How old is old for transplantation?

BOMS: blockchain-enabled organ matching system

This work proposes a Blockchain-enabled Organ Matching System (BOMS) designed to manage the process of matching, storing, and sharing information. Biological factors are incorporated into matching and the cross-matching process is implemented into the smart contracts. Privacy is guaranteed by using patient-associated blockchain addresses, without transmitting or using patient personal records in the matching process. The matching algorithm implemented as a smart contract is verifiable by any party. Clinical records, process updates, and matching results are also stored on the blockchain, providing tamper-resistance of recipient's records and the recipients' waiting queue. The system also is capable of handling cases in which there is a donor without an immediate compatible recipient. The system is implemented on the Ethereum blockchain and several scenarios were tested. The performance of the proposed system is compared to other existing organ donation systems, and ours outperformed any existing organ matching system built on blockchain. BOMS is tested to ascertain its compatibility with public, private, and consortium blockchain networks, checks for security vulnerabilities and cross-matching efficiency. The implementation codes are available online.

Graft and Patient Survival in Kidney Transplant Recipients Over the Age of Sıxty-Five

Introduction: Elderly patients have increased morbidity and mortality compared to younger patients due to existing comorbid diseases and chronic immunosuppression. Therefore, the option of kidney transplantation for renal replacement therapy in elderly patients is still being controversial. Our aim in this study was to evaluate graft function, graft and patient survival, and associated factors in kidney transplant recipients over 65 years of age, at 11 years of follow-up.

Methods: The study included 53 patients aged 65-76 years, out of a total of 1319 patients who underwent live kidney transplantation in the Organ Transplant Center of Acibadem International Hospital between October 2010 and July 2021. Demographic characteristics and creatinine values were recorded. Graft survival rates and patient survival rates at one, three, and five years were analyzed.

Results: Fifty-three patients, 14 female, 39 male, aged 65-76 years were included in the study. The follow-up period of the patients was 7-125 months. During the follow-up, 20 patients died. Graft loss occurred in two of 20 patients who died, and 18 patients died with working grafts. Graft loss developed in two of the 33 surviving patients. In the whole group, one-, three-, and five-year patient survival rates were 94%, 81%, and 76%, respectively.

Conclusion: These results emphasize that kidney transplantation is a viable treatment option in elderly patients who have been well evaluated before kidney transplantation.

Immunosuppression Considerations for Older Kidney Transplant Recipients

PURPOSE OF REVIEW

While kidney transplantation improves the long-term survival of the majority of patients with end-stage kidney disease (ESKD), age-related immune dysfunction and associated comorbidities make older transplant recipients more susceptible to complications related to immunosuppression. In this review, we discuss appropriate management of immunosuppressive agents in older adults to minimize adverse events, avoid acute rejection, and maximize patient and graft survival.

RECENT FINDINGS

Physiological changes associated with senescence can impact drug metabolism and increase the risk of posttransplant infection and malignancy. Clinical trials assessing the safety and efficacy of immunosuppressive agents in older adults are lacking. Recent findings from U.S. transplant registry-based studies suggest that risk-adjusted death-censored graft failure is higher among older patients who received antimetabolite avoidance, mammalian target of rapamycin inhibitor (mTORi)-based, and cyclosporine-based regimens. Observational data suggest that risk-adjusted mortality may be increased in older patients who receive mTORi-based and cyclosporine-based regimens but lower in those managed with T-cell induction and maintenance steroid avoidance/withdrawal.

SUMMARY

Tailored immunosuppression management to improve patient and graft survival in older transplant recipients is an important goal of personalized medicine. Lower intensity immunosuppression, such as steroid-sparing regimens, appear beneficial whereas mTORi- and cyclosporine-based maintenance are associated with greater potential for adverse effects. Prospective clinical trials to assess the safety and efficacy of immunosuppression agents in older recipients are urgently needed.

Impact of Recipient Age on Outcomes After Pancreas Transplantation

BACKGROUND

Few reports have provided the ages of pancreas transplant recipients. The aim of this study was to determine whether recipient age affects survival of pancreatic grafts after transplantation.

METHODS

We analyzed 73 patients who had undergone pancreas transplantation at our institution from August 2001 to March 2020 and assessed the effects of recipient age on pancreas graft survival within 5 years after pancreas transplantation.

RESULTS

The cutoff value for recipient age established by receiver operating characteristic curve was 35 years. The pancreas graft survival rate of recipients aged 35 years or younger (1, 3, and 5 years: 72.9%, 41.7%, and 41.7%, respectively) was significantly lower than that of recipients aged over 35 years (1, 3, and 5 years: 93.2%, 88.4%, and 88.4%, respectively). Multivariate Cox hazard regression analysis showed that recipient age 35 years or younger (hazard ratio = 3.60; 95% confidence interval, 1.04-12.50; P = .044) and solitary pancreas transplantation (hazard ratio = 10.72; 95% confidence interval, 2.72-42.28; P < .001) were significant risk factors for pancreas graft loss within 5 years.

CONCLUSION

Our data suggest that younger recipient age is a risk factor for pancreas graft loss after transplantation.

Assessing the Complex Causes of Kidney Allograft Loss

BACKGROUND

Although graft loss is a primary endpoint in many studies in kidney transplantation and a broad spectrum of risk factors has been identified, the eventual causes of graft failure in individual cases remain ill studied.

METHODS

We performed a single-center cohort study in 1000 renal allograft recipients, transplanted between March 2004 and February 2013.

RESULTS

In total, 365 graft losses (36.5%) were identified, of which 211 (57.8%) were due to recipient death with a functioning graft and 154 (42.2%) to graft failure defined as return to dialysis or retransplantation. The main causes of recipient death were malignancy, infections, and cardiovascular disease. The main causes of graft failure were distinct for early failures, where structural issues and primary nonfunction prevailed, compared to later failures with a shift towards chronic injury. In contrast to the main focus of current research efforts, pure alloimmune causes accounted for only 17.5% of graft failures and only 7.4% of overall graft losses, although 72.7% of cases with chronic injury as presumed reason for graft failure had prior rejection episodes, potentially suggesting that alloimmune phenomena contributed to the chronic injury.

