Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Canadian Centre for Health Economics, Toronto, Ontario, Canada.
Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
Kidney Int. 2019 Aug;96(2):450-459. doi: 10.1016/j.kint.2019.03.007. Epub 2019 Mar 19.
Dialysis prior to kidney transplantation may have a detrimental effect on post-transplant outcomes. However, prior studies have not fully characterized the nature of this relationship and may have been subject to residual confounding. Here we investigated the association between pre-transplant dialysis duration and two post-transplant outcomes: all-cause death and death with functioning graft. This was a retrospective, population-based, cohort study in all deceased donor kidney transplants performed in Ontario, Canada, from April 1, 2002 to March 31, 2013. Patient blood type was chosen as an instrumental variable and a two-stage modeling procedure that included a threshold-adjusted Cox proportional hazards model was used to assess the association between dialysis time and the two post-transplant outcomes. Among 4,440 transplant recipients, the relative risk of all-cause death associated with each dialysis year prior to three years was 42% and fell to 5% per additional dialysis year thereafter. For death with functioning graft, each dialysis year before and after 2.8 years increased the relative risk by 31% and 4%, respectively. Peak panel reactive antibody of more than 50% was independently associated with an elevated risk of death with functioning graft but not with the risk of all-cause death. Thus, our findings highlight the urgency to develop strategies to ensure timely transplant listing and to shorten the total dialysis time before transplantation, with the goal of enhancing kidney transplant outcomes.
在肾移植前进行透析可能对移植后的结果产生不利影响。然而，先前的研究并未充分描述这种关系的本质，并且可能受到残余混杂因素的影响。在这里，我们研究了移植前透析持续时间与两种移植后结局之间的关联：全因死亡和有功能移植物的死亡。这是一项在加拿大安大略省进行的回顾性、基于人群的队列研究，研究对象为 2002 年 4 月 1 日至 2013 年 3 月 31 日期间所有接受过已故供体肾移植的患者。患者血型被选为工具变量，采用两阶段建模程序，包括调整阈值的 Cox 比例风险模型，评估透析时间与两种移植后结局之间的关联。在 4440 名移植受者中，与移植前三年每透析一年相关的全因死亡的相对风险为 42%，此后每增加一年透析相对风险降至 5%。对于有功能移植物的死亡，在 2.8 年之前和之后每透析一年，相对风险分别增加 31%和 4%。面板反应性抗体峰值超过 50%与有功能移植物死亡的风险增加独立相关，但与全因死亡的风险无关。因此，我们的研究结果强调了制定策略的紧迫性，以确保及时进行移植登记，并缩短移植前的总透析时间，以提高肾移植的结果。
