RECURRENCE OF OBLITERATIVE BRONCHIOLITIS AND DETERMINANTS OF OUTCOME IN 139 PULMONARY RETRANSPLANT RECIPIENTS
RECURRENCE OF OBLITERATIVE BRONCHIOLITIS AND DETERMINANTS OF OUTCOME IN 139 PULMONARY RETRANSPLANT RECIPIENTS
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DOI：
10.1016/s0022-5223(95)70063-3
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发表时间：
1995-11-01
影响因子：
6
通讯作者：
PATTERSON, GA
中科院分区：
文献类型：
--
作者：
NOVICK, RJ;SCHAFERS, HJ;PATTERSON, GA
更新了一项国际再次肺移植系列，以确定手术后闭塞性毛细支气管炎的发生率和复发率以及预后的预测因素。该研究队列包括在1985年至1994年期间在北美和欧洲的34个机构接受再次移植的139名患者。80例因闭塞性毛细支气管炎再次移植，33例因急性移植失败，13例因难治性呼吸道并发症，8例因急性排斥反应，4例因其他适应症。存活的患者平均随访630天，其中38名患者在再次移植后1年存活，30名患者在2年存活，16名患者在再次移植后3年存活。术后1个月、3个月、1年、2年和3年的精算存活率分别为65%+/-4%、54%+/-4%、45%+/-4%、38%+/-5%和36%+/-5%；然而，在术后90天的幸存者中，65%+/-6%的患者在再次移植后3年仍存活。寿命表和单因素COX分析显示，再次移植后较近的一年(p=0.009.0 1)、ABO血型完全匹配(p=0.0 1)、没有供受者巨细胞病毒错配(p=0.0 3)、再次移植前即刻行走(p=0.0 4)与存活有关。通过多变量COX分析，再次移植前行走是最显著的存活预测因素(p=0.008)，其次是欧洲的再次手术(p=0.044)。每名再次移植的幸存者每年都要进行全面的肺功能测试，并对闭塞性毛细支气管炎综合征进行分期。11%的患者在再次移植后1年处于3期，20%在2年，25%在3年。术后1s用力呼气量由术前的1.89±0.13 L降至术后1年的1.80±0.15 L和术后2年的1.54±0.16 L(P=0.006)。大部分下降发生在因闭塞性毛细支气管炎而接受再次移植的患者，而因其他疾病接受再次移植的患者的肺功能没有明显变化。我们的结论是，再次肺移植后的存活率正在提高。再次移植前不能活动的患者可获得最佳结果。与初次肺移植后的最新数据相比，闭塞性细支气管炎综合征在再次移植后似乎没有加速复发的趋势。只要能将感染导致的早期死亡率降至最低，再次肺移植似乎为高度精选的患者提供了一个合理的选择。
An international series of pulmonary retransplantation was updated to identify the predictors of outcome and the prevalence and recurrence rate of obliterative bronchiolitis after operation. The study cohort included 139 patients who underwent retransplantation in 34 institutions in North America and Europe between 1985 and 1994. Eighty patients underwent retransplantation because of obliterative bronchiolitis, 33 because of acute graft failure, 13 because of intractable airway complications, 8 because of acute rejection, and 4 because of other indications. Survivors were followed up for a median of 630 days, with 38 patients alive at 1 year, 30 at 2 years, and 16 at 3 years after retransplantation. Actuarial survival was 65% +/- 4% at 1 month, 54% +/- 4% at 3 months, 45% +/- 4% at 1 year, 38% +/- 5% at 2 gears, and 36% +/- 5% at 3 years; nonetheless, of 90-day postoperative survivors, 65% +/- 6% were alive 3 years after retransplantation. Life-table and univariate Cox analysis revealed that more recent year of retransplantation (p = 0.009), identical match of ABO blood group (p = 0.01), absence of a donor-recipient cytomegalovirus mismatch (p = 0.03), and being ambulatory immediately before retransplantation (p = 0.04) were associated with survival. By multivariate Cox analysis, being ambulatory before retransplantation was the most significant predictor of survival (p = 0.008), followed by reoperation in Europe (p = 0.044). Complete pulmonary function tests were done yearly in every survivor of retransplantation and bronchiolitis obliterans syndrome stages were assigned. Eleven percent of patients were in stage 3 at 1 year, 20% at 2 years, and 25% at 3 years after retransplantation. Values of forced expiratory volume in 1 second decreased from 1.89 +/- 0.13 L early after retransplantation to 1.80 +/- 0.15 L at 1 year and 1.54 +/- 0.16 L at 2 years (p = 0.006, year 2 versus baseline postoperative value). Most of this decrease occurred in patients who underwent retransplantation because of obliterative bronchiolitis, whereas the pulmonary function of patients who underwent retransplantation because of other conditions did not significantly change. We conclude that survival after pulmonary retransplantation is improving. Optimal results can be obtained in patients who are ambulatory before retransplantation. Compared with recent data after primary lung transplantation, bronchiolitis obliterans syndrome does not appear to recur in an accelerated manner after retransplantation. As long as early mortality as a result of infection can be minimized, pulmonary retransplantation appears to offer a reasonable option in highly selected patients.