CONCLUSIONS

In conclusion, this study provides better insight in the eventual causes of graft failure, and their relative contribution, highlighting the weight of nonimmune causes. Future efforts aimed to improve outcome after kidney transplantation should align with the relative weight and expected impact of targeting these causes.

Two decades of the Eurotransplant Senior Program: the gender gap in mortality impacts patient survival after kidney transplantation

BACKGROUND

Long-term outcomes of the Eurotransplant Senior Program (ESP) are urgently needed to improve selection criteria and allocation policies in the elderly.

METHODS

We analysed patient and allograft outcomes of 244 ESP-kidney transplant recipients (KTRs) between 1999 and 2019 and assessed quality of living compared with 82 ESP-waitlisted dialysis patients using standardized short form-8.

RESULTS

We observed 1-, 5- and 10-year patient survival of 91.7, 66.3 and 38.0%, respectively. Mortality risk factors included male gender (P = 0.006) and T-cell-mediated rejection (P < 0.001). Median patient survival of male ESP-KTRs was 80 versus 131 months for female ESP-KTRs (P = 0.006). 1-, 5- and 10-year death-censored allograft survival was 93.3, 82.6 and 70.4%. Risk factors included high body mass index (P < 0.001) and T-cell-mediated rejection (P < 0.001). After re-initiation of dialysis median patient survival was 58 months. Change of estimated glomerular filtration rate showed a mean decline of 2.3 and 6.8 mL/min at 5 and 10 years. Median physical and mental component scores of ESP-KTRs were 40.2 and 48.3, significantly higher compared with dialysis patients (P < 0.05). Of ESP-KTRs, 97.5% who underwent transplantation would again do so.

CONCLUSIONS

Long-term outcomes of ESP-KTRs ultimately support the effectiveness of an age-matched allocation system. Our data suggest that the survival advantage of women is maintained after kidney transplantation and calls for gender-specific care.

Lower soluble Klotho levels in the pretransplant period are associated with an increased risk of renal function decline in renal transplant patients

Serum soluble Klotho levels are associated with renal function in predialysis patients with chronic kidney disease. However, few reports exist regarding the association between soluble Klotho levels and renal function in kidney transplant (KTx) recipients. This was a retrospective observational study of 41 living KTx recipients. The serum soluble Klotho levels were classed as "high" (>456 pg/mL [i.e., high-Klotho group]) or "low" (≤456 pg/mL [i.e., low-Klotho group]). Renal function decline was defined as a decrease in the estimated glomerular filtration rate (eGFR) of 30% or more from the baseline value within 3 months after KTx. A multivariable time-to-event analysis between the groups was conducted. Among the KTx recipients, the incidence of a 30% decrease in the eGFR was significantly higher in the low-Klotho group than in the high-Klotho group (P = .036). After adjusting for donor age, donor sex, the presence of rejection, and the number of cytomegalovirus infections, multivariable Cox models revealed that low soluble Klotho levels remained associated with a higher risk of a 30% decrease in the eGFR (hazard ratio, 2.38; 95% confidence interval, 1.02-6.41). These findings suggested that lower soluble Klotho levels in the pre-KTx period are associated with an increased risk of renal function decline in KTx recipients.

Donor Age, Donor-Recipient Size Mismatch, and Kidney Graft Survival

BACKGROUND AND OBJECTIVES

Small donor and/or kidney sizes relative to recipient size are associated with a higher risk of kidney allograft failure. Donor and recipient ages are associated with graft survival and may modulate the relationship between size mismatch and the latter. The aim of this study was to determine whether the association between donor-recipient size mismatch and graft survival differs by donor and recipient age.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENT

We performed a retrospective cohort study of first adult deceased donor kidney transplantations performed between 2000 and 2018 recorded in the Scientific Registry of Transplant Recipients. We used multivariable Cox proportional hazards models to assess the association between donor-recipient body surface area ratio and death-censored graft survival, defined as return to dialysis or retransplantation. We considered interactions between donor-recipient body surface area ratio and each of recipient and donor age.

RESULTS

Among the 136,321 kidney transplant recipients included in this study, 23,614 (17%) experienced death-censored graft loss over a median follow-up of 4.3 years (interquartile range, 1.9-7.8 years). The three-way donor-recipient body surface area ratio by donor age by recipient age interaction was statistically significant (P=0.04). The magnitude of the association between severe size mismatch (donor-recipient body surface area ratio <0.80 versus ≥1.00) and death-censored graft survival was stronger with older donor age and recipient age. In all recipient age categories except the youngest (18-30 years), 5- and 10-year graft survival rates were similar or better with a size-mismatched donor aged <40 years than a nonsize-mismatched donor aged 40 years or older.

CONCLUSIONS

The association of donor-recipient size mismatch on long-term graft survival is modulated by recipient and donor age. Size-mismatched kidneys yield excellent graft survival when the donor is young. Donor age was more strongly associated with graft survival than size mismatch.

Comparison of kidney allograft survival in the Eurotransplant senior program after changing the allocation criteria in 2010-A single center experience

Aims

The European Senior Program (ESP) aims to avoid waiting list competition between younger and elderly patients applying for renal transplantation. By listing patients ≥65 years on a separate waiting list and locally allocating of grafts ≥65 years exclusively to this cohort, waiting and cold ischemia times are predicted to be shortened, potentially resulting in improved kidney transplantation outcomes. This study compared a historic cohort of renal transplant recipients being simultaneously listed on the general and the ESP waiting lists with a collective exclusively listed on the ESP list in terms of surrogates of the transplantation outcome.

Methods

Total 151 eligible patients ≥ 65 years from Münster transplant Center, Germany, between 1999 and 2014 were included. Graft function, graft and patient survival were compared using surrogate markers of short- and long-term graft function. Patients were grouped according to their time of transplantation.

