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Kidney transplantation from elderly donors (> 70 years): a systematic review. World J Urol 2023; 41:695-707. [PMID: 36907943 DOI: 10.1007/s00345-023-04311-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 01/22/2023] [Indexed: 03/14/2023] Open
Abstract
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.
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2
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Vinson AJ, Cardinal H, Parsons C, Tennankore KK, Mainra R, Maru K, Treleaven D, Gill J. Disparities in Deceased Donor Kidney Offer Acceptance: A Survey of Canadian Transplant Nephrologists, General Surgeons and Urologists. Can J Kidney Health Dis 2023; 10:20543581231156855. [PMID: 36861114 PMCID: PMC9969426 DOI: 10.1177/20543581231156855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 12/19/2022] [Indexed: 02/26/2023] Open
Abstract
Background Significant variability in organ acceptance thresholds have been demonstrated across the United States, but data regarding the rate and rationale for kidney donor organ decline in Canada are lacking. Objective To examine decision making regarding deceased kidney donor acceptance and non-acceptance in a population of Canadian transplant professionals. Design A survey study of theoretical deceased donor kidney cases of increasing complexity. Setting Canadian transplant nephrologists, urologists, and surgeons making donor call decisions responding to an electronic survey between July 22 and October 4, 2022. Participants Invitations to participate were distributed to 179 Canadian transplant nephrologists, surgeons, and urologists through e-mail. Participants were identified by contacting each transplant program and requesting a list of physicians who take donor call. Measurements Survey respondents were asked whether they would accept or decline a given donor, assuming there was a suitable recipient. They were also asked to cite reasons for donor non-acceptance. Methods Donor scenario-specific acceptance rates (total acceptance divided by total number of respondents for a given scenario and overall) and reasons for decline were determined and presented as a percentage of the total cases declined. Results In all, 72 respondents from 7 provinces completed at least one question of the survey, with considerable variability between acceptance rates for centers; the most conservative center declined 60.9% of donor cases, whereas the most aggressive center declined only 28.1%, P-value < .001. There was an increased risk of non-acceptance with advancing age, donation after cardiac death, acute kidney injury, chronic kidney disease, and comorbidities. Limitations As with any survey, there is the potential for participation bias. In addition, this study examines donor characteristics in isolation, however, asks respondent to assume there is a suitable candidate available. In reality, whenever donor quality is considered, it should be considered in the context of the intended recipient. Conclusion In a survey of increasingly medically complex deceased kidney donor cases, there was significant variability in donor decline among Canadian transplant specialists. Given relatively high rates of donor decline and apparent heterogeneity in acceptance decisions, Canadian transplant specialists may benefit from additional education regarding the benefits achieved from even medically complex kidney donors for appropriate candidates relative to remaining on dialysis on the transplant waitlist.
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Affiliation(s)
- A. J. Vinson
- Nova Scotia Health Authority, Halifax,
Canada,Division of Nephrology, Department of
Medicine, Dalhousie University, Halifax, NS, Canada,A. J. Vinson, Division of Nephrology,
Department of Medicine, Dalhousie University, Room 5081, 5th Floor Dickson
Building, Victoria General Hospital, 5820 University Ave, Halifax, NS B3H 1V8,
Canada.
| | - H. Cardinal
- Centre de recherche du Centre
hospitalier de l’Université de Montréal, QC, Canada
| | - C. Parsons
- Organ and Tissue Donation and
Transplantation, Canadian Blood Services, Ottawa, ON, Canada
| | - K. K. Tennankore
- Nova Scotia Health Authority, Halifax,
Canada,Division of Nephrology, Department of
Medicine, Dalhousie University, Halifax, NS, Canada
| | - R. Mainra
- Division of Nephrology, Department of
Medicine, University of Saskatchewan, Regina, Canada
| | - K. Maru
- Canadian Blood Services, Ottawa, ON,
Canada
| | - D. Treleaven
- Division of Nephrology, Department of
Medicine, McMaster University, Hamilton, ON, Canada
| | - J. Gill
- Division of Nephrology, Department of
Medicine, The University of British Columbia, Vancouver, Canada
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3
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Outcomes of Deceased Donor Kidney Transplantation in the Eurotransplant Senior Program with A Focus on Recipients ≥75 Years. J Clin Med 2021; 10:jcm10235633. [PMID: 34884335 PMCID: PMC8658179 DOI: 10.3390/jcm10235633] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 11/21/2021] [Accepted: 11/22/2021] [Indexed: 12/02/2022] Open
Abstract
