School of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
Data Science Team, Research Development and Innovation, University Hospitals Birmingham, Birmingham, UK.
Br J Surg. 2024 Jan 3;111(1). doi: 10.1093/bjs/znae001.
Kidney transplantation is the treatment of choice for people living with kidney failure who are suitable for surgery, but survival benefits for older and/or ethnic minority candidates are unclear. To inform decision-making, the survival of patients on a waiting list for kidney transplantation was assessed.
A retrospective study was undertaken of registry data for patients with kidney failure listed for transplantation in the UK. From 1 January 2000 until 30 September 2019, all patients listed for a first kidney-alone transplant were included. The primary outcome was all-cause mortality. After testing for violations of the proportional hazards assumption, an extended Cox regression model factoring in transplantation as a time-dependent variable according to the intention-to-treat principle was developed.
The study cohort included 47 917 patients on a waiting list for kidney transplantation, of whom 34 558 (72.1%) subsequently received a transplant. Transplantation compared with remaining on dialysis was associated with an overall survival benefit (HR 0.17, 95% c.i. 0.16 to 0.18; P < 0.001), occurring immediately within 30 days, and observed regardless of ethnicity. For White kidney transplant candidates aged at least 65 or at least 70 years, a significant survival benefit was observed within 6 months (HR 0.49, 0.29 to 0.82) and 1 year (HR 0.45, 0.25 to 0.79) after transplantation respectively, which contrasted with 3 years after kidney transplantation for candidates from ethnic minorities aged at least 65 years (HR 0.53, 0.36 to 0.78) or at least 70 years (HR 0.53, 0.36 to 0.78).
Although time-to-survival benefits are stratified by age and ethnicity, all kidney transplant candidates on the waiting list are better off with transplantation compared with remaining on dialysis. The absence of any early postoperative mortality suggests that some high-risk patients with kidney failure may not be receiving transplantation opportunities.
对于适合手术的肾衰竭患者，肾移植是首选治疗方法，但尚不清楚老年和/或少数族裔候选者的生存获益情况。为了辅助决策，评估了等待肾移植患者的生存情况。
本研究对英国器官移植登记数据进行了回顾性研究。自 2000 年 1 月 1 日至 2019 年 9 月 30 日，所有接受首次单独肾脏移植的患者均被纳入研究。主要结局为全因死亡率。在检验比例风险假设是否违反后，根据意向治疗原则，开发了一个扩展的 Cox 回归模型，将移植作为一个时变变量。
该队列研究纳入了 47917 名等待肾移植的患者，其中 34558 名（72.1%）随后接受了移植。与继续透析相比，移植与整体生存获益相关（HR 0.17，95%CI 0.16 至 0.18；P < 0.001），这种获益在 30 天内即刻出现，且无论种族如何都可观察到。对于年龄至少为 65 岁或至少 70 岁的白人肾移植候选者，在移植后 6 个月（HR 0.49，0.29 至 0.82）和 1 年（HR 0.45，0.25 至 0.79）时观察到明显的生存获益，而对于年龄至少为 65 岁的少数族裔候选者，在肾移植后 3 年（HR 0.53，0.36 至 0.78）或至少 70 岁（HR 0.53，0.36 至 0.78）时观察到这种获益。
尽管生存获益存在时间和种族分层，但与继续透析相比，所有等待移植的候选者进行移植后都将获益。没有任何术后早期死亡的情况表明，一些高危肾衰竭患者可能没有获得移植机会。
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