Improved Health-Related Quality of Life in Older Kidney Recipients 1 Year After Transplantation

Kidney Transplantation Improves Health-Related Quality of Life in Older Recipients

Kidney transplantation is the best treatment for kidney failure in older patients. However, little is known regarding changes in health-related quality of life (HRQoL) from before to after transplantation and determinants of HRQoL in older kidney transplant recipients (KTR). We studied both, using data of older (≥65 years) patients waitlisted for kidney transplantation and older KTR 1 year after transplantation from the TransplantLines Biobank and Cohort Study. HRQoL was assessed using the SF-36 questionnaire. We included 145 older waitlisted patients (68% male, age 70 ± 4 years) and 115 older KTR at 1 year after transplantation (73% male, age 70 ± 4 years). Both mental (48.5 ± 8.4 versus 51.2 ± 7.7, p = 0.009) and physical (47.4 ± 8.5 versus 52.1 ± 7.2, p < 0.001) HRQoL were higher among included KTR, compared to the waitlisted patients. In paired analyses among 46 patients with HRQoL-data both before and after transplantation, there was a trend towards increased mental HRQoL (49.1 ± 8.4 to 51.6 ± 7.5, p = 0.054), and significantly increased physical HRQoL (48.1 ± 8.0 to 52.4 ± 6.7, p = 0.001) after transplantation. Among all assessed factors, the number of patient-reported immunosuppressive drug-related side effects was most strongly negatively associated with both mental and physical HRQoL. In conclusion, HRQoL is significantly higher among older KTR after kidney transplantation compared to older waitlisted patients.

Do pre-transplant cultural factors predict health-related quality of life after kidney transplantation?

BACKGROUND

Post-transplant health-related quality of life (HRQOL) is associated with health outcomes for kidney transplant (KT) recipients. However, pretransplant predictors of improvements in post-transplant HRQOL remain incompletely understood. Namely, important pretransplant cultural factors, such as experience of discrimination, perceived racism in healthcare, or mistrust of the healthcare system, have not been examined as potential HRQOL predictors. Also, few have examined predictors of decline in HRQOL post-transplant.

METHODS

Using data from a prospective cohort study, we examined HRQOL change pre- to post-transplant, and novel cultural predictors of the change. We measured physical, mental, and kidney-specific HRQOL as outcomes, and used cultural factors as predictors, controlling for demographic, clinical, psychosocial, and transplant knowledge covariates.

RESULTS

Among 166 KT recipients (57% male; mean age 50.6 years; 61.4% > high school graduates; 80% non-Hispanic White), we found mental and physical, but not kidney-specific, HRQOL significantly improved post-transplant. No culturally related factors outside of medical mistrust significantly predicted change in any HRQOL outcome. Instead, demographic, knowledge, and clinical factors significantly predicted decline in each HRQOL domain: physical HRQOL-older age, more post-KT complications, higher pre-KT physical HRQOL; mental HRQOL-having less information pre-KT, greater pre-KT mental HRQOL; and, kidney-specific HRQOL-poorer kidney functioning post-KT, lower expectations for physical condition to improve, and higher pre-KT kidney-specific HRQOL.

CONCLUSIONS

Instead of cultural factors, predictors of HRQOL decline included demographic, knowledge, and clinical factors. These findings are useful for identifying patient groups that may be at greater risk of poorer post-transplant outcomes, in order to target individualized support to patients.

COVID-19 and Access to Kidney Transplantation for Older Candidates in the United States: A National Registry Study

Rationale & Objective

Coronavirus disease (COVID)-19 has likely impacted accessibility to transplantation services among older adults (age ≥65 years). We quantified the impact of COVID-19 on kidney transplantation access for older kidney-only candidates registered on the United States (US) kidney waitlist.

Study Design

Retrospective analysis of registry data.

Setting & Participants

57,222 older adults who were part of or added to the US kidney waitlist between January 1, 2016 and February 28, 2022, identified using the Scientific Registry of Transplant Recipients (SRTR).

Exposures

Four COVID-19 waves and one nonwave period based on the national incidence of COVID-19 in the US (initial: March 15-May 30, 2020; winter 2020-2021: December 1, 2020-January 31, 2021; delta: August 1, 2021-September 30, 2021; omicron: December 1, 2021-February 28, 2022; nonwave: inter-wave periods).

