Older candidates for kidney transplantation: Who to refer and what to expect?

Abstract

The number of older end-stage renal disease patients being referred for kidney transplantation continues to increase. This rise is occurring alongside the continually increasing prevalence of older end-stage renal disease patients. Although older kidney transplant recipients have decreased patient and graft survival compared to younger patients, transplantation in this patient population is pursued due to the survival advantage that it confers over remaining on the deceased donor waiting list. The upper limit of age and the extent of comorbidity and frailty at which transplantation ceases to be advantageous is not known. Transplant physicians are therefore faced with the challenge of determining who among older patients are appropriate candidates for kidney transplantation. This is usually achieved by means of an organ systems-based medical evaluation with particular focus given to cardiovascular health. More recently, global measures of health such as functional status and frailty are increasingly being recognized as potential tools in risk stratifying kidney transplant candidates. For those candidates who are deemed eligible, living donor transplantation should be pursued. This may mean accepting a kidney from an older living donor. In the absence of any living donor, the choice to accept lesser quality kidneys should be made while taking into account the organ shortage and expected waiting times on the deceased donor list. Appropriate counseling of patients should be a cornerstone in the evaluation process and includes a discussion regarding expected outcomes, expected waiting times in the setting of the new Kidney Allocation System, benefits of living donor transplantation and the acceptance of lesser quality kidneys.

Análise Físico Funcional E Cardiorrespiratória De Pacientes Em Lista De Espera Para O Transplante Renal: Estudo Transversal

“…A média de idade dos pacientes cadastrados em lista de espera do nosso estudo foi semelhante à encontrada em um estudo recente realizado em São Paulo 15 . Na Noruega, a média de idade dos pacientes em lista de espera foi de 71,1 anos, 16 e nos Estados Unidos está sendo realizado com maior frequência transplantes com pacientes idosos acima de 65 anos 17 . Tais dados sugerem que a população brasileira está desenvolvendo mais precocemente a doença renal ou que a progressão da doença está ocorrendo mais rapidamente na nossa população.…”

Cardiovascular Evaluation of Renal Transplant Recipients

“…An appropriate renal transplant recipient is defined as ''a patient whose survival and quality of life are expected to improve with transplantation as compared to remaining on dialysis'' [9]. However, there is no accurately and reliably clinical criteria to predict this.…”

“…However, there is no accurately and reliably clinical criteria to predict this. Therefore, it is logical to choose the appropriate candidate with reasonable long term prognosis [9]. CAD is one of the major disease entity with high prevalence in patients with CKD.…”

Why Should Vascular Surgeons be More Involved in Kidney Transplantation?

“…Indeed, with an ageing population, there is an increase in the older end stage renal disease patients and candidates aged 65 or older now represent 22% of the waiting list. 1 In 1980, patients older than 50 were not listed for a kidney transplant, but in 2004 almost 90% of those aged 60 years with end stage renal disease were listed, and even patients older than 80. 1 As a matter of fact, in addition to elderly recipient comorbidities such as diabetes or hypertension, the prevalence of arterial disease, especially extensive vascular calcification, has increased.…”

“…1 In 1980, patients older than 50 were not listed for a kidney transplant, but in 2004 almost 90% of those aged 60 years with end stage renal disease were listed, and even patients older than 80. 1 As a matter of fact, in addition to elderly recipient comorbidities such as diabetes or hypertension, the prevalence of arterial disease, especially extensive vascular calcification, has increased. In chronic kidney disease, there is an accumulation of calcium and phosphate in arteries with mineral deposits in the intimal or medial layer of the vessel wall.…”