Cardiovascular Outcomes Research Laboratories (CORELAB) at the David Geffen School of Medicine, University of California, Los Angeles.
Division of Cardiac Surgery, University of California, Los Angeles.
Surgery. 2019 Dec;166(6):1142-1147. doi: 10.1016/j.surg.2019.07.009. Epub 2019 Aug 14.
Occasionally, lung transplant candidates improve to the point where they are removed from the transplant list. We sought to determine the characteristics and outcomes of lung transplant candidates who improved to delisting both before and after implementation of the lung allocation score.
Using the United Network for Organ Sharing database, we reviewed all adult patients listed for lung transplant between 1987 and 2012. The last permanent status change was classified into transplanted, improved to delisting (improved), or deteriorated to delisting (deteriorated). Survival time was calculated using the linked date of death from the Social Security Administration. Survival analysis was performed via the Kaplan-Meier method, and adjusted multivariable logistic regressions identified characteristics predicting improvement to delisting.
Of 13,688 candidates, 12,188 (89.0%) were transplanted, 454 (3.3%) improved, and 1,046 (7.6%) deteriorated. The 5-year mortality was greater in improved (hazard ratio = 1.21 [1.07-1.38], P = .002) and deteriorated (hazard ratio = 3.36 [3.11-3.64], P < .001) candidates relative to those transplanted; however, 1-year survival was greater in improved versus transplanted candidates (75.9% vs 67.2%, log rank P < .001). Older, female patients listed for primary pulmonary hypertension and retransplantation were more likely to improve to delisting. The proportion of improved patients varied by hospital quartile volume (P < .001) and the United Network for Organ Sharing geographic region (P < .001). The number of patients improving to delisting decreased after implementation of the lung allocation score.
Lung transplant candidates improving to delisting faced less short-term but greater long-term mortality relative to transplanted candidates. Given that the improved population decreased dramatically after implementation of the lung allocation score, redefining patient listing criteria appears to have improved patient appropriateness for transplant.
偶尔，肺移植候选人的病情会有所改善，以至于他们从移植名单中被除名。我们试图确定在肺分配评分实施前后，改善情况而被除名的肺移植候选人的特征和结果。
我们使用器官共享联合网络数据库，回顾了 1987 年至 2012 年间所有接受肺移植的成年患者名单。最后一次永久性状态变化被分为移植、改善除名（改善）或恶化除名（恶化）。使用社会保障管理局的死亡链接日期计算生存时间。通过 Kaplan-Meier 方法进行生存分析，并进行调整多变量逻辑回归以确定改善除名的特征。
在 13688 名候选人中，12188 名（89.0%）被移植，454 名（3.3%）改善，1046 名（7.6%）恶化。与移植组相比，改善组（风险比=1.21[1.07-1.38]，P=0.002）和恶化组（风险比=3.36[3.11-3.64]，P<0.001）的 5 年死亡率更高；然而，与移植组相比，改善组的 1 年生存率更高（75.9%比 67.2%，对数秩 P<0.001）。原发性肺动脉高压和再次移植患者中年龄较大、女性患者更有可能改善除名。改善患者的比例因医院四分位体积而异（P<0.001）和器官共享联合网络地理区域（P<0.001）。实施肺分配评分后，改善除名的患者数量减少。
与移植候选人相比，改善除名的肺移植候选人面临的短期死亡率较低，但长期死亡率较高。由于实施肺分配评分后，改善人群数量急剧下降，重新定义患者列入标准似乎提高了患者接受移植的适当性。