Outcomes

Waitlist registrations, deceased-donor kidney transplants, living-donor kidney transplants, waitlist mortality, and waitlist removals due to deteriorating condition (hereafter referred to as removals).

Analytical Approach

Poisson regression for the adjusted incidence rate ratio (aIRR) of each outcome during the COVID-19 waves and the nonwave period relative to reference (January 1, 2016-December 31, 2019), adjusted for seasonality and secular trends.

Results

Waitlist registrations initially declined and increased henceforth. Deceased-donor kidney transplants and living-donor kidney transplants remained below-expected levels during all waves. Waitlist mortality peaked during the winter 2020-2021 wave (aIRR: 1.701.982.30) and has declined since; mortality rates were 139%, 107%, and 251% above expected for Black candidates, men, and candidates aged ≥75 years, respectively, during the winter 2020-2021 wave. Removals increased from 22% below expected levels (initial wave) to 26% above expected levels (omicron wave); removals were nonsignificantly higher than expected during the omicron wave for older Black and Hispanic candidates.

Limitations

The findings are not generalizable to those listed at earlier ages with prolonged waitlist times. Additionally, using national COVID-19 incidence does not consider local policy and health care variations. Lastly, aIRRs must be interpreted cautiously due to smaller daily event counts.

Conclusions

COVID-19 was associated with fewer transplants and increased mortality and removals in older kidney transplant candidates. Transplant providers should consider this impact and implement policies and practices to ensure the continuity of care.

Plain-Language Summary

The proportion of older adults on the kidney transplant waitlist is increasing, but the impact of COVID-19 on this population is not well characterized. In this study, we looked at incident waitlist registrations, deceased- and living-donor kidney transplants, and waitlist mortality and removals due to deteriorating condition over 4 waves of COVID-19. We found that transplantation services did not fully recover to prepandemic levels as of March 2022. Notably, racial/ethnic minorities and older men experienced lower rates of kidney transplants and higher rates of waitlist mortality, respectively, relative to White candidates and older women. Identifying vulnerable subpopulations affected by COVID-19 and its long-term impact is crucial for creating strategies to ensure the continuity of care in this population during public health emergencies.

Subjective cognitive complaints in end-stage renal disease: a systematic review and meta-analysis

Cognitive impairment is common in patients with end-stage renal disease (ESRD) and is associated with compromised quality of life and functional capacity, as well as worse clinical outcomes. Most previous research and reviews in this area were focused on objective cognitive impairment, whereas patients' subjective cognitive complaints (SCCs) have been less well-understood. This systematic review aimed to provide a broad overview of what is known about SCCs in adult ESRD patients. Electronic databases were searched from inception to January 2022, which identified 221 relevant studies. SCCs appear to be highly prevalent in dialysis patients and less so in those who received kidney transplantation. A random-effects meta-analysis also shows that haemodialysis patients reported significantly more SCCs than peritoneal dialysis patients (standardised mean difference -0.20, 95% confidence interval -0.38 to -0.03). Synthesis of longitudinal studies suggests that SCCs remain stable on maintenance dialysis treatment but may reduce upon receipt of kidney transplant. Furthermore, SCCs in ESRD patients have been consistently associated with hospitalisation, depression, anxiety, fatigue, and poorer quality of life. There is limited data supporting a strong relation between objective and subjective cognition but preliminary evidence suggests that this association may be domain-specific. Methodological limitations and future research directions are discussed.

Frailty and the psychosocial components of the edmonton frail scale are most associated with patient experience in older kidney transplant candidates - a secondary analysis within the kidney transplantation in older people (KTOP) study

Background

Older people with end-stage kidney disease (ESKD) are vulnerable to frailty, which impacts on clinical and experiential outcomes. With kidney transplantation in older people increasing, a better understanding of patient experiences is necessary for guiding decision making. The Kidney Transplantation in Older People (KTOP):impact of frailty on outcomes study aims to explore this. We present a secondary analysis of the Edmonton Frail Scale (EFS) and its relationship with patient experience scores.

