心臟移植之後 黑人的存活比白人少3年


  April 11, 2008 (波士頓) — 此間的心臟移植團隊報告指出,心臟移植之後,黑人病患的平均存活比白人病患少將近3年,比西班牙裔少將近2年。
  
  紐約Montefiore醫學中心/Albert Einstein醫學院的心臟胸腔助理教授Ricardo A. Bello博士報告指出,器官分享聯合網絡(United Network for Organ Sharing,UNOS)10年來近36,000名病患的回顧資料顯示,黑人心臟移植者比白人的存活機率少了將近 30%,且此結果和捐贈者與受贈者之間的種族不配對無關。
  
  Bello醫師在國際心臟與肺臟移植第28屆年會與科學會議中向Medscape Transplantation表示,雖然他們控制了高血壓、糖尿病、肌酸酐、年紀、與移植因素,看起來控制的所有的因素,但或許種族之間並無差異。
  
  未參與此研究的麻州綜合醫院心臟中心、心臟外科醫師Thomas E. MacGillivray向Medscape Transplantation提出對此研究的看法;MacGillivray醫師出,其團隊在去年發表了類似的發現,在存活上有不同,與抗原配對錯誤有關。
  
  MacGillivray醫師指出,發表於同一會議中的另一個不同的研究,有著不同的結果;在底特律亨利福特醫院的一個較小型單一中心研究中,研究者發現黑人和白人病患的3年追蹤期間有類似的存活率。
  
  在Bello醫師的研究中,他們探討UNOS從1987年10月到2006年10月之間所有接受心臟移植的成人病患的資料,他們根據捐贈者和受贈者的種族將這些病患分組,將他們的注意力集中在佔這段期間87%移植病例的3組:白人、黑人、西班牙裔,總共有34,069名受贈者,28,835名白人、4,454名黑人、780名西班牙裔。
  
  他們接著根據是否有捐贈者-受贈者種族配對進行後續分組,有配對者總共佔三分之二(23,272對),捐贈者/受贈者未配對者有10,797對。
  
  初步研究結果為移植後平均精算存活,作者使用Kaplan-Meier方法估計存活,以及比較使用指數系列法(log-rank test)獲得的結果,他們也進行Cox迴歸分析,以決定種族的影響,校正其他影響存活因素的效果。
  
  Bello醫師向Medscape Transplantation表示,他們發現,黑人的平均存活顯著較低,為7.7年,而白人為10.4年 (差異P值< .0005),西班牙裔為9.5 年 (P = .51),白人和西班牙裔之間的存活差異也是顯著(P = .037),但此研究中西班牙裔的人數太少。
  
  在未校正的分析中,研究者發現,黑人之間較短的存活可以用捐贈者-受贈者未配對來解釋 ,這情形減少了平均2.9年的存活。
  
  但是,當他們在多變項分析中再度檢視資料,控制高血壓、糖尿病、肌酸酐、移植等候狀態與人口統計學等因素之後,他們發現,相較於白人,黑人心臟移植受贈者是不佳存活的獨立預測因子(風險比1.28; 95% 信心區間,1.08 – 1.51; P = .003)。
  
  第二篇研究中,亨利福特醫院的Ajay Srivastava醫師等人回顧了在2001年1月到2006年6月之間,在他們醫院接受心臟移植的92名病患3年追蹤資料,使用自我辨識種族資料比較黑人和白人的結果,他們使用Kaplan-Meier曲線和指數系列法分析死亡時間、排斥與感染。
  
  結果發現,在3年的追蹤之後,兩組之間的存活類似,黑人組為74%、白人組為76% (P = .99);兩組之間的其他參數也類似,感染率方面黑人組為58%、白人組為64% (P = .94),排斥方面黑人組為70%、白人組為76% (P = .99)。
  
  相對的,黑人的再度住院率比白人低,分別是88%與92% (P < .05);Srivastava醫師表示,他們的資料顯示,非洲裔美國人在心臟移植之後並非不良結果的高風險群。
  
  MacGillivray醫師表示,在一群複雜因素中找到單一特定因素是困難的,你得排除其他諸多因素;但是我們試圖瞭解每個人的存活改善可以有多好、以及試圖瞭解不同病患之間的所有變項,以幫助每個人有最佳結果。
  
  Bello醫師、 Srivastava醫師、 MacGillivray醫師宣稱沒有相關資金往來。
  
  國際心臟與肺臟移植第28屆年會與科學會議:摘要147 與148。發表於2008年4月10日。

Blacks Survive 3 Years Shorter

By Neil Osterweil
Medscape Medical News

April 11, 2008 (Boston) — After a heart transplantation, the median survival of black patients is on average nearly 3 years shorter than that of whites, and almost 2 years shorter than that of Hispanics, reported members of a heart transplant team here.

