年長病患可慎用肺臟移植


  March 24, 2009 — 根據3月美國外科醫學期刊中的回溯研究結果,60歲以上病患可以謹慎使用肺臟移植,但是70歲以上者不建議使用。
  
  約翰霍普金斯醫學研究中心的Eric S. Weiss醫師等人寫道,年長病患增加了肺臟移植(LTx)。之前的研究受限於樣本數少。器官分享聯合網絡(UNOS)資料庫提供檢視更多年長病患之存活的機會。
  
  研究樣本包括1999至2006年間的8,363名接受肺臟移植的成年病患,主要結果是30天時的短期死亡率、90天與一年時的死亡率,根據病患年紀的四分位數確定。用Cox相對危險迴歸比較移植後的存活。
  
  平均年紀為51 ± 12歲(平均年紀55歲;範圍18 – 79歲)。最年輕的一組(Q1)是18-45歲(n = 2192)、其次是Q2組 (46 – 55歲; n = 2160)、Q3組(56 – 60歲;n = 2000)、以及最老的一組(Q4)是61-79 歲(n = 2011)。
  
  慢性阻塞性肺部疾病是最常見的移植原因,佔整個世代的40%,其次為特發性肺纖維化、佔22%。不過,根據年紀分組時,適應症顯著不同,年輕組比較常見的例如囊狀纖維化。
  
  60歲以上病患(Q4組)的死亡風險比Q1組增加約37%(風險比[HR]為1.37; 95%信心區間[CI]為1.16 - 1.62; 校正後P < .001)。對於60歲以上病患,30天死亡率無顯著不同(HR, 1.22; 95% CI, 0.82 - 1.80; P = .33)。
  
  相對的,70歲以上病患的30天死亡率風險(HR, 2.9; 95% CI, 1.2 - 7.1; P = .02)比70歲以下病患顯著增加,90天死亡率也是(HR, 3.0; 95% CI, 1.5 - 5.9; P < .001),一年時也是(HR, 2.2; 95% CI, 1.2 - 3.9; P = .008)。
  
  研究作者寫道,年長病患(>60歲)需謹慎肺臟移植,且不應用於70歲以上病患。儘管我們的分析發現,60歲以上病患在肺臟移植之後一和兩年的死亡率較高,30天和90天死亡率則是相似。此外,這些存活差異也需將未進行肺臟移植的末期肺病患者的不良存活率納入考量。
  
  研究限制包括屬於回溯設計、無法辨識資料庫以外的病患特徵、缺乏不同機構間免疫抑制與手術技術的標準化、資料或許不是臨床專家所紀錄。
  
  研究作者結論表示,70歲以上病患的存活特別差,此一年齡層有明顯風險。這些結果支持70歲以下適合之病患進行肺臟移植。
  
  健康資源與服務管理合約以及Ruth L. Kirschstein國家研究服務獎(國家健康研究中心)支持本研究之一部份。文章內容並不代表健康與人類服務部的政策觀點,也不代表美國政府為這些商品或機構背書。研究作者宣告沒有相關財務關係。

Lung Transplantation May Be Used With Caution in Older Patients

By Laurie Barclay, MD
Medscape Medical News

March 24, 2009 — Lung transplantation may be used with caution in patients older than 60 years but should not be used for patients older than 70 years, according to the results of a retrospective study reported in the March issue of the Journal of the American College of Surgeons.

"Elderly patients are increasingly referred for lung transplantation (LTx) evaluation," write Eric S. Weiss, MD, from the Johns Hopkins Medical Institutions in Baltimore, Maryland, and colleagues. "Earlier outcomes studies in this cohort are limited by sample size. The United Network for Organ Sharing (UNOS) database provides an opportunity to examine survival in a large cohort of elderly patients."

The study sample consisted of 8363 adult patients who received lung transplantation between 1999 and 2006. The main outcome was short-term mortality at 30 days, 90 days, and 1 year, determined for patient quartiles based on age. Cox proportional hazards regression allowed comparison of posttransplantation survival.

Mean age was 51 ± 12 years (median age, 55 years; range, 18 - 79 years). The youngest quartile (Q1) was 18 to 45 years (n = 2192), followed by Q2 (46 - 55 years; n = 2160), Q3 (56 - 60 years; n = 2000), and the oldest quartile (Q4) was 61 to 79 years (n = 2011).

Chronic obstructive pulmonary disease was the most common indication for transplantation, present in 40% of the overall cohort, followed by idiopathic pulmonary fibrosis, present in 22%. However, indications were markedly different based on age groups, with additional indications, such as cystic fibrosis, more common in the younger groups.

The risk for death was increased by 37% in patients older than 60 years (Q4) vs those in Q1 (hazards ratio [HR], 1.37; 95% confidence interval [CI], 1.16 - 1.62; P < .001 after risk adjustment). For patients older than 60 years, 30 -day mortality rate was not statistically different (HR, 1.22; 95% CI, 0.82 - 1.80; P = .33).

In contrast, patients at least 70 years old had dramatically increased risks for mortality vs those younger than 70 years at 30 days (HR, 2.9; 95% CI, 1.2 - 7.1; P = .02), 90 days (HR, 3.0; 95% CI, 1.5 - 5.9; P < .001), and 1 year (HR, 2.2; 95% CI, 1.2 - 3.9; P = .008).

"Lung transplantation may be used with caution in older patients (>60 years) but should not be used for patients older than age 70," the study authors write. "Although our analysis revealed higher mortality at 1 and 2 years after LTx for patients older than 60, 30-day and 90-day mortality rates were similar. In addition, these survival differences must be taken in the context of the dismal survival estimates for elderly patients with advanced lung diseases who do not receive LTx."

Limitations of this study include retrospective design, inability to identify patient characteristics not documented in the database, lack of standardization in immunosuppression and surgical techniques between institutions, and data probably not recorded by individuals with clinical expertise.

"Survival for patients age 70 and older was exceptionally poor and points to substantial risk for this age group," the study authors conclude. "These results support lung transplantation in acceptable candidates younger than age 70."

A Health Resources and Services Administration contract and a Ruth L. Kirschstein National Research Service Award (National Institutes of Health) supported this study in part. The content of the article does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US government. The study authors have disclosed no relevant financial relationships.

J Am Coll Surg. 2009;208:400-409.

    
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