Criteria for and Appropriateness of Renal Transplantation in Elderly Patients With End-Stage Renal Disease

Abstract

During the last 20 years, waiting lists for renal transplantation (RT) have grown significantly older. However, elderly patients (ie ≥65 years of age) are still more rarely referred or accepted to waiting lists and, if enlisted, have less chances of actually receiving a kidney allograft, than younger counterparts. In this review, we looked at evidence for the benefits and risks of RT in the elderly trying to answer the following questions: Should RT be advocated for elderly patients? What should be the criteria to accept elderly patients on the waiting list for RT? What strategies might be used to increase the rate of RT in waitlisted elderly candidates? For selected elderly patients, RT was shown to be superior to dialysis in terms of patient survival. Virtually all guidelines recommend that patients should not be deemed ineligible for RT based on age alone, although a short life expectancy generally might preclude RT. Concerning the assessment of comorbidities in the elderly, special attention should be paid to cardiac evaluation and screening for malignancy. Comorbidity scores and frailty assessment scales might help the decision making on eligibility. Psychosocial issues should also be evaluated. To overcome the scarcity of organ donors, elderly RT candidates should be encouraged to consider expanded criteria donors and living donors, as alternatives to deceased standard criteria donors. It has been demonstrated that expanded criteria donor RT in patients 60 years or older is associated with higher survival rates than remaining on dialysis, whereas living donor RT is superior to all other options.

Mortality in Elderly Waiting-List Patients Versus Age-Matched Kidney Transplant Recipients: Where is the Risk?

“…Given the emerging evidence of the benefits of KT on survival in the elderly ESRD population, the age of patients on the WL for KT has risen significantly over the last decades worldwide [3, 4, 18-21]. However, previous reports have documented that approximately half of elderly KT candidates (>60 years) in the United States die on the WL before receiving a deceased-donor transplant [22].…”

“…It is plausible, therefore, that, given the immunosenescence of the elderly, the use of lower doses of immunosuppressants and a more careful surveillance could minimize these life-threatening side effects, while still being able to provide adequate levels of immunosuppression. Given this background, careful selection of elderly candidates for KT based on a thoroughly comprehensive medical, psychosocial and functional evaluation would be recommendable, with emphasis on a CV work-up, to make the best clinical decisions in order to decrease post-transplant mortality, as reported [4]. Unfortunately, the optimal method of screening for CV diseases in these patients is still unclear.…”

“…that can modify their transplant status whilst on the WL [3, 4]. In addition, assessment of elderly KT candidates is complex and evidence-based clinical guidelines for the management of this particular population are lacking [4-8]. Moreover, many transplant teams are still reluctant to include elderly patients on the WL for KT as objective selection criteria for transplantation in this population are poorly defined [3, 4, 9].…”

“…>65 years) are less frequently placed on the waiting list (WL), due to uremia-related life-threatening comorbidities, and, if they are listed, they have fewer chances of receiving a KT than their younger counterparts, partly owing to emergent events (cardiovascular disorders, infections, neoplasias, etc.) that can modify their transplant status whilst on the WL [3, 4]. In addition, assessment of elderly KT candidates is complex and evidence-based clinical guidelines for the management of this particular population are lacking [4-8].…”

“…In addition, assessment of elderly KT candidates is complex and evidence-based clinical guidelines for the management of this particular population are lacking [4-8]. Moreover, many transplant teams are still reluctant to include elderly patients on the WL for KT as objective selection criteria for transplantation in this population are poorly defined [3, 4, 9]. Misconceptions regarding the inclusion criteria for elderly patients for KT could delay early referral to a transplant center or delay WL inclusion, leading to a longer time spent on dialysis.…”