Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland.
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
Clin J Am Soc Nephrol. 2021 Mar 8;16(3):407-414. doi: 10.2215/CJN.02720320. Epub 2021 Feb 25.
Patients with sickle cell disease-associated kidney failure have high mortality, which might be lowered by kidney transplantation. However, because they show higher post-transplant mortality compared with patients with other kidney failure etiologies, kidney transplantation remains controversial in this population, potentially limiting their chance of receiving transplantation. We aimed to quantify the decrease in mortality associated with transplantation in this population and determine the chance of receiving transplantation with sickle cell disease as the cause of kidney failure as compared with other etiologies of kidney failure.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Using a national registry, we studied all adults with kidney failure who began maintenance dialysis or were added to the kidney transplant waiting list in 1998-2017. To quantify the decrease in mortality associated with transplantation, we measured the absolute risk difference and hazard ratio for mortality in matched pairs of transplant recipients versus waitlisted candidates in the sickle cell and control groups. To compare the chance of receiving transplantation, we estimated hazard ratios for receiving transplantation in the sickle cell and control groups, treating death as a competing risk.
Compared with their matched waitlisted candidates, 189 transplant recipients with sickle cell disease and 220,251 control recipients showed significantly lower mortality. The absolute risk difference at 10 years post-transplant was 20.3 (98.75% confidence interval, 0.9 to 39.8) and 19.8 (98.75% confidence interval, 19.2 to 20.4) percentage points in the sickle cell and control groups, respectively. The hazard ratio was also similar in the sickle cell (0.57; 95% confidence interval, 0.36 to 0.91) and control (0.54; 95% confidence interval, 0.53 to 0.55) groups (interaction =0.8). Nonetheless, the sickle cell group was less likely to receive transplantation than the controls (subdistribution hazard ratio, 0.73; 95% confidence interval, 0.61 to 0.87). Similar disparities were found among waitlisted candidates (subdistribution hazard ratio, 0.62; 95% confidence interval, 0.53 to 0.72).
Patients with sickle cell disease-associated kidney failure exhibited similar decreases in mortality associated with kidney transplantation as compared with those with other kidney failure etiologies. Nonetheless, the sickle cell population was less likely to receive transplantation, even after waitlist registration.
镰状细胞病相关性肾衰竭患者死亡率较高，肾移植可能降低其死亡率。然而，由于镰状细胞病相关性肾衰竭患者的移植后死亡率高于其他肾衰竭病因患者，因此肾移植在该人群中仍存在争议，可能限制了他们接受移植的机会。我们旨在量化该人群中与移植相关的死亡率降低情况，并确定以镰状细胞病为肾衰竭病因与其他肾衰竭病因相比接受移植的机会。
设计、地点、参与者和测量方法：利用全国性登记处，我们研究了所有在 1998 年至 2017 年间开始维持性透析或被纳入肾移植等待名单的肾衰竭成年患者。为了量化与移植相关的死亡率降低情况，我们在镰状细胞病组和对照组的移植受者与等待移植的候选者配对中，测量了死亡率的绝对风险差异和风险比。为了比较接受移植的机会，我们估计了镰状细胞病组和对照组接受移植的风险比，将死亡视为竞争风险。
与匹配的等待移植候选者相比，189 名镰状细胞病移植受者和 220251 名对照组受者的死亡率明显较低。移植后 10 年的绝对风险差异在镰状细胞病组和对照组分别为 20.3（98.75%置信区间，0.9 至 39.8）和 19.8（98.75%置信区间，19.2 至 20.4）个百分点。镰状细胞病组的风险比也与对照组相似（0.57；95%置信区间，0.36 至 0.91）和对照组（0.54；95%置信区间，0.53 至 0.55）（交互作用=0.8）。然而，镰状细胞病组比对照组更不可能接受移植（亚分布风险比，0.73；95%置信区间，0.61 至 0.87）。在等待移植的候选者中也发现了类似的差异（亚分布风险比，0.62；95%置信区间，0.53 至 0.72）。
与其他肾衰竭病因患者相比，镰状细胞病相关性肾衰竭患者的肾移植死亡率降低情况相似。然而，即使在登记等待移植后，镰状细胞病患者接受移植的可能性也较小。