Methods

The KTOP study is a single centre, prospective study, which began in October 2019. All ESKD patients aged ≥60 considered for transplantation at Imperial College Renal and Transplant Centre were eligible. Frailty was assessed using the EFS and 5 questionnaires assessed patient experience and quality of life (QoL) (Short Form-12(v2), Palliative Care Outcome Scale-Symptoms Renal, Depression Patient Health Questionnaire-9, Illness Intrusiveness Ratings Scale, Renal Treatment Satisfaction Questionnaire). The EFS was divided into 4 subdomains (psychosocial, physical function, medical status, and general health) and then compared with the questionnaire scores.

Results

210 patients have been recruited (aged 60-78), 186 of whom completed EFS assessments. 118 (63.4%) participants were not frail, 36 (19.4%) vulnerable, and 32 (17.2%) were frail. Worse frailty scores were associated with poorer patient experience and QoL scores across all questionnaires. Severe deficits in the EFS psychosocial subdomain showed a statistically significant association with higher depression screen scores (coefficient 4.9, 95% CI 3.22 to 6.59), lower physical (coefficient -4.35, 95% CI -7.59 to -1.12) and mental function scores (coefficient -8.33, 95% CI -11.77 to -4.88) from the Short Form-12(v2), and lower renal treatment satisfaction scores (coefficient -5.54, 95% CI -10.70 to -0.37). Deficits in the physical function and medical status EFS subdomians showed some association with patient experience scores.

Conclusion

In the KTOP study cohort at recruitment vulnerable and frail candidates reported worse QoL and patient experiences. Severe deficits in the psychosocial subdomains of the EFS showed a strong association with patient experience and QoL, whilst physical function and medical status deficits showed a lesser association. This has highlighted specific EFS domains that may be suitable for targeted interventions to improve experiences and optimise outcomes.

Living Donor Kidney Transplantation in Older Individuals: An Ethical Legal and Psychological Aspects of Transplantation (ELPAT) View

Living donor transplantation is the optimal treatment for suitable patients with end-stage kidney disease. There are particular advantages for older individuals in terms of elective surgery, timely transplantation, and early graft function. Yet, despite the superiority of living donor transplantation especially for this cohort, older patients are significantly less likely to access this treatment modality than younger age groups. However, given the changing population demographic in recent decades, there are increasing numbers of older but otherwise healthy individuals with kidney disease who could benefit from living donor transplantation. The complex reasons for this inequity of access are explored, including conscious and unconscious age-related bias by healthcare professionals, concerns relating to older living donors, ethical anxieties related to younger adults donating to aging patients, unwillingness of potential older recipients to consider living donation, and the relevant legislation. There is a legal and moral duty to consider the inequity of access to living donor transplantation, recognising both the potential disparity between chronological and physiological age in older patients, and benefits of this treatment for individuals as well as society.

Dialysis or kidney transplantation in older adults? A systematic review summarizing functional, psychological, and quality of life-related outcomes after start of kidney replacement therapy

Background

In older patients, the choice between kidney transplantation (KT) and dialysis may be complicated because of a high prevalence of comorbidities and geriatric syndromes. Ideally, this decision-making process focusses on older patients’ outcome priorities, which frequently include functional, psychological, and quality of life (QOL)-related outcomes.

Purpose

This systematic review aims to summarize functional, psychological (including cognition), and QOL-related outcomes after start of kidney replacement therapy (KRT) in older adults.

Methods

We searched PubMed and Embase for research that investigated change in these variables after start of KRT in patients aged ≥ 60 years. Data were extracted using the summary measures reported in the individual studies. Risk of bias was assessed with the ROBINS-I tool.

Results

Sixteen observational studies (prospective n = 9, retrospective n = 7; KT-recipients n = 3, dialysis patients n = 13) were included. The results show that QOL improves in the majority of the older KT recipients. After start of dialysis, QOL improved or remained stable for most patients, but this seems less prevalent than after KT. Functional status decreases in a substantial part of the older dialysis patients. Furthermore, the incidence of serious fall injuries increases after start of dialysis. Nutritional status seems to improve after start of dialysis.