To evaluate the outcomes of kidney transplantations (KTs) in the Eurotransplant Senior Program (ESP) with a focus on the very old, defined as recipients ≥75 years. This retrospective clinical study included 85 patients, who under the ESP protocol underwent deceased donor kidney transplantation from January 2010 to July 2018 at the Charité–Universitätsmedizin Berlin in Germany. Recipients were divided in three age groups, i.e., Group 65–69, Group 70–74, Group ≥75, and compared. Prognostic risk factors for short and long-term outcomes of kidney transplantations were investigated. Graft survival at 1 and 5 years were respectively 90.7% and 68.0% for group 65–69, 88.9% and 76.2% for Group 70–74, and 100% and 71.4% for Group ≥75. Patient survival at 1 and 5 years were respectively 92.9% and 68.0% for Group 65–69, 85.7% and 61.5% for Group 70–74 and 100% and 62.5% for Group ≥75. Serum creatinine did not significantly differ between the three groups, with the exception of serum creatinine at 1 year. Increased recipient age and prolonged time on dialysis correlated with increased occurrence of postoperative complication. An increase in BMI, pretransplant diabetes mellitus and prolonged time on dialysis correlated with the occurrence of delayed graft function (DGF). History of smoking was identified as an independent risk factor for events of rejection. Increased human leukocyte antigen mismatches (HLA-MM) and prolonged cold ischemia time (CIT) correlated with higher rates of intensive care unit (ICU) treatment. This study supports kidney transplantations for the very old. End-stage renal disease (ESRD) patients ≥75 years of age who underwent kidney transplantation experienced comparable results to their younger counterparts. A comprehensive evaluation of ESRD patients with consideration of prognostic risk factor is the most suitable mean of identifying adequate kidney transplant candidates.
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Schachtner T, Otto NM, Reinke P. Two decades of the Eurotransplant Senior Program: the gender gap in mortality impacts patient survival after kidney transplantation. Clin Kidney J 2020; 13:1091-1100. [PMID: 33391754 PMCID: PMC7769544 DOI: 10.1093/ckj/sfz118] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 08/09/2019] [Indexed: 12/22/2022] Open
Abstract
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.
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Affiliation(s)
- Thomas Schachtner
- Department of Nephrology and Internal Intensive Care, Charité University Medicine Berlin, Berlin, Germany
- Berlin-Brandenburg Center of Regenerative Therapies, Berlin, Germany
- Department of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Natalie M Otto
- Department of Nephrology and Internal Intensive Care, Charité University Medicine Berlin, Berlin, Germany
- Berlin-Brandenburg Center of Regenerative Therapies, Berlin, Germany
| | - Petra Reinke
- Department of Nephrology and Internal Intensive Care, Charité University Medicine Berlin, Berlin, Germany
- Berlin-Brandenburg Center of Regenerative Therapies, Berlin, Germany
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5
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[Very-old deceased donors in kidney transplantation: How far can we go?]. Nephrol Ther 2020; 16:408-413. [PMID: 33203614 DOI: 10.1016/j.nephro.2020.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 06/24/2020] [Accepted: 06/29/2020] [Indexed: 11/23/2022]
Abstract
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.
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6
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Zeuschner P, Sester U, Stöckle M, Saar M, Zompolas I, El-Bandar N, Liefeldt L, Budde K, Öllinger R, Ritschl P, Schlomm T, Mihm J, Friedersdorff F. Should We Perform Old-for-Old Kidney Transplantation during the COVID-19 Pandemic? The Risk for Post-Operative Intensive Stay. J Clin Med 2020; 9:E1835. [PMID: 32545566 PMCID: PMC7356807 DOI: 10.3390/jcm9061835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/09/2020] [Accepted: 06/10/2020] [Indexed: 12/14/2022] Open
Abstract
Health care systems worldwide have been facing major challenges since the outbreak of the SARS-CoV-2 pandemic. Kidney transplantation (KT) has been tremendously affected due to limited personal protective equipment (PPE) and intensive care unit (ICU) capacities. To provide valid information on risk factors for ICU admission in a high-risk cohort of old kidney recipients from old donors in the Eurotransplant Senior Program (ESP), we retrospectively conducted a bi-centric analysis. Overall, 17 (16.2%) patients out of 105 KTs were admitted to the ICU. They had a lower BMI, and both coronary artery disease (CAD) and hypertensive nephropathy were more frequent. A risk model combining BMI, CAD and hypertensive nephropathy gained a sensitivity of 94.1% and a negative predictive value of 97.8%, rendering it a valuable search test, but with low specificity (51.1%). ICU admission also proved to be an excellent parameter identifying patients at risk for short patient and graft survivals. Patients admitted to the ICU had shorter patient (1-year 57% vs. 90%) and graft (5-year 49% vs. 77%) survival. To conclude, potential kidney recipients with a low BMI, CAD and hypertensive nephropathy should only be transplanted in the ESP in times of SARS-CoV-2 pandemic if the local health situation can provide sufficient ICU capacities.
