老年再次肾移植受者风险特征和结局的变化趋势。
Evolving Trends in Risk Profiles and Outcomes in Older Adults Undergoing Kidney Retransplantation.
机构信息
Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada.
Research Institute of the McGill University Health Centre, Montreal, QC, Canada.
出版信息
Transplantation. 2022 May 1;106(5):1051-1060. doi: 10.1097/TP.0000000000003842. Epub 2021 Jun 2.
BACKGROUND
In older adults (≥65), access to and outcomes following kidney transplantation (KT) have improved over the past 3 decades. It is unknown if there were parallel trends in re-KT. We characterized the trends, changing landscape, and outcomes of re-KT in older adults.
METHODS
Among the 44,149 older kidney-only recipients (1995-2016) in the Scientific Registry of Transplant Recipients, we identified 1743 who underwent re-KT. We analyzed trends and outcomes (mortality, death-censored graft failure [DCGF]) by eras (1995-2002, 2003-2014, and 2015-2016) that were defined by changes to the expanded criteria donors and Kidney Donor Profile Index policies.
RESULTS
Among all older kidney-only recipients during 1995-2002, 2003-2014, 2015-2016 the proportion that were re-KTs increased from 2.7% to 4.2% to 5.7%, P < 0.001, respectively. Median age at re-KT (67-68-68, P = 0.04), years on dialysis after graft failure (1.4-1.5-2.2, P = 0.003), donor age (40.0-43.0-43.5, P = 0.04), proportion with panel reactive antibody 80-100 (22.0%-32.7%-48.7%, P < 0.001), and donation after circulatory death (1.1%-13.4%-19.5%, P < 0.001) have increased. Despite this, the 3-y cumulative incidence for mortality (22.3%-19.1%-11.5%, P = 0.002) and DCGF (13.3%-10.0%-5.1%, P = 0.01) decreased over time. Compared with deceased donor retransplant recipients during 1995-2002, those during 2003-2014 and 2015-2016 had lower mortality hazard (aHR = 0.78, 95% confidence interval, 0.63-0.86 and aHR = 0.55, 95% confidence interval, 0.35-0.86, respectively). These declines were noted but not significant for DCGF and in living donor re-KTs.
CONCLUSIONS
In older retransplant recipients, outcomes have improved significantly over time despite higher risk profiles; yet they represent a fraction of the KTs performed. Our results support increasing access to re-KT in older adults; however, approaches to guide the selection and management in those with graft failure need to be explored.
背景
在过去的 30 年中，老年（≥65 岁）人群接受肾移植（KT）的机会和预后均有所改善。尚不清楚再 KT 是否存在类似的趋势。我们对老年人群再 KT 的趋势、变化情况和结局进行了描述。
方法
在 Scientific Registry of Transplant Recipients 中，我们在 44149 名仅接受肾脏移植的老年（1995-2016 年）受者中，识别出 1743 名接受再 KT 的患者。我们根据扩大标准供者和 Kidney Donor Profile Index 政策的变化，通过时代（1995-2002 年、2003-2014 年和 2015-2016 年）来分析趋势和结局（死亡率、死亡风险调整移植物丢失）。
结果
在 1995-2002 年、2003-2014 年和 2015-2016 年所有仅接受肾脏移植的老年受者中，再 KT 的比例分别从 2.7%增至 4.2%，再增至 5.7%，P<0.001。再 KT 时的中位年龄（67-68-68，P=0.04）、移植物失败后接受透析的年数（1.4-1.5-2.2，P=0.003）、供者年龄（40.0-43.0-43.5，P=0.04）、Panel Reactive Antibody 80-100 的比例（22.0%-32.7%-48.7%，P<0.001）和心脏死亡后捐献（1.1%-13.4%-19.5%，P<0.001）均增加。尽管如此，3 年累积死亡率（22.3%-19.1%-11.5%，P=0.002）和 DCGF（13.3%-10.0%-5.1%，P=0.01）的发生率仍随时间下降。与 1995-2002 年接受已故供者再次移植的受者相比，2003-2014 年和 2015-2016 年接受再次移植的受者死亡率的危险比（aHR=0.78，95%置信区间，0.63-0.86 和 aHR=0.55，95%置信区间，0.35-0.86）较低。这些趋势在 DCGF 和活体供者再 KT 中虽有提示但不显著。
结论
尽管老年再移植受者的风险特征有所增加，但他们的预后在过去 30 年中显著改善；但他们仅占 KT 总数的一部分。我们的研究结果支持增加老年人群再 KT 的机会，但需要探索指导选择和管理的方法。
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