心脏移植后早期出现的复发性急性细胞排斥反应（ISHLT 1R）分级为 1B 和 2 级，对长期预后有不良影响：1990 年 ISHLT 分级的预后意义。
Recurrent acute cellular rejection graded ISHLT 1R early after heart transplantation negatively affects long-term outcomes: The prognostic significance of 1990 ISHLT grades 1B and 2.
机构信息
The Olga and Lev Leviev Heart Center, Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
The Olga and Lev Leviev Heart Center, Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
出版信息
Transpl Immunol. 2019 Aug;55:101204. doi: 10.1016/j.trim.2019.03.003. Epub 2019 Mar 21.
PURPOSE
We investigated the implications of early recurrent 1R rejections for long-term outcomes after heart transplantation (HT) and evaluated the prognostic significance of 1990 ISHLT grading 1B/2 versus 1A.
METHODS
Data on all patients who underwent HT between 1992 and 2017 were reviewed. Patients with ≥2 endomyocardial biopsies graded 1R in the first 3 months were classified as "recurrent 1R." Those patients were further categorized according to 1A vs. 1B/2. Outcomes (>3 months) were long-term rejections and the combined endpoint of cardiac allograft vasculopathy (CAV) and cardiovascular (CV) mortality.
RESULTS
Sixty-nine out of 228 patients were classified as recurrent grade 1R. In the recurrent 1R group, 2R rejection rate was significantly higher (2.6 ± 0.6 vs 1.2 ± 0.4, p = 0.03), while survival free of rejections was lower (5-year: 57.1% vs. 72.3%, p = 0.022). Multivariate analysis showed that early recurrent 1R rejection was associated with a 30% increased risk for subsequent major rejection. Among 28 patients classified as 1B/2 of the recurrent group, rejection scores were higher, while survival free of rejections was lower, compared to 37 patients of the recurrent group classified as 1A (5-year: 57.1% vs. 72.7%, p = 0.013). Kaplan-Meier analysis showed that CAV/CV mortality at 10 years of follow-up was significantly higher among the recurrent 1R group (38% vs. 18% p < 0.05). Multivariate analysis showed that early recurrent 1R rejections were associated with a 2.5-fold increased risk for CAV/CV mortality.
CONCLUSION
Early recurrent grade 1R rejections negatively affect long-term outcomes. The adverse outcomes are experienced mainly by 1R patients subcategorized as1B/2 and not 1A.
目的
我们研究了心脏移植（HT）后早期反复 1R 排斥反应对长期结果的影响，并评估了 1990 年 ISHLT 分级 1B/2 与 1A 的预后意义。
方法
回顾了 1992 年至 2017 年间所有接受 HT 的患者的数据。将前 3 个月内≥2 次心内膜心肌活检分级 1R 的患者归类为“反复 1R”。根据 1A 与 1B/2，进一步对这些患者进行分类。（随访时间>3 个月）的结果为长期排斥反应以及心脏移植物血管病（CAV）和心血管（CV）死亡率的联合终点。
结果
228 例患者中有 69 例被归类为反复 1R 级。在反复 1R 组中，2R 排斥率明显较高（2.6±0.6 vs. 1.2±0.4，p=0.03），而无排斥反应的存活率较低（5 年：57.1% vs. 72.3%，p=0.022）。多变量分析表明，早期反复 1R 排斥反应与随后发生主要排斥反应的风险增加 30%相关。在 28 例被归类为反复组 1B/2 的患者中，排斥评分较高，而无排斥反应的存活率较低，而在 37 例被归类为反复组 1A 的患者中（5 年：57.1% vs. 72.7%，p=0.013）。Kaplan-Meier 分析显示，在 10 年随访期间，反复 1R 组的 CAV/CV 死亡率明显较高（38% vs. 18%，p<0.05）。多变量分析表明，早期反复 1R 排斥反应与 CAV/CV 死亡率增加 2.5 倍相关。
结论
早期反复 1R 排斥反应对长期结果产生负面影响。不良结果主要由被归类为 1B/2 而非 1A 的 1R 患者承担。
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