Conclusion

The interpretability and comparability of the included studies are limited by the heterogeneity in study designs and significant risk of bias in most studies. Despite this, our overview of functional, psychological (including cognition), and QOL-related outcomes is useful for older adults and their clinicians facing the decision between KT and dialysis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11255-022-03208-2.

A Comorbidity Index and Pretransplant Physical Status Predict Survival in Older Kidney Transplant Recipients: A National Prospective Study

Kidney transplantation (KT) is considered the best treatment for end-stage kidney disease (ESKD). In the increasing elderly ESKD population, KT should be reserved for carefully selected candidates who are expected to experience favorable outcomes. We aimed to prospectively evaluate pretransplant recipient factors that may predict patient survival and can eventually guide therapeutic decisions in elderly with ESKD.

Inequitable Access to Transplants: Adults With Impaired Decision-Making Capacity

Inequitable access to deceased donor organs for transplantation has received considerable scrutiny in recent years. Emerging evidence suggests patients with impaired decision-making capacity (IDC) face inequitable access to transplantation. The "Ethical and Legal Issues" working group of the European Society of Transplantation undertook an expert consensus process. Literature relating to transplantation in patients with IDC was examined and collated to investigate whether IDC is associated with inferior transplant outcomes and the legitimacy of this healthcare inequality was examined. Even though the available evidence of inferior transplant outcomes in these patients is limited, the working group concluded that access to transplantation in patients with IDC may be inequitable. Consequently, we argue that IDC should not in and of itself be considered as a barrier to either registration on the transplant waiting list or allocation of an organ. Strategies for non-discrimination should focus on ensuring eligibility is based upon sound evidence and outcomes without reference to non-medical criteria. Recommendations to support policy makers and healthcare providers to reduce unintended inequity and inadvertent discrimination are set out. We call upon transplant centres and national bodies to include data on decision-making capacity in routine reporting schedules in order to improve the evidence base upon which organ policy decisions are made going forward.

Health-Related Quality of Life in Older Kidney Transplant Recipients: A National Cohort Study of Short- and Longer-Term Outcomes

Rationale & Objective

Assessing the optimal therapy for older patients (aged ≥65 years) with end-stage kidney disease requires knowledge of longevity and health-related quality of life (HRQoL) outcomes. Kidney transplantation prolongs survival but its long-term impact on HRQoL in older recipients is not well defined. We aimed to prospectively evaluate HRQoL changes from enlisting until 3 years posttransplantation and examine pretransplantation predictors of posttransplantation outcomes.

Study Design

Prospective cohort study.

Setting & Participants

Patients 65 years and older enlisted at the Norwegian National Transplant Center between January 2013 and November 2016.

Predictors

Kidney transplantation, dialysis vintage, and pretransplantation comorbidity assessed using the Liu Comorbidity Index.

Outcomes

HRQoL, assessed using the Kidney Disease Quality of Life Short Form, version 1.3.

Analytical Approach

HRQoL scores obtained at 3 years posttransplantation were compared with those obtained pretransplantation and after 1 year using a paired-sample t test. Multivariable linear mixed-effect models were used to identify possible predictors of HRQoL changes over time.

Results

Among 289 patients included, 220 (mean age, 71.5 years) had undergone transplantation and 136 had completed the 3-year HRQoL follow-up by October 2020. Posttransplant HRQoL, both generic and kidney specific, substantially improved and the benefit persisted for 3 years. For wait-listed candidates remaining on dialysis, HRQoL gradually deteriorated, and recipients who died within 3 years posttransplantation experienced no improvement during the first year. Moderately elevated pretransplantation comorbidity scores and prolonged dialysis vintage independently predicted poor HRQoL outcomes posttransplantation. Recipients receiving dialysis for 1 year or longer with pretransplantation comorbidity scores ≥ 7 experienced a marked and sustained physical deterioration after transplantation.

Limitations

Homogenous and highly selected population.

Conclusions

Transplantation is associated with a sustained HRQoL improvement and should be the preferred treatment for selected older patients. The value of a pretransplant comorbidity score to predict posttransplantation outcomes warrants further evaluation and may improve the selection process.

