而 MCS 评分保持稳定（p=0.593），两者均在一般人群的参考值范围内。然而，移植类型与时间的交互作用效应（p=0.002）表明，与 DLT 相比，SLT 受者的 PCS 评分在整个观察期内每年下降 2.4 分。大约 60 个月时，SLT 受者的 PCS 评分低于一般人群的参考值，但 DLT 受者的 PCS 评分没有低于一般人群的参考值。
与 DLT 相比，接受 SLT 的患者的生理 HRQOL 轨迹随时间下降，表明在较长时间内，SLT 受者的生理 HRQOL 评分更有可能实质性地低于一般人群的参考值。5 年后的生理 HRQOL 可能是肺分配的一个考虑因素，并且在建议 SLT 或 DLT 时，可能需要对患者的咨询和期望进行考虑。