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Affiliation(s)
- Philip Zeuschner
- Department of Urology and Pediatric Urology, Saarland University, Kirrberger Street 100, 66421 Homburg/Saar, Germany; (P.Z.); (M.S.); (M.S.)
| | - Urban Sester
- Department of Nephrology and Hypertension, Internal Medicine IV, Saarland University, Kirrberger Street 100, 66421 Homburg/Saar, Germany; (U.S.); (J.M.)
| | - Michael Stöckle
- Department of Urology and Pediatric Urology, Saarland University, Kirrberger Street 100, 66421 Homburg/Saar, Germany; (P.Z.); (M.S.); (M.S.)
| | - Matthias Saar
- Department of Urology and Pediatric Urology, Saarland University, Kirrberger Street 100, 66421 Homburg/Saar, Germany; (P.Z.); (M.S.); (M.S.)
| | - Ilias Zompolas
- Department of Urology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humbold-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany; (I.Z.); (N.E.-B.); (T.S.)
| | - Nasrin El-Bandar
- Department of Urology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humbold-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany; (I.Z.); (N.E.-B.); (T.S.)
| | - Lutz Liefeldt
- Department of Nephrology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humbold-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany; (L.L.); (K.B.)
| | - Klemens Budde
- Department of Nephrology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humbold-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany; (L.L.); (K.B.)
| | - Robert Öllinger
- Department of Surgery, Campus Charité Mitte/Campus Virchow-Klinikum CCM/CVK, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humbold-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany; (R.Ö.); (P.R.)
| | - Paul Ritschl
- Department of Surgery, Campus Charité Mitte/Campus Virchow-Klinikum CCM/CVK, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humbold-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany; (R.Ö.); (P.R.)
| | - Thorsten Schlomm
- Department of Urology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humbold-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany; (I.Z.); (N.E.-B.); (T.S.)
| | - Janine Mihm
- Department of Nephrology and Hypertension, Internal Medicine IV, Saarland University, Kirrberger Street 100, 66421 Homburg/Saar, Germany; (U.S.); (J.M.)
| | - Frank Friedersdorff
- Department of Urology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humbold-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany; (I.Z.); (N.E.-B.); (T.S.)
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7
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Martins J, Barreto S, Bravo P, Santos JP, Ferreira MJ, Oliveira C, Ramos A. Kidney Transplant From Elderly Donors: A Center Experience. Transplant Proc 2020; 52:1265-1268. [PMID: 32217014 DOI: 10.1016/j.transproceed.2019.12.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 12/06/2019] [Indexed: 10/24/2022]
Abstract
BACKGROUND Renal transplantation is the treatment of choice in end-stage renal disease. With the aging of the population and better medical care available, the number of high-risk patients in terms of age and comorbidities on transplant waiting lists is increasing. Due to severe organ shortage, the use of expanded criteria and elderly donors is also increasing. We will review the outcomes of graft function and survival from a series of transplants from elderly deceased donors and compare the characteristics of the organs from donors older and younger than 70 years. METHODS We collected data from our transplant unit from 1993 until May 2019 and considered 2 groups of donors: donors A (aged ≥70 years) and donors B (aged <70 years). RESULTS The donors A group had more comorbidities with consequently higher Kidney Donor Profile Index scores than the donors B group, although there was no statistical difference regarding pre-donation serum creatinine level. Among transplant recipients, we also considered 2 groups, according to the age of the organ received: recipients A and recipients B. No difference was found between groups regarding the number of HLA mismatches, incidence of delayed graft function, number of hospitalizations, or incidence of acute rejection. Recipients' age, cold ischemia time, and graft function 1 year after transplant were worse in the recipients A group. CONCLUSIONS Although kidney graft function was worse in recipients from elderly donors, this difference had no clinical relevance, showing a possible benefit in patient survival compared with permanence in dialysis, so this type of transplant could be considered for older recipients.
