Renal allografts from donors older than 70 years are useful for single transplantation

Kidney transplantation from elderly donors (> 70 years): a systematic review

PURPOSE

The incidence of kidney transplants from elderly donors over 70 years of age has increased significantly over the past 10 years to reach 20% of available kidney graft in some European countries. However, there is little data available on the outcomes of transplants from these donors. We performed a systematic review to evaluate the outcomes of transplantation from donors over 70 years of age.

METHODS

A systematic review was performed according to preferred reporting items for systematic reviews and meta-analyses. Medline, Embase, and Cochrane databases were searched to identify all studies reporting outcomes on kidney transplants from donors over 70 years. Due to the heterogeneity of the studies, a meta-analysis could not be performed.

RESULTS

A total of 29,765 patients in 27 studies were included. The mean donors age was 74.79 years, and proportion of kidney graft from women was 53.54%. The estimated 1- and 5-year kidney death-censored graft survivals from donors > 70 years old were, respectively, 85.95 and 80.27%, and the patient survivals were 90.88 and 71.29%. The occurrence of delayed graft function was 41.75%, and primary non-function was 4.67%. Estimated graft function at 1 and 5 years was 36 and 38 mL/min/1.73 m². Paucity data were available on post-operative complications.

CONCLUSIONS

Elderly donors appear to be a reliable source of grafts. However, these transplants are associated with a high rate of delayed graft function without repercussion on long-term graft survival. Allocation strategy to elderly recipients is the main factor of decreased recipient survival.

Impaired renal function before kidney procurement has a deleterious impact on allograft survival in very old deceased kidney donors

As the use of elderly kidney donors for transplantation is increasing with time, there is a need to understand which factors impact on their prognosis. No data exist on the impact of an impaired renal function (IRF) in such population. 116 kidney recipients from deceased kidney donors over 70 years were included from 2005 to 2015 in a single-center retrospective study. IRF before organ procurement was defined as a serum creatinine above 1.0 mg/dl or a transient episode of oligo-anuria. Mean ages for donors and recipients were respectively 74.8 ± 3.5 and 66.7 ± 8.0. Graft survival censored for death at 5 years was of 77%. Using a multivariate analysis by Cox model, the only predictor of graft loss present in the donor was IRF before organ procurement (HR 4.2 CI95[1.8–9.7]). IRF was also associated with significant lower estimated glomerular filtration rates up to 1 year post-transplantation. By contrast, KDPI score (median of 98 [96–100]), was not associated with the risk of graft failure. Then, IRF before kidney procurement may define a risk subgroup among very-old deceased kidney donors, in whom pre-implantatory biopsies, dual kidney transplantation or calcineurin inhibitor-free immunosuppressive regimen could help to improve outcomes.

[Very-old deceased donors in kidney transplantation: How far can we go?]

In order to increase the pool of organ donors, kidney transplantation from very old-donors, notably aged more than 70, is increasing. Compared to the United States, where the use of these grafts does not reach 5%, in France it reaches over 20%. Kidney aging is determined by a progressive glomerusclerosis, interstitial fibrosis, and nephrosclerosis, responsible of a linear decrease of glomerular filtration rate with time. Aging in kidney transplantation goes along also with an increased immunogenicity and risk of ischemia-reperfusion injuries. Hence, the prognosis of these transplantations is worse than those from younger donors, even though it remains better than dialysis. Data is lacking on risk factors of graft loss in this specific population. Hypothermic perfusion machine, pre-implantation kidney biopsy, dual kidney transplantation and immunosuppressive strategies have been evaluated to improve the long-term prognosis of these grafts.

Strategies for an Expanded Use of Kidneys From Elderly Donors

The old-for-old allocation policy used for kidney transplantation (KT) has confirmed the survival benefit compared to remaining listed on dialysis. Shortage of standard donors has stimulated the development of strategies aimed to expand acceptance criteria, particularly of kidneys from elderly donors. We have systematically reviewed the literature on those different strategies. In addition to the review of outcomes of expanded criteria donor or advanced age kidneys, we assessed the value of the Kidney Donor Profile Index policy, preimplantation biopsy, dual KT, machine perfusion and special immunosuppressive protocols. Survival and functional outcomes achieved with expanded criteria donor, high Kidney Donor Profile Index or advanced age kidneys are poorer than those with standard ones. Outcomes using advanced age brain-dead or cardiac-dead donor kidneys are similar. Preimplantation biopsies and related scores have been useful to predict function, but their applicability to transplant or refuse a kidney graft has probably been overestimated. Machine perfusion techniques have decreased delayed graft function and could improve graft survival. Investing 2 kidneys in 1 recipient does not make sense when a single KT would be enough, particularly in elderly recipients. Tailored immunosuppression when transplanting an old kidney may be useful, but no formal trials are available.Old donors constitute an enormous source of useful kidneys, but their retrieval in many countries is infrequent. The assumption of limited but precious functional expectancy for an old kidney and substantial reduction of discard rates should be generalized to mitigate these limitations.