Adult Living-Donor Kidney Transplantation, Donor Age, and Donor-Recipient Age

INTRODUCTION

Owing to organ shortage, the number of kidney transplantation (KT) involving older adult living donors is increasing. We aimed to investigate the effects of living-donor age and donor-recipient age differences on KT outcomes.

METHODS

This single-center, retrospective cohort study involved 853 adult LDKTs performed between January 2008 and December 2018. Recipients were stratified into the following 5 groups based on donor age and donor-recipient age difference: donor age, 30 to 49 years and age difference, -10 to 15 years; donor age, 50 to 69 years and age difference, -10 to 15 years; donor age, 50 to 69 years and age difference, 15 to 40 years; donor age, 70 to 89 years and age difference, -10 to 15 years; and donor age, 70 to 89 years and age difference, 15 to 40 years (groups 1, 2, 3, 4, and 5, respectively). As a primary outcome, the risk of graft loss was investigated. The secondary outcomes were postoperative estimated glomerular filtration rates (eGFRs) and mortality rates of recipients.

RESULTS

Group 4, representing KT between older adult donors and older adult recipients, had the highest graft loss risk and mortality. The eGFRs of the recipients from donors aged 70 to 89 years (groups 4 and 5) were significantly lower than those from donors in the other groups. Although the differences in the eGFR between groups 4 and 5 were not significant, the eGFR of group 4 was lower than that of group 5 at 6 months post-KT.

CONCLUSION

LDKTs from older adult donors to older adult recipients resulted in the worst graft survival and mortality rates.

Drug-related problems in older patients with advanced chronic kidney disease identified during pretransplant comprehensive geriatric assessment

BACKGROUND

Older patients with advanced chronic kidney disease may be exposed to a higher risk of adverse drug events due to chronic kidney disease and aging. The integration of clinical pharmacist into pretransplant comprehensive geriatric assessment is an opportunity to perform medication optimization.

OBJECTIVE

The aim was to describe drug-related problems in older patients with advanced chronic kidney disease.

METHODS

Observational study was conducted with retrospective data from July 2017 to April 2019. Patients≥65 years with advanced chronic kidney disease, referred by nephrologists for pretransplant comprehensive geriatric assessment were included. During medication optimization, the pharmacist evaluated the appropriateness of each medication prescribed and identified drug-related problems. Any drug-related problem identified lead to a pharmaceutical intervention.

RESULTS

In total, 103 patients were included (74.5±2.9 years, 26.2% female, 47.6% on dialysis). Overall, 394 drug-related problems were identified in 93.2% of patients (3.8±2.4 drug-related problems per patient) during the medication optimization. Cardiovascular medications (25.1%), antithrombotics (13.5%) and drugs for peptic ulcer and reflux disease (10.2%) were the most involved drugs in drug-related problems. Drug-related problems mainly concerned drugs without indication (27.1%), inappropriate method of administration (24.4%) and non-conformity to guidelines (20.1%).

CONCLUSION

A high prevalence of drug-related problems in older patients with advanced chronic kidney disease was identified during medication optimization. The systematic integration of a clinical pharmacist in the multidisciplinary team performing pretransplant comprehensive geriatric assessment may be relevant to detect inappropriate prescriptions and to prevent from adverse drug events.

Mapping Health-Related Quality Of Life After Kidney Transplantation By Group Comparisons: A Systematic Review

Background

Health-related quality of life (HRQOL) is becoming an increasingly important outcome in kidney transplantation (KT). To describe HRQOL in kidney transplant recipients (KTRs), this systematic review summarizes literature that compared HRQOL among KTRs and other relevant populations [i.e. patients receiving dialysis, patients on the waiting list (WL) for KT, patients with chronic kidney disease (CKD) not receiving renal replacement therapy (RRT), the general population (GP) and healthy controls (HCs)] and themselves before KT.

Methods

The literature search was conducted in PubMed, Embase, Web of Science and the Cochrane Library. Eligible studies published between January 2000 and October 2020 were included.

