Renal transplantation in the elderly

Abstract

Elderly patients are increasingly being considered for kidney transplantation due to a global explosion of the aging population with end-stage renal disease (ESRD). However, mounting scarcity of available organs for transplant has led to a wider disparity between organ supply and demand. Consequently, the criteria for accepting kidneys for transplantation have been extended in an attempt to allow the use of organs from elderly donors or those with significant co-morbidities, so-called "expanded criteria donor" (ECD) kidneys. Excellent outcomes have been achieved from ECD kidneys with appropriate donor and recipient profiling and selection. With increasing recovery efforts directed at older donors, the concept of age-matching is becoming more accepted as a method of optimizing utilization of organs in elderly donors and recipients. Utilization of pulsatile perfusion has further improved ECD outcomes and helped the decision-making process for the UNOS (United Network for Organ Sharing) offer. However, age-related immune dysfunction and associated co-morbidities make the elderly transplant recipients ever more susceptible to complications associated with immunosuppressive agents. Consequently, the elderly population is at a higher risk to develop infections and malignancy in the post-transplant period notwithstanding improved transplant outcomes. Appropriate immunosuppressive agents and dosages should be selected to minimize adverse events while reducing the risk of acute rejections and maximizing patient and renal allograft survival.

Expanded Criteria Donors in Kidney Transplantation: The Role of Older Donors in a Setting of Older Recipients

“…Marginal donors are also considered those with diabetes, the non-heart-beating cadaver donors, or those with anatomical abnormalities [1,29]. These factors are usually considered during the clinical decision to accept or decline a marginal graft.…”

“…Furthermore when patients aged 60 years and older with comorbidities received an ECD kidney, there was a further substantial increase in 1-year mortality ranging from 16% for patients with diabetes to 42.3% for patients with chronic obstructive pulmonary disease. Comorbid conditions such as diverticular disease, diabetes, vascular insufficiency, and urinary tract abnormalities can also lead to a higher risk of post-transplant infections [1]. An increase in incidence of infections with aging has been described [67][68][69], which in turn can be responsible of a higher post-transplant mortality [69].…”

“…Elderly patients are usually excluded from transplantation trials [1,80], and the available evidences derive from small, single center, observational studies [1]. Due to this lack of evidences, the choice of the immunosuppressive therapy remains largely subjective, usually based on data from younger recipients.…”

“…In the last two decades while kidney transplantation (KT) has been definitively recognized as the therapy of choice for end-stage renal disease (ESRD), the elderly population has progressively and largely increased over the years, all around the world [1]. At present there are two renal replacement therapies for ESRD: dialysis (including hemodialysis and peritoneal dialysis) and KT.…”

It is not polite to ask a dialysis patient his age!

“…Moreover, HRQoL is an important predictor of outcomes in kidney transplanted patients [27]. Kidney transplantation is the treatment of choice for most ESRD patients independent of age [28][29][30]. However, the generalizability of the studies comparing survival after renal transplantation with dialysis therapy is compromised by such methodological flaws as selection bias [31,32].…”