Vanhove Thomas, Elias Nahel, Safa Kassem, Cohen-Bucay Abraham, Schold Jesse D, Riella Leonardo V, Gilligan Hannah
Renal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
Department of Nephrology, Centre Hospitalier de Luxembourg, Luxembourg.
Kidney Int Rep. 2022 Aug 31;7(11):2397-2409. doi: 10.1016/j.ekir.2022.08.010. eCollection 2022 Nov.
The kidney transplant recipient population in the United States is aging rapidly, which may exacerbate some of the limitations of conventional outcome metrics.
Using data from the Scientific Registry of Transplant Recipients (SRTR), age-stratified unadjusted Kaplan-Meier and competing risk survival analyses were performed on a cohort of 238,123 adult recipients of a first-time single kidney transplant between 2000 and 2017. These were compared with a multistate model incorporating 5 post-transplant states (alive with functioning graft, death with functioning graft, graft failed (alive), retransplanted, and death after graft failure).
Kaplan-Meier resulted in an age-dependent overestimation of the risks of graft failure and death with functioning graft, compared with competing risk or multistate models. In elderly (≥75 years old) recipients, the absolute overestimation of the risk of death with functioning graft was 4-fold higher than in those younger than 55 years. The multistate model demonstrated that for patients transplanted at age 55 years and older, the probability of being back on dialysis was never more than 4% at any point post-transplant. The underlying reasons were low graft failure rates and high mortality after resuming dialysis as follows: 2-year mortality after graft failure was 38%, 54%, and 67% in recipients aged from 55 to 64 years, from 65 to 74 years, and those aged 75 years and older, versus 20% in those younger than 55 years.
Multistate models provide an accurate and comprehensive assessment of the life course of kidney transplant recipients. This may be particularly relevant in older recipients, who are more prone to event rate overestimation and for whom outcomes after graft failure are substantially worse than for younger recipients.
美国肾移植受者群体正在迅速老龄化，这可能会加剧传统预后指标的一些局限性。
利用移植受者科学注册系统（SRTR）的数据，对2000年至2017年间首次接受单肾移植的238123名成年受者进行年龄分层的未调整Kaplan-Meier分析和竞争风险生存分析。将这些分析结果与纳入5种移植后状态（移植肾存活、移植肾存活时死亡、移植肾失败（存活）、再次移植、移植肾失败后死亡）的多状态模型进行比较。
与竞争风险模型或多状态模型相比，Kaplan-Meier分析导致对移植肾失败风险和移植肾存活时死亡风险的年龄依赖性高估。在老年（≥75岁）受者中，移植肾存活时死亡风险的绝对高估比55岁以下受者高4倍。多状态模型表明，对于55岁及以上移植的患者，移植后任何时间点重新开始透析的概率从未超过4%。根本原因是移植肾失败率低和恢复透析后的高死亡率，具体如下：移植肾失败后2年死亡率在55至64岁受者中为38%，65至74岁受者中为54%，75岁及以上受者中为67%，而55岁以下受者为20%。
多状态模型提供了对肾移植受者生命历程的准确而全面的评估。这在老年受者中可能尤为重要，因为他们更容易出现事件发生率高估，且移植肾失败后的预后比年轻受者差得多。