Results

Forty-four studies comprising 6929 KTRs were included in this systematic review. Despite the study heterogeneity, KTRs reported a higher HRQOL after KT compared with pre-transplantation and compared with patients receiving dialysis with or without being on the WL, especially in disease-specific domains (i.e. burden and effects of kidney disease). Additionally, KTRs had similar to marginally higher HRQOL compared with patients with CKD Stages 3–5 not receiving RRT. When compared with HCs or the GP, KTRs reported similar HRQOL in the first 1 or 2 years after KT and lower physical HRQOL and lower to comparable mental HRQOL in studies with longer post-transplant time.

Conclusions

The available evidence suggests that HRQOL improves after KT and can be restored to but not always maintained at pre-CKD HRQOL levels. Future studies investigating intervention targets to improve or maintain post-transplant HRQOL are needed.

Pretransplant Comprehensive Geriatric Assessment in Older Patients with Advanced Chronic Kidney Disease

BACKGROUND

In older patients with advanced chronic kidney disease (CKD), the decision of kidney transplantation (KT) is a challenge for nephrologists. The use of comprehensive geriatric assessment (CGA) is increasingly gaining interest into the process of decision-making about treatment modality choice for CKD. The aim of this study was to assess the prevalence of geriatric impairment and frailty in older dialysis and nondialysis patients with advanced CKD using a pretransplant CGA model and to identify geriatric impairments influencing the geriatricians' recommendations for KT.

METHODS

An observational study was conducted with retrospective data from July 2017 to January 2020. Patients aged ≥65 years with advanced CKD, treated or not with dialysis, and referred by the nephrologist were included in the study. The CGA assessed comorbidity burden, cognition, mood, nutritional status, (instrumental) activities of daily living, physical function, frailty, and polypharmacy. Geriatric impairments influencing the geriatricians' recommendations for KT were identified using univariate and multivariate logistic regressions.

RESULTS

156 patients were included (74.2 ± 3.5 years and 62.2% on dialysis). Geriatric conditions were highly prevalent in both dialysis and nondialysis groups. The rate of geriatric impairments was higher in dialysis patients regarding comorbidity burden, symptoms of depression, physical function, autonomy, and frailty. Geriatrician's recommendations for KT were as follows: favorable (79.5%) versus not favorable or multidisciplinary discussion needed with nephrologists (20.5%). Dependence for Instrumental Activities of Daily Living (IADL) (odds ratio [OR] = 3.01 and 95% confidence interval [CI] = 1.30-7.31), physical functions (OR = 2.91 and 95% CI = 1.08-7.87), and frailty (OR = 2.66 and 95% CI = 1.07-6.65) were found to be independent geriatric impairments influencing geriatrician's recommendations for KT.

CONCLUSIONS

Understanding the burden of geriatric impairment provides an opportunity to direct KT decision-making and to guide interventions to prevent functional decline and preserve quality of life.

Outcomes after kidney transplantation, let's focus on the patients' perspectives

Graft function and patient survival are traditionally the most used parameters to assess the objective benefits of kidney transplantation. Monitoring graft function, along with therapeutic drug concentrations and transplant complications, comprises the essence of outpatient management in kidney transplant recipients (KTRs). However, the patient's perspective is not always included in this process. Patients' perspectives on their health after kidney transplantation, albeit subjective, are increasingly acknowledged as valuable healthcare outcomes and should be considered in order to provide patient-centred healthcare. Such outcomes are known as patient-reported outcomes (PROs; e.g. health-related quality of life and symptom burden) and are captured using PRO measures (PROMs). So far, PROMs have not been routinely used in clinical care for KTRs. In this review we will introduce PROMs and their potential application and value in the field of kidney transplantation, describe commonly used PROMs in KTRs and discuss structural PROMs implementation into kidney transplantation care.

Changes in quality of life (QoL) and other patient-reported outcome measures (PROMs) in living-donor and deceased-donor kidney transplant recipients and those awaiting transplantation in the UK ATTOM programme: a longitudinal cohort questionnaire survey with additional qualitative interviews

OBJECTIVE

To examine quality of life (QoL) and other patient-reported outcome measures (PROMs) in kidney transplant recipients and those awaiting transplantation.

DESIGN

Longitudinal cohort questionnaire surveys and qualitative semi-structured interviews using thematic analysis with a pragmatic approach.

SETTING

Completion of generic and disease-specific PROMs at two time points, and telephone interviews with participants UK-wide.

