Effect of donor smoking on survival after lung transplantation: a cohort study of a prospective registry
Effect of donor smoking on survival after lung transplantation: a cohort study of a prospective registry
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DOI：
10.1016/s0140-6736(12)60160-3
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发表时间：
2012-08-25
期刊：
影响因子：
168.9
通讯作者：
Neuberger, James
中科院分区：
文献类型：
--
作者：
Bonser, Robert S.;Taylor, Rhiannon;Neuberger, James
背景 肺捐献者的阳性吸烟史可能会对移植受者的生存产生不利影响，这一风险引起了人们的关注。相反，通过排除有吸烟史的捐献者来减少捐献者库可能会损害等待接受移植的患者的生存。我们研究了供体吸烟对移植后生存的影响，以及不移植此类供体肺的潜在影响。方法我们通过英国移植登记处数据的 Cox 回归模型，分析了 1999 年 7 月 1 日至 2010 年 12 月 31 日期间进行的首次脑死亡供体成人肺移植后，供体吸烟对 3 年生存的影响。我们评估了接受有阳性吸烟史的捐赠者的肺对生存的影响，并通过使用风险调整的顺序分层 Cox 回归模型分析同一时期的所有等待名单登记，将其与保留在有阴性吸烟史的捐赠者的潜在移植的等待名单上的影响进行比较。结果在 1295 例肺移植中，510 例 (39%) 使用了来自有阳性吸烟史的捐赠者的肺。与接受有阴性吸烟史的供体肺的患者相比，接受此类肺的患者移植后 3 年生存率较差（未调整的风险比 [HR] 1.46，95% CI 1.20-1.78；调整后的 HR 1.36、1.11-1.67）。影响生存的独立因素是受者年龄、供者-受者巨细胞病毒匹配、供者-受者身高差、供者性别和总缺血时间。在登记在等待名单上的 2181 名患者中，有 802 名（37%）死亡或在没有接受移植的情况下被从名单中删除。与那些仍在等待名单上的患者相比，接受有阳性吸烟史的捐赠者的肺的患者在登记后未经调整的死亡风险较低（0.79，95% CI 0.70-0.91）。 1999-2003年登记的脓毒性或纤维化肺病患者的风险调整风险分别为0.60（95% CI 0.42-0.87）和0.39（0.28-0.55）。 解释 在英国，使用来自有吸烟史的捐献者的肺的器官选择政策提高了登记肺移植的患者的总体生存率，应该继续下去。尽管来自此类捐赠者的肺与较差的结果相关，但如果他们被接受，则个体生存的概率比被拒绝的情况更大，并且患者选择等待来自有阴性吸烟史的捐赠者的潜在移植。这种情况应该向接受肺移植的患者充分解释和讨论。
Background The risk that a positive smoking history in lung donors could adversely affect survival of transplant recipients causes concern. Conversely, reduction of the donor pool by exclusion of donors with positive smoking histories could compromise survival of patients waiting to receive a transplant. We examined the consequences of donor smoking on post-transplantation survival, and the potential effect of not transplanting lungs from such donors.Methods We analysed the effect of donor smoking on 3 year survival after first adult lung transplantation from brain-dead donors done between July 1, 1999, and Dec 31, 2010, by Cox regression modelling of data from the UK Transplant Registry. We estimated the effect of acceptance of lungs from donors with positive smoking histories on survival and compared it with the effect of remaining on the waiting list for a potential transplant from a donor with a negative smoking history donor, by analysing all waiting-list registrations during the same period with a risk-adjusted sequentially stratified Cox regression model.Findings Of 1295 lung transplantations, 510 (39%) used lungs from donors with positive smoking histories. Recipients of such lungs had worse 3 year survival after transplantation than did those who received lungs from donors with negative smoking histories (unadjusted hazard ratio [HR] 1.46, 95% CI 1.20-1.78; adjusted HR 1.36, 1.11-1.67). Independent factors affecting survival were recipient's age, donor-recipient cytomegalovirus matching, donor-recipient height difference, donor's sex, and total ischaemic time. Of 2181 patients registered on the waiting list, 802 (37%) died or were removed from the list without receiving a transplant. Patients receiving lungs from donors with positive smoking histories had a lower unadjusted hazard of death after registration than did those who remained on the waiting list (0.79, 95% CI 0.70-0.91). Patients with septic or fibrotic lung disease registered in 1999-2003 had risk-adjusted hazards of 0.60 (95% CI 0.42-0.87) and 0.39 (0.28-0.55), respectively.Interpretation In the UK, an organ selection policy that uses lungs from donors with positive smoking histories improves overall survival of patients registered for lung transplantation, and should be continued. Although lungs from such donors are associated with worse outcomes, the individual probability of survival is greater if they are accepted than if they are declined and the patient chooses to wait for a potential transplant from a donor with a negative smoking history. This situation should be fully explained to and discussed with patients who are accepted for lung transplantation.