Purpose

To determine whether the reduced risk of immunologic rejection with Descemet membrane endothelial keratoplasty (DMEK) results in a 5-year survival advantage relative to Descemet stripping endothelial keratoplasty (DSEK) and to determine whether matching the donor and recipient sex affects the rejection episode and graft survival rates.

Design

Retrospective cohort study.

Participants

Patients with Fuchs’ endothelial corneal dystrophy treated with DSEK or DMEK.

Methods

This study reviewed 2017 consecutive cases (1312 DSEK and 705 DMEK) performed by 13 surgeons between 2003 and 2012 and included the surgeons’ first cases. Survival rates were calculated by Kaplan–Meier analysis.

Main Outcome Measures

Immunologic rejection episodes, graft failure or replacement for any reason, and endothelial cell loss.

Results

The 5-year rejection episode rate was lower with DMEK (2.6% vs. 7.9% with DSEK, relative risk, 0.29; 95% confidence interval, 0.16–0.53) despite early reduction of topical corticosteroids in 25% of the DMEK cases. African Americans (n = 46) had a higher risk of rejection episodes than other races (relative risk, 4.4; 95% confidence interval, 2.0–9.6). The cumulative 5-year survival rate was 93% with DSEK and DMEK (P = 0.86). Forty-four DMEK and 69 DSEK grafts failed or were replaced within 5 years, but only 1 DMEK and 4 DSEK failures followed a rejection episode. Rejection episodes increased endothelial cell loss (P = 0.004) but were not a significant risk factor for graft failure within 5 years (P = 0.90). The mean 5-year endothelial cell loss was similar between DMEK (48%±19%) and DSEK (47%±19%) (P = 0.22). Graft rejection episode and survival rates were not significantly influenced by whether the sex of the donor matched that of the recipient (rejection episodes: P = 0.07 for female recipients and P = 0.33 for male recipients; graft survival: P = 0.67 for female recipients and P = 0.17 for male recipients).

Conclusions

Five-year graft survival was similar between DMEK and DSEK. Although DMEK had a significantly lower risk of immunologic rejection, rejection episodes rarely resulted in graft failure within 5 years with either procedure. Sex matching the donor and recipient provided no survival advantage with DSEK or DMEK.

中文翻译：

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Descemet膜内皮角膜移植术（EK）与Descemet剥离EK的五年移植存活率和供体性别匹配的影响

目的

确定Descemet膜内皮角膜移植术（DMEK）相对于Descemet剥离内皮角膜移植术（DSEK）降低免疫排斥反应的风险是否具有5年生存优势，并确定供体和受体性别的匹配是否影响排斥事件和移植物生存率。

设计

回顾性队列研究。

参加者

用DSEK或DMEK治疗的Fuchs内皮角膜营养不良患者。

方法

这项研究回顾了2003年至2012年期间由13位外科医生执行的2017年连续病例（1312 DSEK和705 DMEK），并包括了外科医生的首例病例。生存率通过Kaplan-Meier分析计算。

主要观察指标

免疫排斥反应，任何原因的移植物衰竭或替换以及内皮细胞损失。

结果

尽管25％的DMEK病例早期局部使用了皮质类固醇激素，但DMEK的5年排斥反应发生率较低（2.6％对比DSEK的7.9％，相对危险度为0.29； 95％的置信区间为0.16-0.53）。非裔美国人（n = 46）的排斥反应发生风险高于其他种族（相对风险，4.4； 95％置信区间，2.0-9.6）。DSEK和DMEK的5年累积生存率为93％（P  = 0.86）。5年内有44例DMEK和69例DSEK移植失败或被更换，但仅1例DMEK和4例DSEK失败发生在排斥反应之后。排斥反应增加了内皮细胞的损失（P  = 0.004），但不是5年内移植失败的重要危险因素（P = 0.90）。DMEK（48％±19％）和DSEK（47％±19％）之间的5年平均内皮细胞损失相似（P  = 0.22）。移植排斥反应的发生率和存活率不受捐赠者性别是否与受者性别相匹配的影响（排斥发作： 女性受者的P = 0.07，男性受者的P  = 0.33；移植物的存活： 女性受者和女性的P = 0.67）。 对于男性接受者，P = 0.17）。

结论

DMEK和DSEK的五年移植物存活率相似。尽管DMEK的免疫排斥风险显着降低，但无论采用哪种方法，排斥事件很少会在5年内导致移植失败。匹配供体和接受者的性别对DSEK或DMEK没有提供生存优势。