PARTICIPANTS

101 incident deceased-donor (DD) and 94 incident living-donor (LD) kidney transplant recipients, together with 165 patients on the waiting list (WL) from 18 UK centres recruited to the Access to Transplantation and Transplant Outcome Measures (ATTOM) programme completed PROMs at recruitment (November 2011 to March 2013) and 1 year follow-up. Forty-one of the 165 patients on the WL received a DD transplant and 26 received a LD transplant during the study period, completing PROMs initially as patients on the WL, and again 1 year post-transplant. A subsample of 10 LD and 10 DD recipients participated in qualitative semi-structured interviews.

RESULTS

LD recipients were younger, had more educational qualifications and more often received a transplant before dialysis. Controlling for these and other factors, cross-sectional analyses at 12 months post-transplant suggested better QoL, renal-dependent QoL and treatment satisfaction for LD than DD recipients. Patients on the WL reported worse outcomes compared with both transplant groups. However, longitudinal analyses (controlling for pre-transplant differences) showed that LD and DD recipients reported similarly improved health status and renal-dependent QoL (p<0.01) pre-transplant to post-transplant. Patients on the WL had worsened health status but no change in QoL. Qualitative analyses revealed transplant recipients' expectations influenced their recovery and satisfaction with transplant.

CONCLUSIONS

While cross-sectional analyses suggested LD kidney transplantation leads to better QoL and treatment satisfaction, longitudinal assessment showed similar QoL improvements in PROMs for both transplant groups, with better outcomes than for those still wait-listed. Regardless of transplant type, clinicians need to be aware that managing expectations is important for facilitating patients' adjustment post-transplant.

Blood Pressure Treatment in Kidney Transplant Recipients-Can We Improve?

Hypertension in kidney transplant (KTx) recipients is common, affecting both patient and graft survival. Annual data from the Norwegian Renal Registry reveal that <50% of adult (>18 y) KTx recipients reach target blood pressure (BP) ≤130/80 mm Hg. The aim of this study was to identify the determinants of failure to achieve BP control.

Should kidney allografts from old donors be allocated only to old recipients?

In several deceased donor kidney allocation systems, organs from elderly donors are allocated primarily to elderly recipients. The Eurotransplant Senior Program (ESP) was implemented in 1999, and since then, especially in Europe, the use of organs from elderly donors has steadily increased. The proportion of ≥60-year-old donors reported to the Collaborative Transplant Study (CTS) by European centers has doubled, from 21% in 2000-2001 to 42% in 2016-2017. Therefore, in the era of organ shortage it is a matter of debate whether kidney organs from elderly donors should only be allocated to elderly recipients or whether <65-year-old recipients can also benefit from these generally as "marginal" categorized organs. To discuss this issue, a European Consensus Meeting was organized by the CTS on April 12, 2018, in Heidelberg, in which 36 experts participated. Based on available evidence, it was unanimously concluded that kidney organs from 65- to 74-year-old donors can also be allocated to 55- to 64-year-old recipients, especially if these organs are from donors with no history of hypertension, no increased creatinine, no cerebrovascular death, and no other reasons for defining a marginal donor, such as diabetes or cancer.

Kidney transplantation: an attractive and cost-effective alternative for older patients? A cost-utility study

Background

In the elderly, kidney transplantation is associated with increased survival and improved health-related quality of life compared with dialysis treatment. We aimed to study the short-term health economic effects of transplantation in a population of elderly kidney transplant candidates.

Methods

Self-perceived health, quality-adjusted life years (QALYs) and costs were evaluated and compared 1 year before and 1 year after kidney transplantation in patients included in a single-centre prospective study of 289 transplant candidates ≥65 years of age.

Results

Self-perceived health and QALYs both significantly improved after transplantation. At 1 year, the costs per QALY were substantially higher for transplantation (€88 100 versus €76 495), but preliminary analyses suggest a favourable long-term health economic effect.

Conclusions

Kidney transplantation in older kidney transplant recipients is associated with improved health but also with increased costs the first year after engraftment when compared with remaining on the waiting list. Any long-term cost-effectiveness needs to be confirmed in studies with longer observation times.