Results

Recipients and donors in the newESP (nESP) cohort were significantly older (69.6 ± 3.5 years vs 67.1 ± 2 years, p<0.05; 72.0 ± 5.0 years vs 70.3 ± 5.0 years, p = 0.039), had significantly shorter dialysis vintage (19.6 ± 21.7 months vs 60.2 ± 28.1 months, p<0.001) and suffered from significantly more comorbidities (2.2 ± 0.9 vs 1.8 ± 0.8, p = 0.009) than the historic cohort (HC). Five-year death-censored graft survival was better than in the HC, but 5-year graft and patient survival were better in the ESP cohort. After 2005, cold ischemia time between groups was comparable. nESP grafts showed more primary function and significantly better long-term graft function 18 months after transplantation and onwards.

Conclusion

nESP recipients received significantly older grafts, but experienced significantly shorter time on dialysis. Cold ischemia times were comparable, but graft function in the nESP cohort was significantly better in the long term.

Time-Varying Covariates and Risk Factors for Graft Loss in Kidney Transplantation

OBJECTIVES

The present study was designed to evaluate the factors involved in long-term graft survival in recipients of kidney transplantation.

MATERIALS AND METHODS

We reviewed 755 Iranian adult recipients who underwent kidney transplantation at Shahid Labbafinejad Medical Center in Tehran, Iran. Patients were followed for 5 years after transplantation. The primary outcome was the time between transplantation and graft loss. Using Cox regression, we studied the effect of time-independent variables (recipients' age and sex, donors' age, and type of donor), time-dependent covariates (body mass index [BMI], systolic blood pressure, diastolic blood pressure, high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol levels, proteinuria and serum creatinine level), and immunosuppressive drugs on graft loss 60 months after transplantation. The results are presented as the hazard ratio (HR) with 95% confidence intervals.

RESULTS

Result from Cox proportional hazards model showed that the HR of graft loss was 1.62 (95% CI: 1.03-2.54) in cadaveric donor compared with living donor kidney recipients. The HR of graft loss for recipient age was 1.02 (95% CI: 1.002-1.030). Moreover, according to obtained results, the risk of losing functional transplant increased for each mg/dL rise in serum creatinine at least 9% and at most 40%. Our results also showed that 1 unit increase of BMI has at least a 2% and at most a 15% decremented effect on the hazard ratio of graft loss.

CONCLUSIONS

Having lower levels of creatinine and receiving a kidney from a younger living donor were associated with a decreased risk of graft loss. Graft loss is more likely to occur in patients with lower BMI.

Role of Physical Performance Assessments and Need for a Standardized Protocol for Selection of Older Kidney Transplant Candidates

The older adult population (65 years or older) with advanced or end-stage kidney disease is steadily growing, but rates of transplantation within this cohort have not increased in a similar fashion. Physical deconditioning, resulting in poor post-transplantation outcomes, is a primary concern among older renal patients. The assessment of physical function often holds more weight in the selection process for older candidates, despite evidence showing benefits of transplantation to this vulnerable population. Although several frailty assessment tools are being used increasingly to assess functional status, there is no standardized selection process for older candidates based on these assessment results. Also, it is unknown if timely targeted physical therapy interventions in older patients result in significant improvement of functioning capacity, translating to higher listing and transplantation rates, and improved post-transplantation outcomes. It is therefore of upmost importance not only to incorporate an effective objective functional status assessment process into selection and waitlist evaluation protocols, but also to have targeted interventions in place to maintain and improve physical conditioning among older renal patients. This paper reviews the commonly utilized assessment tools, and their applicability to older patients with renal disease. We also propose the need for definitive selection and waitlist management guidelines to formulate a streamlined assessment of functional capacity and transplant eligibility, as well as a process to maintain functional status, thereby increasing the access of older patients to renal transplantation.

The evolution of donation after circulatory death renal transplantation: a decade of experience

BACKGROUND

This study compared long-term outcomes of renal transplantation from donors following donation after circulatory death (DCD) with those following donation after brain death (DBD) from one of the largest centres in the UK.

METHOD

Recipients of renal transplants from deceased donors between 2002 and 2014 were identified from a prospectively maintained database. Outcomes were compared between DCD (468) and DBD (905) donors and between standard criteria donors (SCDs) and extended criteria donors (ECDs).

RESULTS

Graft survival (GS) and patient survival (PS) from DCD and DBD donors were comparable up to 10 years (GS: 61 versus 55%, P = 0.780; PS: 78 versus 71%, P = 0.285, respectively). Graft function was comparable after 3 months. GS and function were worse in the ECD groups, with no difference between EC-DBD and EC-DCD. PS in the ECD groups was worse than the SCD groups and PS in the EC-DCD group was worse than in the EC-DBD group. DCD donors were an independent risk factor for delayed graft function. Post-operative complications and EC-DCD donation were independent risk factors for reduced GS and PS.

CONCLUSION

This study supports the use of DCD renal grafts with comparable long-term survival and function to DBD grafts. The use of EC-DCD grafts is justified in selected recipients and provides acceptable function and survival advantages over dialysis.

Dialysis Reimbursement: What Impact Do Different Models Have on Clinical Choices?