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Affiliation(s)
- Joana Martins
- Nephrology Department, Hospital Garcia de Orta, Almada, Portugal.
| | - Sara Barreto
- Nephrology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Pedro Bravo
- Nephrology Department, Hospital Garcia de Orta, Almada, Portugal
| | | | | | - Carlos Oliveira
- Nephrology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Aura Ramos
- Nephrology Department, Hospital Garcia de Orta, Almada, Portugal
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8
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Quast LS, Grzella S, Lengenfeld T, Pillokeit N, Hummels M, Zgoura P, Westhoff TH, Viebahn R, Schenker P. Outcome of Kidney Transplantation Using Organs From Brain-dead Donors Older Than 75 Years. Transplant Proc 2019; 52:119-126. [PMID: 31901319 DOI: 10.1016/j.transproceed.2019.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/23/2019] [Accepted: 11/10/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE We investigated whether older donor kidneys aged >75 years have acceptable long-term function and if recipients can benefit sufficiently from the transplantation. METHODS This single-center study retrospectively analyzed patient data from 217 deceased donor kidney transplants performed between 1998 and 2014 as part of the Eurotransplant Senior Program, where the organ donors were ≥65 years old. Depending on donor age, the groups "older donors" (OD; n = 161) and "very old donors" (VOD; n = 56) received transplants from donors aged 65 to 75 years and >75 years, respectively. Donor and recipient clinical characteristics, delayed graft function, estimated glomerular filtration rate, 1-year rejection rate, patient and graft survival, and postoperative complications were investigated. RESULTS Comparing VOD group vs OD group, the 1-year, 3-year, and 5-year graft survival rates were 80.4% vs 76.4%, 62.5% vs 65.8%, and 42.6% vs 57.3%, respectively. Patient survival rates after 1, 3, and 5 years were 89.3% vs 88.2%, 71.4% vs 78.2%, and 57.5% vs 71.8%, respectively. There were no significant differences between the 2 groups (graft survival P = .107; patient survival P = .126). Kidney graft function after 1, 2, and 3 years was significantly better in the OD group than in the VOD group. No differences were found regarding postoperative complications, rejection rate, and delayed graft function. CONCLUSION The utilization of selected kidney-grafts from donors >75 years resulted in acceptable outcomes after kidney transplantation and could expand the donor pool. In contrast to the high mortality rate during dialysis, recipients in both groups benefited from transplantation.
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Affiliation(s)
- Louisa Sarah Quast
- Department of Surgery, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Sascha Grzella
- Department of Surgery, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Thorsten Lengenfeld
- Department of Surgery, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Nina Pillokeit
- Department of Surgery, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Marielle Hummels
- Department of Surgery, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Panagiota Zgoura
- Medical Department I, University Hospital Marienhospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Timm H Westhoff
- Medical Department I, University Hospital Marienhospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Richard Viebahn
- Department of Surgery, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Peter Schenker
- Department of Surgery, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany.
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9
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Lau A, Kennedy BK, Kirkland JL, Tullius SG. Mixing old and young: enhancing rejuvenation and accelerating aging. J Clin Invest 2019; 129:4-11. [PMID: 30601138 DOI: 10.1172/jci123946] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Donor age and recipient age are factors that influence transplantation outcomes. Aside from age-associated differences in intrinsic graft function and alloimmune responses, the ability of young and old cells to exert either rejuvenating or aging effects extrinsically may also apply to the transplantation of hematopoietic stem cells or solid organ transplants. While the potential for rejuvenation mediated by the transfer of youthful cells is currently being explored for therapeutic applications, aspects that relate to accelerating aging are no less clinically significant. Those effects may be particularly relevant in transplantation with an age discrepancy between donor and recipient. Here, we review recent advances in understanding the mechanisms by which young and old cells modify their environments to promote rejuvenation- or aging-associated phenotypes. We discuss their relevance to clinical transplantation and highlight potential opportunities for therapeutic intervention.
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Affiliation(s)
- Ashley Lau
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brian K Kennedy
- Departments of Biochemistry and Physiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Singapore Institute for Clinical Sciences, Singapore.,Agency for Science, Technology and Research (A*STAR), Singapore.,Buck Institute for Research on Aging, Novato, California, USA
| | - James L Kirkland
- Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, Minnesota, USA
| | - Stefan G Tullius
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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10
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Schamberger B, Lohmann D, Sollinger D, Stein R, Lutz J. Association of Kidney Donor Risk Index with the Outcome after Kidney Transplantation in the Eurotransplant Senior Program. Ann Transplant 2018; 23:775-781. [PMID: 30397188 PMCID: PMC6248015 DOI: 10.12659/aot.909622] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background We evaluated the Kidney Donor Risk Index (KDRI) scoring system for kidney transplantation in the Eurotransplant Senior Program (ESP) that allocates kidneys from older donors to older recipients (≥65 years). Material/Methods We retrospectively analyzed data of 37 kidney transplant recipients and 36 kidney donors who participated in kidney transplantation program according to the ESP at our center from January 2004 until December 2013. Results Mean recipient and donor age was 67.9±2.6 and 70.5±4.0 years respectively. The mean KDRI score was 1.7±0.27. Uncensored graft survival after 1 year and 5 years was 64.2% and 53.7% respectively. Subgroup analysis showed that in kidney transplantation with KDRI >1.83, graft survival was significantly reduced compared to lower KDRI subgroups. KDRI was significantly correlated with serum creatinine level at discharge (r=0.4). Conclusions ESP kidneys represent a group of high-risk grafts with high KDRI scores. Higher KDRI scores in ESP kidneys was associated with reduced postoperative short-term and long-term graft outcomes. KDRI might be useful in decision-making for selecting donors for ESP kidney transplantation.
