背景:肺移植(LT)是终末期肺部疾病的高风险手术。这项研究描述了接受LT的患者的结局,这些患者需要根据围手术期出血(UDBB)的通用定义进行大量输血。
方法:对在单一学术中心接受双侧LT的成年患者进行回顾性调查。患者按无关紧要的分组,温和,或中度围手术期出血(轻度至中度出血)和重度或大量围手术期出血(重度至大量出血)基于UDBB分类。结果包括1年生存率和术后72小时的3级原发性移植物功能障碍(PGD)。多变量模型根据接受者年龄进行了调整,性别,体重指数(BMI),肺分配评分(LAS),术前血红蛋白(Hb),术前体外膜氧合(ECMO)状态,移植数量,和捐赠者身份。建立了一个额外的多变量模型,以发现术前和术中严重至大量出血的预测因素。选择小于0.05的P值用于显著性。
结果:共纳入528例患者,357个轻度至中度出血者和171个重度至重度出血者。术后,重度至重度出血者在72小时有较高的PGD3级发生率,住院时间更长,30天和一年的死亡率更高,并且不太可能实现LT的教科书成果。他们还需要术后ECMO,再插管超过48小时,气管造口术,再干预,和透析率更高。在多变量分析中,在调整受体和供体因素后,重度至大出血与不良结局显著相关,PGD3在72小时的比值比为7.73(95%CI:4.27-14.4,p<0.001),1年死亡率为4.30(95%CI:2.30-8.12,p<0.001),和1.75(95%CI:1.52-2.01,p<0.001),住院时间较长。此外,严重到大量的出血者不太可能达到教科书的结果,比值比为0.07(95%CI:0.02-0.16,p<0.001)。术前和术中确定了严重/大量出血的预测因素,白人患者的几率低于黑人患者(OR:041,95%CI:0.22-0.80,p=0.008)。BMI每增加1个单位,出血几率就会降低(OR:0.89,95%CI:0.83-0.95,p<0.001),而MPAP每增加1个单位则增加出血几率(OR:1.04,95%CI:1.02-1.06,p<0.001)。首次移植受者的风险较低(OR:0.16,95%CI:0.06-0.36,p<0.001),而有DCD供者的患者出现严重至大出血的风险较高(OR:3.09,95%CI:1.63-5.87,p=0.001).
结论:这些结果表明,大量出血高危患者需要更高的医院资源利用率。了解它们的结果很重要,因为它可能为将来的移植类似患者的决定提供信息。
BACKGROUND: Lung transplantation (LT) represents a high-risk procedure for end-stage lung diseases. This study describes the outcomes of patients undergoing LT that require massive transfusions as defined by the universal definition of perioperative bleeding (UDPB).
METHODS: Adult patients who underwent bilateral LT at a single academic center were surveyed retrospectively. Patients were grouped by insignificant, mild, or moderate perioperative bleeding (insignificant-to-moderate bleeders) and severe or massive perioperative bleeding (severe-to-massive bleeders) based on the UDPB classification. Outcomes included 1-year survival and primary graft dysfunction (PGD) of grade 3 at 72 h postoperatively. Multivariable models were adjusted for recipient age, sex, body mass index (BMI), Lung allocation score (LAS), preoperative hemoglobin (Hb), preoperative extracorporeal membrane oxygenation (ECMO) status, transplant number, and donor status. An additional multivariable model was created to find preoperative and intraoperative predictors of severe-to-massive bleeding. A p-value less than 0.05 was selected for significance.
RESULTS: A total of 528 patients were included, with 357 insignificant-to-moderate bleeders and 171 severe-to-massive bleeders. Postoperatively, severe-to-massive bleeders had higher rates of PGD grade 3 at 72 h, longer hospital stays, higher mortality rates at 30 days and one year, and were less likely to achieve textbook outcomes for LT. They also required postoperative ECMO, reintubation for over 48 h, tracheostomy, reintervention, and dialysis at higher rates. In the multivariate analysis, severe-to-massive bleeding was significantly associated with adverse outcomes after adjusting for recipient and donor factors, with an odds ratio of 7.73 (95% CI: 4.27-14.4, p < 0.001) for PGD3 at 72 h, 4.30 (95% CI: 2.30-8.12, p < 0.001) for 1-year mortality, and 1.75 (95% CI: 1.52-2.01, p < 0.001) for longer hospital stays. Additionally, severe-to-massive bleeders were less likely to achieve textbook outcomes, with an odds ratio of 0.07 (95% CI: 0.02-0.16, p < 0.001). Preoperative and intraoperative predictors of severe/massive bleeding were identified, with White patients having lower odds compared to Black patients (OR: 041, 95% CI: 0.22-0.80, p = 0.008). Each 1-unit increase in BMI decreased the odds of bleeding (OR: 0.89, 95% CI: 0.83-0.95, p < 0.001), while each 1-unit increase in MPAP increased the odds of bleeding (OR: 1.04, 95% CI: 1.02-1.06, p < 0.001). First-time transplant recipients had lower risk (OR: 0.16, 95% CI: 0.06-0.36, p < 0.001), whereas those with DCD donors had a higher risk of severe-to-massive bleeding (OR: 3.09, 95% CI: 1.63-5.87, p = 0.001).
CONCLUSIONS: These results suggest that patients at high risk of massive bleeding require higher utilization of hospital resources. Understanding their outcomes is important, as it may inform future decisions to transplant comparable patients.