Allowing patients to live for decades without the function of a vital organ is a medical miracle, but one that is not without cost both in terms of morbidity and quality of life and in economic terms. Renal replacement therapy (RRT) consumes between 2% and 5% of the overall health care expenditure in countries where dialysis is available without restrictions. While transplantation is the preferred treatment in patients without contraindications, old age and comorbidity limit its indications, and low organ availability may result in long waiting times. As a consequence, 30–70% of the patients depend on dialysis, which remains the main determinant of the cost of RRT. Costs of dialysis are differently defined, and its reimbursement follows different rules. There are three main ways of establishing dialysis reimbursement. The first involves dividing dialysis into a series of elements and reimbursing each one separately (dialysis itself, medications, drugs, transportation, hospitalisation, etc.). The second, known as the capitation system, consists of merging these elements in a per capita reimbursement, while the third, usually called the bundle system, entails identifying a core of procedures intrinsically linked to treatment (e.g., dialysis sessions, tests, intradialyitc drugs). Each one has advantages and drawbacks, and impacts differently on the organization and delivery of care: payment per session may favour fragmentation and make a global appraisal difficult; a correct capitation system needs a careful correction for comorbidity, and may exacerbate competition between public and private settings, the latter aiming at selecting the least complex cases; a bundle system, in which the main elements linked to the dialysis sessions are considered together, may be a good compromise but risks penalising complex patients, and requires a rapid adaptation to treatment changes. Retarding dialysis is a clinical and economical goal, but the incentives for predialysis care are not established and its development may be unfavourable for the provider. A closer cooperation between policymakers, economists and nephrologists is needed to ensure a high quality of dialysis care.

Assessing Consensus Between UK Renal Clinicians on Listing for Kidney Transplantation: A Modified Delphi Study

Background

It is well recognized that there is significant variation between centers in access to kidney transplantation. In the absence of high-grade evidence, it is unclear whether variation is due to patient case mix, other center factors, or individual clinician decisions. This study sought consensus between UK clinicians on factors that should influence access to kidney transplantation.

Methods

As part of the Access to Transplantation and Transplant Outcome Measures project, consultant nephrologists and transplant surgeons in 71 centers were invited to participate in a Delphi study involving 2 rounds. During rounds 1 and 2, participants rated their agreement to 29 statements covering 8 topics regarding kidney transplantation. A stakeholder meeting was used to discuss statements of interest after the 2 rounds.

Results

In total, 122 nephrologists and 16 transplant surgeons from 45 units participated in rounds 1 and 2. After 2 rounds, 12 of 29 statements reached consensus. Fifty people participated in the stakeholder meeting. After the stakeholder meeting, a further 4 statements reached agreement. Of the 8 topics covered, consensus was reached in 6: use of a transplant protocol, patient age, body mass index, patient compliance with treatment, cardiac workup, and use of multidisciplinary meetings. Consensus was not reached on screening for malignancy and use of peripheral Doppler studies.

Conclusions

The Delphi process identified factors upon which clinicians agreed and areas where consensus could not be achieved. The findings should inform national guidelines to support decision making in the absence of high quality evidence and to guide areas that warrant future research.

[Focusing on kidney transplantation in the elderly]

Due to the increase in life expectancy and the ageing of end-stage renal disease patients, the number of patients older than 65 years receiving a kidney transplant has been continuously growing over the last fifteen years. The benefits of renal transplantation compared to dialysis in terms of survival and quality of life have been shown in selected recipients over 65, or 70 years. However, the age remains the main limiting factor for the access to the waiting list, and the reluctance of the clinicians can be explained by the multiple comorbidities of these candidates, their limited life expectancy or the shortage of grafts. The challenge is to select the candidates who can benefit from renal transplantation, thanks to rigorous cardiovascular and neoplastic evaluation before enrolment and by taking into account the specific characteristics of elderly patients. The living donor appears to be the ideal option for elderly recipients, the alternative being the extended criteria donor, allowing waiting times to be limited. The choice of immunosuppressive therapy is also crucial in these patients at high risk of infectious and cardiovascular complications in whom the occurrence of acute rejection can have severe consequences. There are currently no specific recommendations for immunosuppression in elderly recipients, and we would need large-scale randomized studies to improve the prognosis of renal transplantation in this population.

How does age affect the outcome of kidney transplantation in elderly recipients?

The aging of the on-dialysis population raises the issue of whether to propose elderly patients for kidney transplantation and how to manage their immunosuppression. This study aimed to analyze the outcome of kidney transplantation on an Italian series of elderly recipients. We included in this retrospective study all patients over 60 years, receiving a deceased-donor kidney transplantation from January 2004 to December 2014 in two north Italian Centers. We analyzed the correlation of recipient age with graft's and patient's survival, delayed graft function, acute cellular rejection (ACR), surgical complications, infections, and glomerular filtration rate. Four hundred and fifty-two patients with a median age of 65 years were included in the study. One-, 3-, and 5-year patient's and graft's survival were, respectively, of 98.7%, 93%, 89% and 94.4%, 87.9%, 81.4%. The increasing recipient age was an independent risk factor only for the patient's (P=.008) and graft's survival (P=.002). ACR and neoplasia were also associated to a worse graft survival. The reduced graft survival in elderly kidney recipients seems to be related more to the increasing recipient's age than to the donor's features. In this population, the optimization of organ allocation and immunosuppression may be the key factors to endorse improvements.

Should patients older than 65 years be offered a second kidney transplant?

Background

Age and number of recipients in need of kidney re-transplantation are increasing. Re-transplantation practices and outcomes in elderly recipients are not previously explored. We aimed to retrospectively evaluate the outcomes of recipients 65 years and older receiving their second deceased donor allograft.

Methods

The study was designed as a retrospective registry based study. All recipients 65 years or older who received a deceased donor kidney transplant at Oslo University Hospital between 2000 and 2014 were included in the study. Survival outcomes were compared between recipients of first (TX1) and second (TX2) allograft. Survival analyses were performed using the Kaplan–Meier method and Cox proportional hazard models with patient survival, uncensored graft survival and death-censored graft survival as outcomes in the analyses.

Results

Seven hundred and thirty-tree recipients > 65 years received a first (n = 687) or second (n = 46) deceased donor kidney transplant. Five years uncensored graft survival rates were 64% in TX 2 and 67% in TX 1 (P= 0.789). Estimated five years graft survival rates censored for death with functioning graft were 88% in TX2 and 90% in TX1 (P=0.475). Adjusted hazard ratio for uncensored graft loss (TX2 vs. TX1) was 1.24 (95% CI 0.77 – 2.00). Adjusted hazard ratio for graft loss censored for death with functioning graft (TX2 vs. TX1) was 1.70 (0.72-4.02).