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Affiliation(s)
- Beate Schamberger
- Medical Clinic, Section of Nephrology and Infectious Diseases, Gemeinschaftsklinikum Mittelrhein, Koblenz, Germany
| | - Dario Lohmann
- Medical Clinic III, Section of Nephrology, University Hospital Frankfurt, Frankfurt, Germany
| | - Daniel Sollinger
- I Medical Clinic, Section of Nephrology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Raimund Stein
- Department of Pediatric Urology, University Medical Center Mannheim, Mannheim, Germany
| | - Jens Lutz
- Medical Clinic, Section of Nephrology and Infectious Diseases, Gemeinschaftsklinikum Mittelrhein, Koblenz, Germany
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11
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Kute VB, Trivedi HL, Vanikar AV, Shah PR, Gumber MR, Patel HV, Modi PR, Shah VR. Deceased Donor Renal Transplantation from Older Donors to Increase the Donor Pool. Int J Artif Organs 2018. [DOI: 10.1177/039139881203500906] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Vivek B. Kute
- Department of Nephrology and Clinical Transplantation, Institute of Kidney Diseases and Research Center, Dr. HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad - India
| | - Hargovind L Trivedi
- Department of Nephrology and Clinical Transplantation, Institute of Kidney Diseases and Research Center, Dr. HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad - India
| | - Aruna V. Vanikar
- Department of Pathology, Laboratory Medicine, Transfusion Services and Immunohematology, IKDRC-ITS, Ahmedabad - India
| | - Pankaj R. Shah
- Department of Nephrology and Clinical Transplantation, Institute of Kidney Diseases and Research Center, Dr. HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad - India
| | - Manoj R. Gumber
- Department of Nephrology and Clinical Transplantation, Institute of Kidney Diseases and Research Center, Dr. HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad - India
| | - Himanshu V. Patel
- Department of Nephrology and Clinical Transplantation, Institute of Kidney Diseases and Research Center, Dr. HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad - India
| | - Pranjal R. Modi
- Department of Urology and Transplantation, IKDRC-ITS, Ahmedabad - India
| | - Veena R. Shah
- Department of Anesthesia and Critical Care, IKDRC-ITS, Ahmedabad - India
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12
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Abstract
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.
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13
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Mora-Gutiérrez JM, Slon Roblero MF, Castaño Bilbao I, Izquierdo Bautista D, Arteaga Coloma J, Martínez Velilla N. [Chronic kidney disease in the elderly patient]. Rev Esp Geriatr Gerontol 2017; 52:152-158. [PMID: 27161192 DOI: 10.1016/j.regg.2016.03.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 03/13/2016] [Accepted: 03/15/2016] [Indexed: 06/05/2023]
Abstract
Chronic kidney disease (CKD) is widely prevalent worldwide, with a special impact on elderly population. Around half of people aged over 75 meet diagnostic criteria for CKD according to the recent 'Kidney disease improving global outcomes' (KDIGO) 2012 clinical practice guideline on the evaluation and management of CKD. However, geriatric patients have characteristics that may not be addressed by general guidelines. Therefore, it is important to know the natural history of the disease, symptoms, and 'red-flags' that could help in the management of these patients. In this review, a complete approach is presented on the pathophysiology, diagnosis, and treatment of CKD in the geriatric population.
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Affiliation(s)
- José María Mora-Gutiérrez
- Servicio de Nefrología, Clínica Universidad de Navarra, Pamplona, España; Instituto de Investigación Sanitaria de Navarra (IdiSNa), Pamplona, España.