Single-center experience with kidney transplantation using deceased donors older than 75 years

BACKGROUND

Use of kidneys from donors aged 75 years and older is controversial. The purpose of this study was to evaluate the outcome of kidney transplantation (KT) involving these expanded criteria donors.

MATERIALS AND METHODS

From January 2001 to November 2009, 52 patients were transplanted with grafts from deceased donors aged 75 years and older. Donor and recipient data and intra- and postoperative variables were analyzed by univariate and multivariate regression analyses. Graft and patient survival were calculated using the Kaplan-Meier method.

RESULTS

Forty-one single and 11 double KTs were performed. Median recipient age was 66 years. After a median follow-up of 30 months, 37 of 52 patients are alive, 30 with functioning grafts (81%). Graft and patient survival rates at 3 and 5 years are 63% and 53%, and 78% and 64%, respectively. Double KT was significant predictor for graft survival by multivariate analysis. Five-year graft survival for single and double KT was 41% and 90%, respectively (P=0.0394). Comorbidity Index, hospital stay, acute rejection reaction, re-KT, and induction immunosuppressive therapy with interleukin-2 were significant predictors for patient survival by univariate analysis. Hospital stay and induction immunosuppression therapy reached multivariate significance. Double KT, cold ischemia time, and Comorbidity Index were found potential predictors of delayed graft function in our series.

CONCLUSIONS

Fairly good long-term outcome of KT from donors aged 75 years and older can be achieved in elderly recipients with low comorbidities when dual kidney grafting is used and when re-transplantations and high grade surgical complications are avoided.

Acute respiratory failure in kidney transplant recipients: a multicenter study

INTRODUCTION

Data on pulmonary complications in renal transplant recipients are scarce. The aim of this study was to evaluate acute respiratory failure (ARF) in renal transplant recipients.

METHODS

We conducted a retrospective observational study in nine transplant centers of consecutive kidney transplant recipients admitted to the intensive care unit (ICU) for ARF from 2000 to 2008.

RESULTS

Of 6,819 kidney transplant recipients, 452 (6.6%) required ICU admission, including 200 admitted for ARF. Fifteen (7.5%) of these patients had combined kidney-pancreas transplantations. The most common causes of ARF were bacterial pneumonia (35.5%), cardiogenic pulmonary edema (24.5%) and extrapulmonary acute respiratory distress syndrome (ARDS) (15.5%). Pneumocystis pneumonia occurred in 11.5% of patients. Mechanical ventilation was used in 93 patients (46.5%), vasopressors were used in 82 patients (41%) and dialysis was administered in 104 patients (52%). Both the in-hospital and 90-day mortality rates were 22.5%. Among the 155 day 90 survivors, 115 patients (74.2%) were dialysis-free, including 75 patients (65.2%) who recovered prior renal function. Factors independently associated with in-hospital mortality were shock at admission (odds ratio (OR) 8.70, 95% confidence interval (95% CI) 3.25 to 23.29), opportunistic fungal infection (OR 7.08, 95% CI 2.32 to 21.60) and bacterial infection (OR 2.53, 95% CI 1.07 to 5.96). Five factors were independently associated with day 90 dialysis-free survival: renal Sequential Organ Failure Assessment (SOFA) score on day 1 (OR 0.68/SOFA point, 95% CI 0.52 to 0.88), bacterial infection (OR 0.43, 95% CI 0.21 to 0.90), three or four quadrants involved on chest X-ray (OR 0.44, 95% CI 0.21 to 0.91), time from hospital to ICU admission (OR 0.98/day, 95% CI 0.95 to 0.99) and oxygen flow at admission (OR 0.93/liter, 95% CI 0.86 to 0.99).

CONCLUSIONS

In kidney transplant recipients, ARF is associated with high mortality and graft loss rates. Increased Pneumocystis and bacterial prophylaxis might improve these outcomes. Early ICU admission might prevent graft loss.