Conclusions

Older recipients of second transplants have outcomes that are comparable to the outcomes of age-matched first transplant recipients, and far better than previously documented for older transplant candidates remaining on dialysis treatment. Advanced age by itself should not be a contraindication for re-transplantation. Best results are achieved with short time on dialysis before re-transplantation.

What immunosuppression should be used for old-to-old recipients?

Elderly patients receiving a kidney from old donors (old-to-old) are a growing population of transplant recipients. This population cumulates risks of complications due to the co-morbidities and the immunodeficiency state and the frailty of the recipients together with the kidney senescence of the donors. In this context, the choice of immunosuppression is complicated and must take into account some contradictory principles explaining why no consensus exists today.

Transplanting the elderly: Balancing aging with histocompatibility

Across the world, the proportions of senior citizens (i.e. those ≥65years) increase rapidly and are predicted to constitute over 25% of the general population by 2050. In 2012 already 48% of the population with end stage renal disease (ESRD) was aged 65years or older. Transplantation is considered the preferred treatment option for ESRD offering survival advantage over long-term dialysis in the majority of patients. Indeed, acceptable outcomes have been documented for selected patients over the age of 70years or even cases over 80years. The reality of organ scarcity and prolonged waiting times for a deceased donor kidney transplantation, however, indicate that at best 50% of the selected elderly may have realistic expectations to receive a timely transplant offer. By choice or medical selection, access to transplantation also decreases with increasing age. In order to expedite the chance for elderly to receive a kidney transplant dedicated allocation systems have been developed. These allocation systems, like the Eurotransplant Senior Program (ESP), support preferential local allocation of kidneys from older donors to older patients in order to match recipient and graft life while disregarding histocompatibility for HLA antigens. The consequence has been more acute rejection episodes and an increase in immunosuppressive load. In the elderly, the most common cause of graft loss is death with functioning graft and death from infectious diseases is one of the dominant causes. The Eurotransplant Senior DR-compatible Program (ESDP) was designed to further improve the perspective of successful transplantation in the elderly in terms of life and quality of life by re-introducing matching criteria for HLA-DR in the old-for-old algorithm.

Clinical outcomes in Asian elderly kidney transplant recipients: a multicenter cohort study

BACKGROUND

The kidney transplantation rate in elderly patients is increasing rapidly. However, the clinical outcomes of kidney transplantation in elderly patients have not yet been thoroughly evaluated.

METHODS

This multicenter cohort study included adult kidney transplant recipients (KTRs) admitted to five major tertiary hospitals in Korea between 1997 and 2012. A total of 3,565 adult participants were enrolled. Patient survival, allograft survival, and biopsy-proven acute rejection (BPAR) of 242 elderly recipients (≥ 60 years) were assessed and compared with those of a younger population.

RESULTS

Patients were divided into five groups according to age at time of transplantation. The proportion of elderly patients was 6.7 % (mean age, 63.1 ± 2.7 years; n = 242). The numbers of male patients (69.4%), those with diabetes mellitus history (36.3%), and those with pretransplantation ischemic heart disease history (17.7%) were significantly higher in the elderly group than in the younger age groups. Elderly patients were more likely to receive a cadaveric kidney, and overall mortality rates were significantly higher in the elderly patients (1-year survival 93.3%, 5-year survival 91.3%). However, death-censored allograft survival rate and BPAR were not affected by patient age (P = .104 and .501, respectively). Among the elderly, BPAR and female donors were independent risk factors for allograft loss.

CONCLUSION

The overall survival rate of the elderly KTRs was significantly lower than that of younger KTRs. However, the death-censored allograft survival rate did not differ between groups. Kidney transplantation should not be stagnated especially in elderly patients with end-stage renal disease.

Clinical Outcome of Elderly Kidney Transplant Recipients from Spousal Donors

INTRODUCTION

Patients aged 60 years and older stand for the fastest growing group of patients with end-stage renal disease worldwide, and the need for kidney transplants among this population is rising. In Japan, living donor kidney transplantation is mainly performed to deal with the severe shortage of deceased donors, and the number of spousal transplants is currently increasing.

PATIENTS AND METHODS

A total of 164 patients with ESRD underwent living donor kidney transplantation at our institution, of whom 21 patients aged 60 years and older had spousal kidney transplantation. ABO-incompatible kidney transplantation was performed in 5 of the 21 cases. We analyzed these recipients.

RESULTS

Patient and graft survival rates were 100%. The incidence of acute rejection was 23.8%. Eight patients experienced cytomegalovirus viremia, two patients experienced Pneumocystis jiroveci infection, and one experienced bacterial pneumonia. Two patients developed cancers and underwent curative operation after transplantation.

CONCLUSIONS

Elderly kidney transplantation from spousal donors is associated with age-related immune dysfunction, which may develop infections and malignancies and could be immunologically high risk due to the high rate of ABO-incompatibility and poor histocompatibility. An effort to minimize the adverse effect of immunosuppression and to reduce the risk of acute rejection may be needed for an excellent long-term outcome.

Trends in kidney transplant outcomes in older adults

OBJECTIVES

To estimate mortality and death-censored graft loss according to year of kidney transplant (KT) between 1990 and 2011.

DESIGN

Cohort study.

SETTING

The Scientific Registry of Transplant Recipients (SRTR).

PARTICIPANTS

KT recipients aged 65 and older at the time of transplantation (N = 30,207).

MEASUREMENTS

Mortality and death-censored graft loss ascertained through center report and linkage to Social Security Death Master File and to Medicare.