| | | | | | | | | | - Nicolás Martínez Velilla
- Servicio de Geriatría, Complejo Hospitalario de Navarra, Pamplona, España; Red de Investigación en Servicios Sanitarios en Enfermedades Crónicas (REDISSEC), España; Instituto de Investigación Sanitaria de Navarra (IdiSNa), Pamplona, España
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14
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Pérez-Sáez MJ, Arcos E, Comas J, Crespo M, Lloveras J, Pascual J. Survival Benefit From Kidney Transplantation Using Kidneys From Deceased Donors Aged ≥75 Years: A Time-Dependent Analysis. Am J Transplant 2016; 16:2724-33. [PMID: 27004984 DOI: 10.1111/ajt.13800] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 02/26/2016] [Accepted: 03/13/2016] [Indexed: 01/25/2023]
Abstract
Patients with end-stage renal disease have longer survival after kidney transplantation than they would by remaining on dialysis; however, outcome with kidneys from donors aged ≥75 years and the survival of recipients of these organs compared with their dialysis counterparts with the same probability of obtaining an organ is unknown. In a longitudinal mortality study, 2040 patients on dialysis were placed on a waiting list, and 389 of them received a first transplant from a deceased donor aged ≥75 years. The adjusted risk of death and survival were calculated by non-proportional hazards analysis with being transplanted as a time-dependent effect. Projected years of life since placement on the waiting list was almost twofold higher for transplanted patients. Nonproportional adjusted risk of death after transplantation was 0.44 (95% confidence interval [CI] 0.61-0.32; p < 0.001) in comparison with those that remained on dialysis. Stratifying by age, adjusted hazard ratios for death were 0.17 (95% CI 0.47-0.06; p = 0.001) for those aged <65 years, 0.56 (95% CI 0.92-0.34; p = 0.022) for those aged 65-69 years and 0.82 (95% CI 1.28-0.52; p = 0.389) for those aged ≥70 years. Although kidney transplantation from elderly deceased donors is associated with reduced graft survival, transplanted patients have lower mortality than those remaining on dialysis.
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Affiliation(s)
- M J Pérez-Sáez
- Department of Nephrology, Hospital del Mar, Barcelona, Spain.,Institut Mar d'Investigacions Médiques, Barcelona, Spain
| | - E Arcos
- Organització Catalana de Trasplantaments, Barcelona, Spain
| | - J Comas
- Organització Catalana de Trasplantaments, Barcelona, Spain
| | - M Crespo
- Department of Nephrology, Hospital del Mar, Barcelona, Spain.,Institut Mar d'Investigacions Médiques, Barcelona, Spain
| | - J Lloveras
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - J Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain.,Institut Mar d'Investigacions Médiques, Barcelona, Spain
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15
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Sutherland AI, IJzermans JNM, Forsythe JLR, Dor FJMF. Kidney and liver transplantation in the elderly. Br J Surg 2015; 103:e62-72. [PMID: 26662845 DOI: 10.1002/bjs.10064] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 10/27/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Transplant surgery is facing a shortage of deceased donor organs. In response, the criteria for organ donation have been extended, and an increasing number of organs from older donors are being used. For recipients, the benefits of transplantation are great, and the growing ageing population has led to increasing numbers of elderly patients being accepted for transplantation. METHODS The literature was reviewed to investigate the impact of age of donors and recipients in abdominal organ transplantation, and to highlight aspects of the fine balance in donor and recipient selection and screening, as well as allocation policies fair to young and old alike. RESULTS Overall, kidney and liver transplantation from older deceased donors have good outcomes, but are not as good as those from younger donors. Careful donor selection based on risk indices, and potentially biomarkers, special allocation schemes to match elderly donors with elderly recipients, and vigorous recipient selection, allows good outcomes with increasing age of both donors and recipients. The results of live kidney donation have been excellent for donor and recipient, and there is a trend towards inclusion of older donors. Future strategies, including personalized immunosuppression for older recipients as well as machine preservation and reconditioning of donor organs, are promising ways to improve the outcome of transplantation between older donors and older recipients. CONCLUSION Kidney and liver transplantation in the elderly is a clinical reality. Outcomes are good, but can be optimized by using strategies that modify donor risk factors and recipient co-morbidities, and personalized approaches to organ allocation and immunosuppression.
