Department of Cardiovascular and Thoracic Surgery.
Pediatrics (Cardiology), University of Texas Southwestern Medical Center and Children's Medical Center, Dallas, Texas, USA.
J Heart Lung Transplant. 2019 Mar;38(3):241-251. doi: 10.1016/j.healun.2018.09.026. Epub 2018 Sep 28.
Pediatric heart transplant waitlist mortality remains significant but allograft offer refusals are common and allografts continue to be discarded. Our aim in this study was to assess the impact of donor organ refusals on mortality after listing using a multi-institutional data set.
In this study we conducted a retrospective review of donor offers made to pediatric (<18 years) recipients in the United States in the period from 2007 to 2017. Candidates were stratified by whether they refused an acceptable donor offer (ADO). Acceptance was defined as an offer from a donor <40 years old and within 1,000 miles that was ultimately accepted by a waitlist candidate. Candidate survival after an offer was assessed.
There were 12,447 hearts offered at least once to a pediatric candidate. Most candidates (n = 4,282, 84.4%) refused the first offer, and 677 (15.4%) of these subsequently died or were removed from the list for deterioration. Refusal of an ADO was associated with higher mortality after listing, independent of transplant, in both univariate (1 year: 92% vs 87%, p = 0.002) and multivariate (hazard ratio 1.5, 95% CI 1.2 to 1.7, p < 0.0001) Cox regression analyses. ADO refusals were not correlated with improved post-transplant survival and >8 ADO refusals was associated with higher risk-adjusted post-transplant mortality (odds ratio 1.7, 95% confidence interval 1.0 to 2.9, p = 0.04).
Refusal of ADOs is associated with higher risk-adjusted mortality after listing (independent of transplantation), without improvement in post-transplant outcomes. So, although a "perfect" organ would be ideal, acceptance of one that is "good enough" has the potential to improve survival among pediatric candidates for heart transplantation.
儿科心脏移植候补者死亡率仍然很高，但异体器官供体拒绝接受的情况很常见，而且异体器官仍在被丢弃。我们在这项研究中的目的是使用多机构数据集评估供体器官拒绝接受对列入名单后的死亡率的影响。
在这项研究中，我们对 2007 年至 2017 年期间在美国接受儿科（<18 岁）受者的供体提出的供体进行了回顾性审查。候选者按是否拒绝可接受的供体（ADO）进行分层。接受定义为来自<40 岁且<1000 英里的供体的供体，最终被候补者接受。评估了接受供体后候选者的生存情况。
共提供了 12447 颗心脏，至少一次提供给了儿科候选者。大多数候选者（n=4282，84.4%）拒绝了第一个供体，其中 677 个（15.4%）随后死亡或因病情恶化而被从名单中删除。ADO 的拒绝与列出后的更高死亡率相关，无论移植与否，在单变量（1 年：92%对 87%，p=0.002）和多变量（风险比 1.5，95%CI 1.2 至 1.7，p<0.0001）Cox 回归分析中均如此。ADO 拒绝与移植后生存改善无关，拒绝>8 次 ADO 与风险调整后移植后死亡率增加相关（比值比 1.7，95%置信区间 1.0 至 2.9，p=0.04）。
ADO 的拒绝与列入名单后的风险调整死亡率升高相关（与移植无关），而移植后结局没有改善。因此，尽管“完美”的器官是理想的，但接受“足够好”的器官有可能提高儿科心脏移植候选者的生存率。
