在排斥反应伴有严重血流动力学障碍的儿科心脏移植受者中，心脏同种异体移植血管病和移植物衰竭。
Cardiac allograft vasculopathy and graft failure in pediatric heart transplant recipients after rejection with severe hemodynamic compromise.
机构信息
Division of Pediatric Cardiology, Ochsner Hospital for Children, New Orleans, Louisiana.
Division of Pediatrics, University of Colorado, Denver, Colorado.
出版信息
J Heart Lung Transplant. 2019 Mar;38(3):277-284. doi: 10.1016/j.healun.2018.12.011. Epub 2018 Dec 21.
BACKGROUND
Rejection with severe hemodynamic compromise (RSHC) carries a mortality risk approaching 50%. We aimed to identify current risk factors for RSHC and predictors of graft failure after RSHC.
METHODS
Data from 3,259 heart transplant (HT) recipients between January 2005 and December 2015 in the Pediatric Heart Transplant Study (PHTS) were analyzed. Predictors for RSHC and outcome after RSHC were sought. Time to RSHC was analyzed using the Cox proportional hazards regression model. Cardiac allograft vasculopathy (CAV) after HT and CAV after RSHC were analyzed as time-dependent covariates. Timing of RSHC was analyzed as occurring before and after 4 years after RSHC.
RESULTS
There were 309 patients (9.5%) with ≥ 1 RSHC episodes. In 143 patients with RSHC, the first episode was within 1 year after HT. Independent risk factors for RSHC were age 1 to 5 years at HT (hazard ratio [HR], 1.51; 95% confidence interval [CI], 1.04-2.18), age > 10 years at HT (HR, 1.83; 95% CI, 1.29-2.60), black race (HR, 1.64; 95% CI, 1.25-2.15), prior cardiac surgery (HR, 1.55; 95% CI, 1.03-2.31), ventricular assist device support at HT (HR, 1.65; 95% CI, 1.18-2.29), maintenance steroids (HR, 1.39; 95% CI, 1.06-1.82), and recipient on inotropes, pressors, or thyroid hormones (HR, 1.45; 95% CI, 1.09-1.94). Graft survival at 5 years after RSHC was 45.7%. RSHC was a greater risk factor for earlier CAV (HR, 7.78; 95% CI, 5.82-10.40) than other rejection types (HR, 2.31; 95% CI, 1.79-3.00). Patients with late RSHC, after 1 year after RSHC had increased risk of graft loss 4 years after RSHC (HR, 7.12; 95% CI, 2.18-23.22). The 5-year graft survival after RSHC was 50.5% for early RSHC and 39.0% for late RSHC.
CONCLUSIONS
Mortality after RSHC is high in the current treatment era. Many patient risk factors for RSHC cannot be modified, including age, race, prior cardiac surgery, and ventricular assist device support. After RSHC, CAV is the only predictor of graft failure. Patients who have late RSHC fare worse than those who have RSHC within the first year after HT.
背景
伴有严重血流动力学障碍的排斥反应（RSHC）的死亡率接近 50%。我们旨在确定 RSHC 的当前危险因素和 RSHC 后移植物衰竭的预测因素。
方法
分析了 2005 年 1 月至 2015 年 12 月期间在儿科心脏移植研究（PHTS）中的 3259 名心脏移植（HT）受者的数据。寻找 RSHC 的预测因素和 RSHC 后的结果。使用 Cox 比例风险回归模型分析 RSHC 的时间。HT 后和 RSHC 后心脏同种异体血管病（CAV）被分析为时间依赖的协变量。RSHC 的时间被分析为发生在 RSHC 后 4 年之前和之后。
结果
有 309 名（9.5%）患者发生≥1 次 RSHC 发作。在 143 例 RSHC 患者中，第一次发作发生在 HT 后 1 年内。RSHC 的独立危险因素是 HT 时年龄为 1 至 5 岁（危险比[HR]，1.51；95%置信区间[CI]，1.04-2.18）、HT 时年龄>10 岁（HR，1.83；95% CI，1.29-2.60）、黑人种族（HR，1.64；95% CI，1.25-2.15）、心脏手术（HR，1.55；95% CI，1.03-2.31）、HT 时心室辅助装置支持（HR，1.65；95% CI，1.18-2.29）、维持性类固醇（HR，1.39；95% CI，1.06-1.82）以及受者接受正性肌力药、加压素或甲状腺激素（HR，1.45；95% CI，1.09-1.94）。RSHC 后 5 年移植物存活率为 45.7%。RSHC 是 CAV （HR，7.78；95% CI，5.82-10.40）发生较早的危险因素，而不是其他排斥反应类型（HR，2.31；95% CI，1.79-3.00）。RSHC 后 1 年出现晚期 RSHC 的患者，在 RSHC 后 4 年发生移植物丢失的风险增加（HR，7.12；95% CI，2.18-23.22）。RSHC 后 5 年的移植物存活率为早期 RSHC 为 50.5%，晚期 RSHC 为 39.0%。
结论
在当前的治疗时代，RSHC 后的死亡率很高。RSHC 的许多患者危险因素无法改变，包括年龄、种族、先前的心脏手术和心室辅助装置支持。RSHC 后，CAV 是移植物衰竭的唯一预测因素。晚期 RSHC 的患者比 HT 后 1 年内发生 RSHC 的患者预后更差。
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