近日，美国芝加哥大学教授Matthew M. Churpek及其研究小组分析了在美国接受心脏移植的成年人中，移植中心与生存效益的关系。相关论文于2019年11月12日发表于国际顶尖学术期刊《美国医学会杂志》上。

在美国，已故捐赠者可供移植的心脏数量有限。由于资源紧缺，美国心脏分配系统主要依据移植中心规定的支持疗法对心脏移植候选者进行排名。

为探讨心脏移植中心与生存效益之间的相关性，2006年1月至2015年12月，研究组对29199名成人心脏移植候选者进行了观察研究，并于2018年8月完成了随访。

这29199名候选者来自美国的113个心脏移植中心，平均年龄为52岁，其中19815名（68%）接受了心脏移植。研究期间，接受心脏移植的患者中有5389人（27%）死亡或接受二次移植。而在9384名未接受心脏移植的候选者中，5669人（60%）死亡。接受移植者的5年生存率为77%，未接受移植者的5年生存率为33%，生存效益为44%。

各个移植中心的生存效益在30%至55%之间，其中31个中心（27%）的生存效益显著高于平均值，30个中心（27%）则显著低于平均值。与低生存效益移植中心相比，高生存效益移植中心对移植前生存率更低的候选者进行了移植（生存率分别为29%和39%），但候选者接受心脏移植后的5年校正生存率并无显著差异（分别为77.6%和77.1%）。总体来说，对于特定的移植中心，候选者的生存率每降低10%，心脏移植后的5年生存率便增加6.2%。

在这项美国心脏移植候选者的注册研究中，移植中心与移植的生存效益显著相关。尽管移植后的5年生存率在高生存效益中心和低生存效益中心间相差不大，但在高生存效益中心接受移植的患者移植前的5年生存率显著低于低生存效益中心。

附：英文原文

Title: Association of Transplant Center With Survival Benefit Among Adults Undergoing Heart Transplant in the United States

Author: William F. Parker, Allen S. Anderson, Robert D. Gibbons, Edward R. Garrity, Lainie F. Ross, Elbert S. Huang, Matthew M. Churpek

Issue&Volume: 2019/11/12

Abstract:

Importance  In the United States, the number of deceased donor hearts available for transplant is limited. As a proxy for medical urgency, the US heart allocation system ranks heart transplant candidates largely according to the supportive therapy prescribed by transplant centers.

Objective  To determine if there is a significant association between transplant center and survival benefit in the US heart allocation system.

Design, Setting, and Participants  Observational study of 29?199 adult candidates for heart transplant listed on the national transplant registry from January 2006 through December 2015 with follow-up complete through August 2018.

Exposures  Transplant center.

Main Outcomes and Measures  The survival benefit associated with heart transplant as defined by the difference between survival after heart transplant and waiting list survival without transplant at 5 years. Each transplant center’s mean survival benefit was estimated using a mixed-effects proportional hazards model with transplant as a time-dependent covariate, adjusted for year of transplant, donor quality, ischemic time, and candidate status.

Results  Of 29?199 candidates (mean age, 52 years; 26% women) on the transplant waiting list at 113 centers, 19?815 (68%) underwent heart transplant. Among heart transplant recipients, 5389 (27%) died or underwent another transplant operation during the study period. Of the 9384 candidates who did not undergo heart transplant, 5669 (60%) died (2644 while on the waiting list and 3025 after being delisted). Estimated 5-year survival was 77% (interquartile range [IQR], 74% to 80%) among transplant recipients and 33% (IQR, 17% to 51%) among those who did not undergo heart transplant, which is a survival benefit of 44% (IQR, 27% to 59%). Survival benefit ranged from 30% to 55% across centers and 31 centers (27%) had significantly higher survival benefit than the mean and 30 centers (27%) had significantly lower survival benefit than the mean. Compared with low survival benefit centers, high survival benefit centers performed heart transplant for patients with lower estimated expected waiting list survival without transplant (29% at high survival benefit centers vs 39% at low survival benefit centers; survival difference, −10% [95% CI, −12% to −8.1%]), although the adjusted 5-year survival after transplant was not significantly different between high and low survival benefit centers (77.6% vs 77.1%, respectively; survival difference, 0.5% [95% CI, −1.3% to 2.3%]). Overall, for every 10% decrease in estimated transplant candidate waiting list survival at a given center, there was an increase of 6.2% (95% CI, 5.2% to 7.3%) in the 5-year survival benefit associated with heart transplant.

Conclusions and Relevance  In this registry-based study of US heart transplant candidates, transplant center was associated with the survival benefit of transplant. Although the adjusted 5-year survival after transplant was not significantly different between high and low survival benefit centers, compared with centers with survival benefit significantly below the mean, centers with survival benefit significantly above the mean performed heart transplant for recipients who had significantly lower estimated expected 5-year waiting list survival without transplant.

DOI: 10.1001/jama.2019.15686

Source: https://jamanetwork.com/journals/jama/article-abstract/2754791