Division of Nephrology, Department of Medicine, Stanford School of Medicine, Palo Alto, CA.
Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX.
Transplantation. 2019 Nov;103(11):2413-2422. doi: 10.1097/TP.0000000000002670.
Graft and patient survival following kidney transplant are improving. However, the drivers of this trend are unclear. To gain further insight, we set out to examine concurrent changes in pretransplant patient complexity, posttransplant survival, and cause-specific hospitalization.
We identified 101 332 Medicare-insured patients who underwent their first kidney transplant in the United States between the years 1998 and 2014. We analyzed secular trends in (1) posttransplant patient and graft survival and (2) posttransplant hospitalization for cardiovascular disease, infection, and cancer using Cox models with year of kidney transplant as the primary exposure of interest.
Age, dialysis vintage, body mass index, and the prevalence of a number of baseline medical comorbidities increased during the study period. Despite these adverse changes in case mix, patient survival improved: the unadjusted and multivariable-adjusted hazard ratios (HRs) for death in 2014 (versus 1998) were 0.61 (confidence interval [CI], 0.52-0.73) and 0.46 (CI, 0.39-0.55), respectively. For graft failure excluding death with a functioning graft, the unadjusted and multivariable adjusted subdistribution HRs in 2014 versus 1998 were 0.4 (CI, 0.25-0.55) and 0.45 (CI, 0.3-0.6), respectively. There was a marked decrease in hospitalizations for cardiovascular disease following transplant between 1998 and 2011, subdistribution HR 0.51 (CI, 0.43-0.6). Hospitalization for infection remained unchanged, while cancer hospitalization increased modestly.
Medicare-insured patients undergoing kidney transplant became increasingly medically complex between 1998 and 2014. Despite this, both patient and graft survival improved during this period. A marked decrease in serious cardiovascular events likely contributed to this positive trend.
肾移植后移植物和患者的存活率正在提高。然而，这种趋势的驱动因素尚不清楚。为了进一步深入了解，我们着手检查移植前患者病情复杂性、移植后存活率和特定病因住院治疗的同期变化。
我们确定了 1998 年至 2014 年间在美国接受首次肾移植的 101332 名医疗保险参保患者。我们使用 Cox 模型分析了（1）移植后患者和移植物存活率以及（2）心血管疾病、感染和癌症的移植后住院率的时间趋势，以肾移植年份作为主要暴露因素。
在研究期间，患者年龄、透析时间、体重指数和多种基线医疗合并症的患病率均有所增加。尽管病例组合存在这些不利变化，但患者的存活率仍有所提高：2014 年（与 1998 年相比）未调整和多变量调整后的死亡风险比（HR）分别为 0.61（置信区间[CI]，0.52-0.73）和 0.46（CI，0.39-0.55）。对于排除有功能移植物的死亡后的移植物衰竭，2014 年与 1998 年相比，未调整和多变量调整的亚分布 HR 分别为 0.4（CI，0.25-0.55）和 0.45（CI，0.3-0.6）。移植后心血管疾病的住院率从 1998 年至 2011 年显著下降，亚分布 HR 为 0.51（CI，0.43-0.6）。感染住院率保持不变，而癌症住院率略有增加。
1998 年至 2014 年间，接受肾移植的医疗保险参保患者的医疗病情复杂性逐渐增加。尽管如此，在此期间患者和移植物的存活率都有所提高。严重心血管事件的显著减少可能是这一积极趋势的原因。