A review of 10 years of United Network for Organ Sharing (UNOS) data on nearly 36,000 patients showed that black heart graft recipients had an almost 30% greater chance than whites of decreased survival, and the effect appeared to be independent of racial mismatch between donor and recipient, reported Ricardo A. Bello, MD, PhD,  assistant professor of cardiothoracic surgery at Montefiore Medical Center/Albert Einstein College of Medicine in the Bronx, New York.

Although they controlled for factors such as hypertension, diabetes, creatinine, age, and transplant factors, "it's possible that with control of enough factors, perhaps there really isn't a difference in race," Dr. Bello told Medscape Transplantation here at the 28th annual meeting and scientific sessions of the International Society of Heart and Lung Transplantation.

"Our group presented [similar findings at a meeting] last year, that there were differences in terms of survival, related to mismatch of antigens," said Thomas E. MacGillivray, MD, from the Division of Cardiac Surgery at the Massachusetts General Hospital Heart Center, who commented on the study for Medscape Transplantation; he was not involved in the study.

Dr. MacGillivray noted that a different study, presented in the same session, came to a different conclusion. In a smaller, single-center study from Henry Ford Hospital in Detroit, Michigan, the authors found similar survival rates at 3 year follow-up between black and white patients.

In Dr. Bello's study, he and his colleagues in the Bronx looked at UNOS data on all adults who underwent heart transplantation from October 1987 through October 2006. They divided the patients into groups according to the race of both donors and recipients, and focused their attention on 3 groups who accounted for 87% of all transplantations during that period: whites, blacks, and Hispanics. The total number of recipients studied was 34,069, consisting of 28,835 whites, 4,454 blacks, and 780 Hispanics.

They further grouped transplant recipients according to whether there was donor-recipient racial match, which occurred in about two thirds of the cases (23,272 pairs), with donor/recipient mismatch occurring in 10,797 pairs.

The primary study outcome was median actuarial survival after heart transplant, with the authors using the Kaplan-Meier method to estimate survival and comparing results using the log-rank test. They also performed Cox regression analyses to determine the impact of race, adjusting for the effects of other factors affecting survival.

They found that median survival for blacks was significantly lower, at 7.7 years, compared with 10.4 years for whites (P for difference < .0005) and 9.5 years for Hispanics (P = .51). The difference in survival between whites and Hispanics was also significant (P = .037), although the number of Hispanics in the study may have been too small, Dr. Bello told Medscape Transplantation.

In unadjusted analysis, the investigators found that shorter survival among blacks could be explained by donor–recipient mismatch, which decreased median survival by 2.9 years.

But when they looked at the data again in multivariate analysis, controlling for factors such as hypertension, diabetes, creatinine, transplant list status, and demographics, they found that being a black heart graft recipient was an independent predictor for worse survival compared with being white (hazard ratio, 1.28; 95% confidence interval, 1.08 – 1.51; P = .003).

In the second study, Ajay Srivastava, MD, and colleagues from Henry Ford Hospital reviewed 3-year follow-up data on 92 patients who underwent heart transplantation at their center from January 2001 through June 2006, using self-identified racial data to compare outcomes between blacks and whites. They used Kaplan-Meier curves and a log-rank test for time to death, rejection, and infection.

They found that after 3 years of follow-up, survival rates were similar between the groups, at 74% for blacks and 76% for whites (P = .99). Other parameters that were similar between the 2 groups included rates of infection, at 58% among blacks and 64% among whites (P = .94) and rates of rejection, at (70% and 76%, respectively (P = .99).

In contrast, blacks had lower rates of rehospitalization than whites, at 88% vs 92% (P < .05). Their data suggest that "African Americans are not at higher risk for adverse outcomes after cardiac transplantation," Dr. Srivastava said.

"The trouble with looking at one specific factor in a very complicated group of factors is that you tend to disregard many of the other pieces, " Dr. MacGillivray said. "But our attempts to understand how best to improve survival for everybody and to try to understand all the variables we can that are different between different patients will I think help everybody get the best results."

Dr. Bello, Dr. Srivastava, and Dr. MacGillivray have disclosed no relevant financial relationships.

International Society for Heart and Lung Transplantation 28th Annual Meeting and Scientific Sessions: Abstracts 147 and 148. Presented April 10, 2008.

J Heart Lung Transplant. 2008;27(2 suppl):S112–S113.

    
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