Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD.
Transplantation. 2020 Jul;104(7):1456-1461. doi: 10.1097/TP.0000000000002989.
There is concern in the transplant community that outcomes for the most highly sensitized recipients might be poor under Kidney Allocation System (KAS) high prioritization.
To study this, we compared posttransplant outcomes of 525 pre-KAS (December 4, 2009, to December 3, 2014) calculated panel-reactive antibodies (cPRA)-100% recipients to 3026 post-KAS (December 4, 2014, to December 3, 2017) cPRA-100% recipients using SRTR data. We compared mortality and death-censored graft survival using Cox regression, acute rejection, and delayed graft function (DGF) using logistic regression, and length of stay (LOS) using negative binomial regression.
Compared with pre-KAS recipients, post-KAS recipients were allocated kidneys with lower Kidney Donor Profile Index (median 30% versus 35%, P < 0.001) but longer cold ischemic time (CIT) (median 21.0 h versus 18.6 h, P < 0.001). Compared with pre-KAS cPRA-100% recipients, those post-KAS had higher 3-year patient survival (93.6% versus 91.4%, P = 0.04) and 3-year death-censored graft survival (93.7% versus 90.6%, P = 0.005). The incidence of DGF (29.3% versus 29.2%, P = 0.9), acute rejection (11.2% versus 11.7%, P = 0.8), and median LOS (5 d versus 5d, P = 0.2) were similar between pre-KAS and post-KAS recipients. After accounting for secular trends and adjusting for recipient characteristics, post-KAS recipients had no difference in mortality (adjusted hazard ratio [aHR]: 0.861.623.06, P = 0.1), death-censored graft failure (aHR: 0.521.001.91, P > 0.9), DGF (adjusted odds ratio [aOR]: 0.580.861.27, P = 0.4), acute rejection (aOR: 0.610.941.43, P = 0.8), and LOS (adjusted LOS ratio: 0.981.161.36, P = 0.08).
We did not find any statistically significant worsening of outcomes for cPRA-100% recipients under KAS, although longer-term monitoring of posttransplant mortality is warranted.
移植界担心，在肾脏分配系统（KAS）高优先级下，高度致敏受者的移植后结果可能较差。
为了研究这一点，我们使用 SRTR 数据比较了 525 名 KAS 前（2009 年 12 月 4 日至 2014 年 12 月 3 日）计算的 panel-reactive antibodies（cPRA）-100%受者与 3026 名 KAS 后（2014 年 12 月 4 日至 2017 年 12 月 3 日）cPRA-100%受者的移植后结局。我们使用 Cox 回归比较死亡率和死亡校正移植物存活率，使用 logistic 回归比较急性排斥反应和延迟移植物功能（DGF），使用负二项回归比较住院时间（LOS）。
与 KAS 前受者相比，KAS 后受者分配的肾脏具有更低的肾脏供者特征指数（中位数 30%对 35%，P<0.001），但冷缺血时间（CIT）更长（中位数 21.0 小时对 18.6 小时，P<0.001）。与 KAS 前 cPRA-100%受者相比，KAS 后受者 3 年患者存活率更高（93.6%对 91.4%，P=0.04）和 3 年死亡校正移植物存活率更高（93.7%对 90.6%，P=0.005）。DGF（29.3%对 29.2%，P=0.9）、急性排斥反应（11.2%对 11.7%，P=0.8）和中位 LOS（5 天对 5 天，P=0.2）在 KAS 前和 KAS 后受者之间相似。在考虑到时间趋势并调整受者特征后，KAS 后受者的死亡率（调整后的危险比[aHR]：0.861.623.06，P=0.1）、死亡校正移植物失败（aHR：0.521.001.91，P>0.9）、DGF（调整后的优势比[aOR]：0.580.861.27，P=0.4）、急性排斥反应（aOR：0.610.941.43，P=0.8）和 LOS（调整后的 LOS 比：0.981.161.36，P=0.08）没有差异。
尽管需要对移植后死亡率进行更长期的监测，但我们没有发现 KAS 下 cPRA-100%受者结果出现任何统计学上显著恶化的情况。