RESULTS

Older adults currently account for 18.4% of KT recipients, up from 3.4% in 1990; similar increases were noted for deceased donor (5.4 times percentage increase) and live donor (9.1 times percentage increase) transplants. Current recipients are not only older, but also more likely to be female and African American, have lengthier pretransplant dialysis, have diabetes mellitus or hypertension, and receive marginal kidneys. Mortality for older deceased donor recipients between 2009 and 2011 was 57% lower (hazard ratio (HR) = 0.43, 95% confidence interval (CI) = 0.33-0.56, P < .001) than between 1990 and 1993; mortality for older live donor recipients was 50% lower (HR = 0.50, 95% CI = 0.36-0.68, P < .001). Death-censored graft loss for older deceased donor recipients between 2009 and 2011 was 65% lower (HR = 0.35, 95% CI = 0.29-0.42, P < .001) than between 1990 and 1993; death-censored graft loss for older live donor recipients was 59% lower (HR = 0.41, 95% CI = 0.24-0.70, P < .001).

CONCLUSION

Despite a major increase in number of older adults transplanted and an expanding window of transplant eligibility, mortality and graft loss have decreased substantially for this recipient population. These trends are important to understand for patient counseling and transplant referral.

Outcome of live and deceased donor renal transplantation in patients aged ≥55 years: A single-center experience

Renal transplantation (RTx) has now become an accepted therapeutic modality of choice for elderly ESRD patients. This single-center study was undertaken to evaluate the outcome of RTx in ESRD patients ≥55 years. A total of 103 patients underwent RTx 79 living related living donors [LD], 24 deceased donors [DD]) at our center. Post-transplant immunosuppression consisted of calcineurin inhibitor-based regimen. The mean donor age was 58.3 years in the LD group and 59.5 years in the DD group. Male recipients constituted 92% in LD and 75% in DD group. In living donor renal transplantation, 1- and 5-year patient survival was 93% and 83.3% respectively and death-censored graft survival was 97.3% and 92.5% respectively. There were 12.6% biopsy proven acute rejection (BPAR) episodes and 12.6% patients were lost, mainly due to infections. In deceased donor renal transplantation, 1- and 5-year patient survival was 79.1% and 74.5% respectively and death-censored graft survival was 95.8% and 85.1% respectively. There were 12.5% BPAR episodes and 25% of patients were lost, mainly due to infections. RTx in ESRD (≥55 years) patients has acceptable patient and graft survival if found to have cardiac fitness and therefore should be encouraged.

Exploring the views of patients not on the transplant waiting list: a qualitative study

BACKGROUND

Not all patients are suitable for kidney transplantation; however, little is known about the views and attitudes of patients who are not on the waiting list for transplantation.

OBJECTIVE

This study aimed to determine the views and attitudes of patients who are not on the waiting list regarding the process of transplant allocation.

METHODS

A grounded theory approach was used to develop theories from patient views, opinions and attitudes. Patients receiving dialysis, and not on the waiting list at a United Kingdom renal unit were identified by the renal counsellor and invited to take part. Five patients formed a focus group to enable construction of an interview schedule. Patients (n=10, different from those in the focus group) were interviewed until themes became saturated. Interview transcripts generated conceptual categories.

RESULTS

Seven conceptual categories emerged regarding access to transplantation. Patients experience emotions of loss relating to transplantation exacerbated by restrictions imposed by dialysis. Patients find coping mechanisms, accept their situation and trust that clinical decisions were equitable.

CONCLUSIONS

Patients trust their carers and support an efficacy argument when considering scarce resources. Communication should be improved to ensure clarity and understanding of clinical decisions.

Kidney transplantation outcomes from expanded criteria donors, standard criteria donors or living donors older than 60 years

OBJECTIVES

To evaluate outcomes in kidney allograft recipients from donors with expanded criteria (ECD) versus standard criteria (SCD) or living donors (LD) >60 years.

METHODS

We studied all patients who received a kidney between 2005 and 2011, focusing in recipients of kidneys from deceased ECD, SCD and LD >60 years. ECD was any deceased donor >60 years or >50 years with two of the following: hypertension (HTN), stroke as the cause of death, or serum creatinine >1.5 mg/dL. We recorded characteristics of the transplant procedure, patient, graft survival and renal function 1 year after transplantation and at the end of follow-up.

RESULTS

Six-hundred and five patients were transplanted between 2005 and 2011 in our department. There were 142 (25.1%) transplantations from ECD, 192 (33.98%) from SCD and 96 (16.99%) from LDs older than 60 years. In a mean follow-up time of 36.4 months, graft survival rates were similar for all groups. Calculated GFR was found statistically different between the ECD and SCD groups, but still satisfactory at first year, and at end of follow-up time. Comparison of the patients, who received transplants from ECD, even older than 70 years, and those from LD >60 years revealed equivalent renal function in short and long term.

CONCLUSIONS

Utilization of marginal kidneys effectively doubled our deceased transplant volume in the period 2005-2011. Patients' and graft survival were shown similar at the end of follow-up for all groups. Renal outcomes were shown equivalent between the ECD and LD >60 years groups, and although significantly lower between the ECD and the SCD group, were still very satisfactory.

Survival of renal transplantation patients older than 60 years: a single-center experience

BACKGROUND

Elderly patients are the fastest growing population requiring renal replacement therapy. It has been stated that renal transplantation may be the best treatment option for these patients. However, it has been observed that older patients have a higher mortality rate than those who are younger. Yet the factors that determine post-transplantation outcomes in this population remain poorly defined. The aims of this study were to evaluate the graft and patient survival in kidney transplant recipients who are older than 60 years of age to identify relevant predictive factors.

METHODS

In this population-based retrospective cohort study of 201 kidney transplantations performed in elderly patients from January 2002 throughout June 2009, we estimated the 1-,3-,and 5-year patients and graft survival rates. We also evaluated the complications and the predictors of poor outcomes. Survival times were analyzed using the Kaplan-Meier method and survival differences assessed with Mantel-Cox log rank-test. We performed a Cox proportional hazards regression models to evaluate the impact of baseline and treatment characteristics on patient and graft survival.

