Access to kidney transplantation in European adults aged 75-84 years and related outcomes: an analysis of the European Renal Association-European Dialysis and Transplant Association Registry

Abstract

To what extent access to, and allocation of kidney transplants and survival outcomes in patients aged ≥75 years have changed over time in Europe is unclear. We included patients aged ≥75-84 years (termed older adults) receiving renal replacement therapy in thirteen European countries between 2005 and 2014. Country differences and time trends in access to, and allocation of kidney transplants were examined. Survival outcomes were determined by Cox regression analyses. Between 2005 and 2014, 1392 older adult patients received 1406 transplants. Access to kidney transplantation varied from ~0% (Slovenia, Greece and Denmark) to ~4% (Norway and various Spanish regions) of all older adult dialysis patients, and overall increased from 0.3% (2005) to 0.9% (2014). Allocation of kidney transplants to older adults overall increased from 0.8% (2005) to 3.2% (2014). Seven-year unadjusted patient and graft survival probabilities were 49.1% (95% confidence interval, 95% CI: 43.6; 54.4) and 41.7% (95% CI: 36.5; 46.8), respectively, with a temporal trend towards improved survival outcomes. In conclusion, in the European dialysis population aged ≥75-84 years access to kidney transplantation is low, and allocation of kidney transplants remains a rare event. Though both are increasing with time and vary considerably between countries. The trend towards improved survival outcomes is encouraging. This information can aid informed decision-making regarding treatment options.

Benefits of kidney transplantation for a national cohort of patients aged 70 years and older starting renal replacement therapy

“…The risk of early mortality after transplantation, compared with matched dialysis patients, was lower in patients with preemptive transplantation and those without cardiovascular comorbidity or diabetes. As reported previously, the most common causes of posttransplant deaths, after infectious diseases and malignancies, were cardiovascular diseases . Cardiovascular comorbidities should therefore continue to be a criterion for waiting‐list selection.…”

“…Because the number of people aged ≥70 on KT waiting lists has been increasing, several studies have been able to examine their outcomes . Using the Scientific Registry of Transplant Recipients (or SRTR), Rao et al analyzed data from patients wait‐listed between 1990 and 2004 at age ≥70 and reported that transplant recipients had an overall risk of death 41% lower than wait‐listed candidates, but with a risk of death during the first 45 days after transplant around twice as high.…”

“…Nephrologists remain divided, however, about placing elderly patients on KT waiting lists, probably because increasing age and age‐related comorbidities are recognized major and independent risk factors for death after transplantation, especially in the perioperative period . Consequently, older patients still have poor access to KT, and age remains a factor associated with nonplacement on the waiting list . In France, between 2002 and 2011, the cumulative incidence rate of access to transplantation for patients younger than 60 years was 57% at 5 years, compared to only 1.5% for those ≥70 years.…”

“…In France, between 2002 and 2011, the cumulative incidence rate of access to transplantation for patients younger than 60 years was 57% at 5 years, compared to only 1.5% for those ≥70 years. The percentage of prevalent dialysis patients aged 75 to 84 years who received a KT in Europe ranged from 0% to 4%, depending on the country . Only 3.4% of US ESRD patients aged ≥70 were on a waiting list …”

Data from the ERA-EDTA Registry were examined for trends in excess mortality in European adults on kidney replacement therapy

“…Moreover, during our study period, the mortality rate in the general population decreased, whereas the mortality rate in kidney transplant patients remained stable or slightly increased, contributing to an increase in excess mortality. The lack of improvement of the mortality rate in transplant patients may be explained by the increased acceptance of older patients for kidney transplantation, 38 as well as by greater acceptance of older and marginal kidney donors. 39 In kidney transplant recipients, the excess mortality remained stable over time for nearly all specific causes of death.…”