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Affiliation(s)
- A I Sutherland
- Division of Hepatopancreatobiliary and Transplant Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - J N M IJzermans
- Division of Hepatopancreatobiliary and Transplant Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - J L R Forsythe
- Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - F J M F Dor
- Division of Hepatopancreatobiliary and Transplant Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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16
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Fischer-Fröhlich CL, Kutschmann M, Feindt J, Schmidtmann I, Kirste G, Frühauf NR, Wirges U, Rahmel A, Schleicher C. Influence of Deceased Donor and Pretransplant Recipient Parameters on Early Overall Kidney Graft-Survival in Germany. J Transplant 2015; 2015:307230. [PMID: 26539298 PMCID: PMC4619958 DOI: 10.1155/2015/307230] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 09/03/2015] [Indexed: 12/02/2022] Open
Abstract
Background. Scarcity of grafts for kidney transplantation (KTX) caused an increased consideration of deceased donors with substantial risk factors. There is no agreement on which ones are detrimental for overall graft-survival. Therefore, we investigated in a nationwide multicentre study the impact of donor and recipient related risks known before KTX on graft-survival based on the original data used for allocation and graft acceptance. Methods. A nationwide deidentified multicenter study-database was created of data concerning kidneys donated and transplanted in Germany between 2006 and 2008 as provided by the national organ procurement organization (Deutsche Stiftung Organtransplantation) and BQS Institute. Multiple Cox regression (significance level 5%, hazard ratio [95% CI]) was conducted (n = 4411, isolated KTX). Results. Risk factors associated with graft-survival were donor age (1.020 [1.013-1.027] per year), donor size (0.985 [0.977-0.993] per cm), donor's creatinine at admission (1.002 [1.001-1.004] per µmol/L), donor treatment with catecholamine (0.757 [0.635-0.901]), and reduced graft-quality at procurement (1.549 [1.217-1.973]), as well as recipient age (1.012 [1.003-1.021] per year), actual panel reactive antibodies (1.007 [1.002-1.011] per percent), retransplantation (1.850 [1.484-2.306]), recipient's cardiovascular comorbidity (1.436 [1.212-1.701]), and use of IL2-receptor antibodies for induction (0.741 [0.619-0.887]). Conclusion. Some donor characteristics persist to impact graft-survival (e.g., age) while the effect of others could be mitigated by elaborate donor-recipient match and care.
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Affiliation(s)
| | - Marcus Kutschmann
- BQS Institute for Quality and Patient Safety, Kanzlerstraße 4, 40472 Düsseldorf, Germany
| | - Johanna Feindt
- MVZ Anaesthesio Nordrhein, Hans-Günther-Sohl-Straße 6-10, 40235 Düsseldorf, Germany
| | - Irene Schmidtmann
- Institut für Medizinische Biometrie, Epidemiologie und Informatik (IMBEI), Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Obere Zahlbacher Straße 69, 55131 Mainz, Germany
| | - Günter Kirste
- Medizinische Fakultät, Albert Ludwigs Universität Freiburg, Hebelstraße 29, 79104 Freiburg, Germany
| | - Nils R. Frühauf
- Landesärztekammer Niedersachsen, Berliner Allee 20, 30175 Hannover, Germany
| | - Ulrike Wirges
- Deutsche Stiftung Organtransplantation, Region Nordrhein-Westfalen, Lindenallee 29-41, 45127 Essen, Germany
| | - Axel Rahmel
- Deutsche Stiftung Organtransplantation, Deutschherrnufer 52, 60594 Frankfurt am Main, Germany
| | - Christina Schleicher
- Deutsche Stiftung Organtransplantation, Region Baden-Württemberg, Kriegerstraße 6, 70192 Stuttgart, Germany
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17
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A Paired Survival Analysis Comparing Hemodialysis and Kidney Transplantation From Deceased Elderly Donors Older Than 65 Years. Transplantation 2015; 99:991-6. [DOI: 10.1097/tp.0000000000000474] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Morales E, Gutiérrez E, Hernández A, Rojas-Rivera J, Gonzalez E, Hernández E, Polanco N, Praga M, Andrés A. Preemptive kidney transplantation in elderly recipients with kidneys discarded of very old donors: A good alternative. Nefrologia 2015; 35:246-55. [DOI: 10.1016/j.nefro.2015.05.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 02/18/2015] [Indexed: 10/23/2022] Open
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19
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A simple clinical tool to inform the decision-making process to refer elderly incident dialysis patients for kidney transplant evaluation. Kidney Int 2015; 88:121-9. [PMID: 25671769 DOI: 10.1038/ki.2015.25] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 12/12/2014] [Accepted: 12/18/2014] [Indexed: 12/26/2022]
Abstract
Patients over the age of 70 constitute the fastest growing segment of the ESKD population worldwide, but most of them are not considered candidates for kidney transplantation (KT). We have developed a simple clinical screening score to identify incident elderly dialysis patients over 70 years with an acceptable long-term prognosis to identify those patients most suitable for KT evaluation. From the French national prospective registry, a logistic regression was used to develop a risk score of mortality within 3 years in a derivation cohort (years 2002-06) and validated in a separate cohort (years 2007-08). Of the 9305 patients in the derivation cohort, the points assigned for the score were: male (1pt); age (75-80); 2pts), (80-85; 5pts), 85 and over (9pts); diabetes (2pts); intermittent hemodialysis (2pt); peripheral vascular disease stage III-IV (5pts); congestive heart failure stages I-II (2pts), III-IV (4pts); dysrhythmia (2pts); chronic respiratory disease (2pts); active malignancy (5pts); severe behavioral disorder (6pts); cardiovascular disease (1pt); mobility (needs assistance for transfers (4pt), totally dependent (9pts)); BMI (21-25; 1pt), BMI (<21; 3pts); and temporary central vascular catheter (3pts). In the 7947 patient validation cohort, the probability of patients being alive within 3 years was around 70% for the lowest risk score quintile (0-6 pts) representing about 20% of incident patients. Thus, our tool identified a subgroup of patients to help nephrologists select individuals who, despite their age, could be suitable candidates for KT evaluation.