RESULTS

Graft and patient survival rates at 1, 3, and 5 years were 76.4%, 71.3%, and 54.3%, and 78.2%, 73.8%, and 56.4%, respectively. Graft survival rates censored for patient death with a functioning graft were 93.1, 92.1, and 89%. Patient survival rates differed between diabetic and nondiabetic subjects at 1, 3 and 5 years (69.5% versus 83.6%; 59.8% versus 72.3%; 43.6% versus 65.7%; P = .008). On multivariate analysis, the factors associated with patients survival were diabetes mellitus (hazard ratio [HR] 2.058, 95% confidence interval [CI] 1.173-3.611, P = .012) and the 1-month serum creatinine value was > 1.6 mg/dL (HR 2.108 for each point increase, 95% CI 1.521-2.921, P = .000). Furthermore, there was an insignificant trend forward an association between active or past smoker and lower patient survival (HR 1.689, 95% CI 0.937-3.043, P = .08). The main causes of graft loss were patient death (79.5%). acute rejection (6.8%), and chronic allograft nephropathy (5.5%).

CONCLUSION

Renal transplantation can be performed safely and with acceptable outcomes in elderly patients after appropriate clinical evaluation. The grafts show excellent survival albeit that deaths with a functional graft continue to be an important issue.

Recipient-related predictors of kidney transplantation outcomes in the elderly

BACKGROUND

It is not clear whether in old people with end-stage renal disease kidney transplantation is superior to dialysis therapy.

METHODS

We compared mortality rates between kidney transplant recipients (KTRs) and the general population across different age categories. We also examined patient and allograft survival in 15 667 elderly KTRs (65-<90 yr old, 36% female) within three age subgroups (65-<70, 70-<75, and ≥75 yr).

RESULTS

The rise in the relative risk of death in older age groups was substantially less in KTRs than in the general population, that is, 1.8 and 2.0 vs. 21.4 and 76.6 in those aged 65-<75 and ≥75 yr, respectively, compared with 15- to <65-yr-old people (reference group). In 65- to <70-yr-old KTRs, obesity (BMI>30 kg/m(2) ) was associated with 19% higher risk of graft failure (HR: 1.19 [1.07-1.33], p = 0.002). Diabetes was a predictor of worse patient survival in all age groups but poorer allograft outcome in the youngest age group (65-<70 yr old) only. None of the examined risk factors affected allograft outcome in the oldest group (≥75 yr old) although there was a 49% lower trend of graft failure in very old Hispanic recipients (HR: 0.51 [0.26-1.01], p = 0.05).

CONCLUSIONS

Kidney transplantation may attenuate the age-associated increase in mortality, and its superior survival gain is most prominent in the oldest recipients (≥75 yr old). The potential protective effect of kidney transplantation on longevity in the elderly deserves further investigation.

ABO-incompatible kidney transplantation in elderly patients over 60 years of age

Introduction

Patients aged 60 years and older represent the fastest-growing population with end-stage renal disease worldwide, and the need for a kidney transplant among this population is increasing. Due to the severe shortage of deceased donors in Japan, ABO-incompatible living donor kidney transplantation has been performed since the late 1980s. Excellent long-term outcomes have been achieved, and the rates of graft survival in these patients are currently similar to those in recipients of ABO-compatible grafts. However, the outcomes of ABO-incompatible kidney transplantation in elderly patients over 60 years of age have not been well studied yet.

Patients and methods

We studied 4 elderly kidney transplant patients who received their grafts from ABO-incompatible living donors at our institution between December 2006 and December 2011, focusing on the immunosuppressive protocols, complications and graft survivals. The mean observation period was 21.5 months (range, 8 months to 62 months). Our immunosuppressive protocols were as follows: to remove the anti-A/B antibodies, the patients underwent 4–8 sessions of double-filtration plasmapheresis and/or plasma exchange prior to kidney transplantation until the anti-A/B titers were less than 1:16. For the patients with low anti-A/B titers (<1:512), the immunosuppressive protocol consisted of a single dose of rituximab (150 mg/m²). The patients with high anti-A/B antibody titers (≥1:512) underwent splenectomy and received 2 doses of rituximab. The pretransplant immunosuppressive protocol included B-lymphocyte suppression with 4 weeks of mycophenolate mofetil (0.5 g/day for low-titer protocol and 1 g/day for high-titer protocol).

Results

All 4 patients underwent successful transplantation. At the end of follow-up, their mean serum creatinine was 1.18 mg/dl. No patient experienced antibody-mediated rejection or acute cellular rejection. Late-onset neutropenia occurred in two cases. Two cases experienced cytomegalovirus reactivation by cytomegalovirus antigenemia. In one patient, diffuse hemorrhage required surgical intervention. However, there were no severe complications.

Conclusions

Although a careful evaluation of patients is needed, ABO-incompatible kidney transplantation may become a viable treatment option for elderly patients with end-stage renal disease.

Epidemiologic trends in chronic renal replacement therapy over forty years: a Swiss dialysis experience

BACKGROUND

Long term longitudinal data are scarce on epidemiological characteristics and patient outcomes in patients on maintenance dialysis, especially in Switzerland. We examined changes in epidemiology of patients undergoing renal replacement therapy by either hemodialysis or peritoneal dialysis over four decades.

METHODS

Single center retrospective study including all patients which initiated dialysis treatment for ESRD between 1970 and 2008. Analyses were performed for subgroups according to dialysis vintage, based on stratification into quartiles of date of first treatment. A multivariate model predicting death and survival time, using time-dependent Cox regression, was developed.

RESULTS

964 patients were investigated. Incident mean age progressively increased from 48 ± 14 to 64 ± 15 years from 1st to 4th quartile (p < 0.001), with a concomitant decrease in 3- and 5-year survival from 72.2 to 67.7%, and 64.1 to 54.8%, respectively. Nevertheless, live span continuously increased from 57 ± 13 to 74 ± 11 years (p < 0.001). Patients transplanted at least once were significantly younger at dialysis initiation, with significantly better survival, however, shortened live span vs. individuals remaining on dialysis. Among age at time of initiating dialysis therapy, sex, dialysis modality and transplant status, only transplant status is a significant independent covariate predicting death (HR: 0.10 for transplanted vs. non-transplanted patients, p = 0.001). Dialysis vintage was associated with better survival during the second vs. the first quartile (p = 0.026).

