目标:自2018年联合器官共享网络(UNOS)修订心脏分配政策以来,静脉动脉体外生命支持(VA-ECLS)的使用已大大增加,成为移植的桥梁。这项研究调查了在新政策时代同时进行心脏-肾脏移植(SHK)的VA-ECLS患者的结局。
方法:本研究纳入了UNOS数据库中的774名成人患者,他们在10/18/18和12/31/21之间接受了SHK,并比较了在VA-ECLS上桥接的患者(n=50)和未桥接的患者(n=724)。
结果:在基线时,从VA-ECLS桥接的SHK接受者更年轻(50.5vs.58.0年,p=0.007),移植时eGFR较高(47.6vs.30.1,p<0.001),在候补名单上花费的天数更少(7.0vs.33.5天,p<0.001)。在围手术期,VA-ECLS与较高的临时透析率相关(56.0%vs.28.0%,p<0.001),但慢性透析的2年累积发病率相似(7.5%vs5.4%,p=0.800)和肾移植失败(12.0%vs8.1%,p=0.500)与非ECLS队列相比。然而,VA-ECLS患者的出院生存率下降(76.0%vs92.7%,p<0.001)和移植后2年生存率(71.7%vs.83.0%,p=0.004),以及心脏移植失败的2年累积发生率更高(10.0%vs2.7%,p=0.002)。多变量分析发现,移植时的VA-ECLS与2年移植后死亡率独立相关(HR[95%CI]:3.40[1.66-6.96],p=0.001)和心脏同种异体移植失败(SHR[95%CI]:8.51[2.77-26.09],p<0.001)。
结论:根据新的分配政策,从VA-ECLS桥接至SHK的患者显示出更高的早期死亡率和心脏同种异体移植物衰竭,但与非ECLS患者的肾脏结局相似.
OBJECTIVE: Since United Network for Organ Sharing (UNOS) revised their heart allocation policy in 2018, usage of veno-arterial extracorporeal life support (VA-ECLS) has dramatically increased as a bridge to transplant. This study investigated outcomes of VA-ECLS patients bridged to simultaneous heart-kidney transplant (SHK) in the new policy era.
METHODS: This study included 774 adult patients from the UNOS database who received SHK between 10/18/18 and 12/31/21 and compared patients bridged to transplant on VA-ECLS (n=50) with those not bridged (n=724).
RESULTS: At baseline, SHK recipients bridged from VA-ECLS were younger (50.5 vs. 58.0 years, p=0.007), had higher eGFR at time of transplant (47.6 vs. 30.1, p<0.001), and spent fewer days on the waitlist (7.0 vs. 33.5 days, p<0.001). In the perioperative period, VA-ECLS was associated with higher rates of temporary dialysis (56.0% vs. 28.0%, p<0.001) but similar 2-year cumulative incidence of chronic dialysis (7.5% vs 5.4%, p=0.800) and renal allograft failure (12.0% vs 8.1%, p=0.500) compared to non-ECLS cohort. However, VA-ECLS patients had decreased survival to discharge (76.0% vs 92.7%, p<0.001) and 2-year post-transplant survival (71.7% vs. 83.0%, p=0.004), as well as greater 2-year cumulative incidence of cardiac allograft failure (10.0% vs 2.7%, p=0.002). Multivariable analyses found VA-ECLS at time of transplant to be independently associated with 2-year post-transplant mortality (HR [95% CI]: 3.40 [1.66-6.96], p=0.001) and cardiac allograft failure (SHR [95% CI]: 8.51 [2.77-26.09], p<0.001).
CONCLUSIONS: Under the new allocation policy, patients bridged to SHK from VA-ECLS displayed greater early mortality and cardiac allograft failure but similar renal outcomes compared to non-ECLS counterparts.