澳大利亚肾移植等待名单中患者动态、暂停、移植和死亡情况。

Journey to kidney transplantation: patient dynamics, suspensions, transplantation and deaths in the Australian kidney transplant waitlist.

机构信息

Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia.

NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia.

出版信息

Nephrol Dial Transplant. 2024 Jun 28;39(7):1138-1149. doi: 10.1093/ndt/gfad253.

BACKGROUND

People on the kidney waitlist are less informed about potential suspensions. Disparities may exist among those who are suspended and who return to the waitlist. We evaluated the patient journey after entering the waitlist, including suspensions and outcomes, and factors associated with these transitions.

METHODS

We included all incident patients waitlisted for their first transplant from deceased donors in Australia from 2006 to 2019. We described all clinical transitions after entering the waitlist. We predicted the restricted mean survival time (unadjusted and adjusted) until first transplant by the number of prior suspensions. We evaluated factors associated with transitions using flexible survival models and clinical endpoints using Cox models.

RESULTS

Of 8466 patients waitlisted and followed over 45 757.4 person-years (median 4.8 years), 6741 (80%) were transplanted, 381 (5%) died waiting and 1344 (16%) were still waiting. A total of 3127 (37%) people were suspended at least once. Predicted mean time from waitlist to transplant was 3.0 years [95% confidence interval (CI) 2.8-3.2] when suspended versus 1.9 years (95% CI 1.8-1.9) when never suspended. Prior suspension increased the likelihood of further suspensions 4.2-fold (95% CI 3.8-4.6) and returning to the waitlist by 50% (95% CI 36-65) but decreased the likelihood of transplantation by 29% (95% CI 62-82). Death risk while waiting was increased 12-fold (95% CI 8.0-18.3) when currently suspended. Australian non-Indigenous males were 13% [hazard ratio (HR) 1.13 (95% CI 1.04-1.23)] and Asian males 23% [HR 1.23 (95% CI 1.06-1.42)] more likely to return to the waitlist compared with females of the same ethnicity.

CONCLUSION

The waitlist journey was not straightforward. Suspension was common, impacted the chance of transplantation and meant waiting an average of 1 year longer until transplant. We have provided estimates for and factors associated with suspension, relisting and outcomes after waitlisting to support more informed discussions. This evidence is critical to further understand drivers of inequitable access to transplantation.

背景

在肾脏候补名单上的人对潜在的候补名单暂停了解较少。暂停候补名单的人和返回候补名单的人之间可能存在差异。我们评估了进入候补名单后的患者旅程，包括候补名单暂停和结果，以及与这些转变相关的因素。

方法

我们纳入了 2006 年至 2019 年期间澳大利亚所有首次接受已故供体移植的候补名单上的患者。我们描述了进入候补名单后的所有临床过渡情况。我们根据之前的候补名单暂停次数预测了首次移植前的受限平均生存时间（未调整和调整）。我们使用灵活的生存模型评估了与过渡相关的因素，并使用 Cox 模型评估了临床终点。

结果

在 8466 名接受候补名单并随访超过 45757.4 人年（中位数 4.8 年）的患者中，6741 名（80%）接受了移植，381 名（5%）在等待中死亡，1344 名（16%）仍在等待。共有 3127 人（37%）至少被暂停一次候补名单。与从未被暂停过相比，候补名单暂停至少一次的预测平均等待时间为 3.0 年[95%置信区间（CI）为 2.8-3.2]，而从未被暂停过的预测平均等待时间为 1.9 年[95% CI 为 1.8-1.9]。之前的候补名单暂停增加了进一步暂停的可能性 4.2 倍（95% CI 3.8-4.6），回到候补名单的可能性增加了 50%（95% CI 36-65），但接受移植的可能性降低了 29%（95% CI 62-82）。目前暂停候补名单的患者等待期间死亡风险增加了 12 倍（95% CI 8.0-18.3）。与同种族的女性相比，澳大利亚非土著男性（危险比（HR）1.13（95% CI 1.04-1.23））和亚洲男性（HR 1.23（95% CI 1.06-1.42））返回候补名单的可能性分别增加了 13%和 23%。