DISCUSSION

We document an increase of a predominantly elderly incident and prevalent dialysis population, with progressively shortened survival after initiation of renal replacement over four decades, and, nevertheless, a prolonged lifespan. Analysis of the data is limited by lack of information on comorbidity in the study population.

CONCLUSIONS

Survival in patients on renal replacement therapy seems to be affected not only by medical and technical advances in dialysis therapy, but may mostly reflect progressively lower mortality of individuals with cardiovascular and metabolic complications, as well as a policy of accepting older and polymorbid patients for dialysis in more recent times. This is relevant to make demographic predictions in face of the ESRD epidemic nephrologists and policy makers are facing in industrialized countries.

Age and the associations of living donor and expanded criteria donor kidneys with kidney transplant outcomes

BACKGROUND

Recent studies show a survival advantage with kidney transplant in elderly patients compared with those on dialysis therapy.

STUDY DESIGN

In our present study, we examined and compared the association of expanded criteria donor (ECD) kidney and living kidney donation with the outcome of kidney transplant across different ages, including elderly recipients.

SETTING & PARTICIPANTS

Using the Scientific Registry of Transplant Recipients, we identified 145,470 adult kidney transplant patients. Mortality and death-censored transplant failure risks were estimated by Cox proportional regression analyses during follow-up with a median of 3.9 years.

PREDICTORS

ECD kidney and living kidney donation and age compared with others.

OUTCOMES

Mortality and death-censored transplant failure risk.

RESULTS

Patients were aged 45 ± 16 years and included 40% women and 19% patients with diabetes. Compared with transplant recipients 55 to younger than 65 years, the fully adjusted death-censored transplant failure risk was higher in patients 75 years and older (HR, 1.30; 95% CI, 1.09-1.56), 35 to younger than 55 years (HR, 1.13; 95% CI, 1.08-1.17), and 18 to younger than 35 years (HR, 1.64; 95% CI, 1.57-1.71). Compared with non-ECD kidneys, ECD kidneys were significant predictors of mortality in nonelderly patients (18-<35 years: HR, 1.46 [95% CI, 1.19-1.77]; 35-<55 years: HR, 1.23 [95% CI, 1.14-1.32]; and 55-<65 years: HR, 1.26 [95% CI, 1.15-1.38]) and patients 65 to younger than 70 years (HR, 1.20; 95% CI, 1.05-1.36), but not in other groups of elderly patients (HRs of 1.12 [95% CI, 0.93-1.36] for 70-<75 years and 1.04 [95% CI, 0.74-1.47] for ≥75 years). Similar results were found for risk of transplant loss. Compared with deceased donor kidneys, a living donor kidney was associated with better survival in all age groups and lower transplant loss risk in patients younger than 70 years.

LIMITATIONS

Unmeasured confounders cannot be adjusted for.

CONCLUSIONS

For deceased donors, ECD kidneys are not associated with increased mortality or transplant failure in recipients older than 70 years. For all types of donors, the persistent association between living donor kidneys and lower all-cause mortality across all ages suggests that, if possible, elderly patients gain longevity from living donor kidney transplant.

The elderly as recipients of living donor kidneys, how old is too old?

PURPOSE OF REVIEW

Transplantation of the elderly often invokes strong and sometimes passionate arguments both in support and in opposition. Age alone has not been an absolute contraindication to a life-sustaining organ transplant for several decades. A comprehensive evaluation of the risks associated with surgery and suppression of the immune system in this often comorbid population becomes the focus. Risk for the recipient, however, must continually be evaluated and frequently updated in the context of that for the donor.

RECENT FINDINGS

Following careful and critical evaluation, elderly patients appreciate the increase in life expectancy and improvements in quality of life as demonstrated in their younger counterparts. The outcome of recipients receiving kidneys from living donors has demonstrated superior graft and patient survival compared to deceased donors. Careful monitoring of medication levels for prevention of rejection while avoiding over immunosuppression and infection is critical to ensure such benefit.

SUMMARY

Transplantation of the elderly via living donation is not only justified but in the appropriately chosen patient, with informed consent of both donor and recipient, is ethically sound. The expectations of both parties must be clearly stated and donor safety must remain the top priority. Living donors must be fully cognizant of the potential risk both in patient and graft survival prior to making such a life-changing decision to donate.

Dual-kidney transplants as an alternative for very marginal donors: long-term follow-up in 63 patients

BACKGROUND

Organ shortage has led to the use of dual-kidney transplant (DKT) of very marginal donors into a single recipient to increase the use of marginal organs. To date, few data are available about the long-term outcome of DKT and its usefulness to increase the pool of available organ.

METHODS

We conducted a single-center cohort study of DKTs with longitudinal follow-up over an 8-year period. Between 1999 and 2007, 63 DKTs were performed. All kidneys from donors younger than 75 years refused by all centers for single transplantation, and kidneys from donors aged 75 years or older were routinely evaluated based on preimplantation glomerulosclerosis. Renal function, patient or graft survival, and perioperative complications were compared with 66 single kidneys from expanded criteria donors (ECD) and 63 ideal kidney donors.

RESULTS

After a median follow-up of 56 months, patient or graft survival was similar between the three groups. Twelve-, 36-, and 84-month creatinine clearance were similar for DKT and ECD (12 months: 58 and 59 mL/min; 36 months: 54 and 60 mL/min; and 84 months: 62 and 51 mL/min, respectively). For the study period, the routine evaluation of very marginal kidneys for DKT in our center has led to an increase of 47% in the transplants from donors aged 50 years or older, which represent 12% at the level of our organ procurement organization.

CONCLUSIONS

DKT patients can expect long-term results comparable with single kidney ECD. The implementation of a DKT program in our unit safely increased the pool of organs from marginal donors.