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20
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Abstract
Donor organ scarcity remains a significant clinical challenge in transplantation. Older organs, increasingly utilized to meet the growing demand for donor organs, have been linked to inferior transplant outcomes. Susceptibility to organ injury, reduced repair capacity, and increased immunogenicity are interrelated and impacted by physiological and pathological aging processes. Insights into the underlying mechanisms are needed to develop age-specific interventional strategies with regards to organ preservation, immunosuppression, and allocation. In this overview, we summarize current knowledge of injury and repair mechanisms and the effects of aging relevant to transplantation.
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21
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Slegtenhorst BR, Dor FJ, Rodriguez H, Voskuil FJ, Tullius SG. Ischemia/reperfusion Injury and its Consequences on Immunity and Inflammation. CURRENT TRANSPLANTATION REPORTS 2014; 1:147-154. [PMID: 25419507 DOI: 10.1007/s40472-014-0017-6] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Ischemia/reperfusion injury (IRI), an inherent component of transplantation, affects organ quality and transplant outcomes. Although the complexity of the pathophysiology is recognized, detailed mechanisms remain unclear, and strategies preventing the consequences of IRI have been challenging. Of critical significance appears the link between IRI, the initiation of innate immune responses, and the (potential) augmentation of adaptive immunity. An improved understanding of those complex mechanisms and interactions may pave the way for more effective treatment strategies.
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Affiliation(s)
- Bendix R Slegtenhorst
- Division of Transplant Surgery and Transplant Surgery Research Laboratory, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School ; Division of Transplant Surgery, Department of Surgery, Erasmus MC-University Medical Center
| | - Frank Jmf Dor
- Division of Transplant Surgery, Department of Surgery, Erasmus MC-University Medical Center
| | - Hector Rodriguez
- Division of Transplant Surgery and Transplant Surgery Research Laboratory, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School ; Department of Cardiovascular Surgery, University Hospital of Zurich
| | - Floris J Voskuil
- Division of Transplant Surgery and Transplant Surgery Research Laboratory, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School ; Division of Nephrology, Renal Transplant Unit, Department of Medicine, University Medical Center Groningen
| | - Stefan G Tullius
- Division of Transplant Surgery and Transplant Surgery Research Laboratory, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School
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22
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Assis-Borba L, Cristelli MP, Paula MI, Franco MF, Tedesco-Silva H, Medina-Pestana JO. Expanding the use of expanded criteria donors in kidney transplantation. Int Urol Nephrol 2014; 46:1663-71. [PMID: 24677001 DOI: 10.1007/s11255-014-0695-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Accepted: 03/17/2014] [Indexed: 01/16/2023]
Abstract
PURPOSE Although the use of kidney allografts from expanded criteria donors (ECD) has increased in recent years, the reported discard rates are also growing. The influence of ECD characteristics on transplant outcomes is still underevaluated. METHODS This retrospective study investigated the influence of preimplantation biopsy findings and delayed graft function (DGF) on patient and graft survivals and renal function at 36 months in a cohort of 372 ECD kidney transplant recipients. RESULTS Patient and graft survivals were 91.6 and 68.9 %. The incidence of biopsy-proven acute rejection was 31 %. There were no differences in patient (88.6 vs. 91.1 vs. 94.7 vs. 78.6 %, p = 0.10) or graft (78.1 vs. 72.2 vs. 60.5 vs. 62.6 %, p = 0.14) survivals and renal function (41.7 ± 25.6 vs. 39.9 ± 29.9 vs. 38.1 ± 30.6 vs. 37.4 ± 29.2 mL/min, p = 0.79) comparing ECD kidneys with mild, moderate, and severe histological changes or with no preimplantation biopsy, respectively. However, severe scored transplants had the worst death-censored graft survival (OR 3.1, 95 % CI 1.4-6.9, p = 0.007). No significant differences in patient (86.2 vs. 83.4 %, p = 0.17) or graft (73.7 vs. 65.9 %, p = 0.06) survivals and renal function (38.9 ± 28.6 vs. 39.9 ± 28.4 mL/min, p = 0.72) were observed comparing patients with or without DGF. Multivariable analysis found diabetes history as the only independent risk factor for graft loss (OR 2.1, 95 % CI 1.3-3.3, p = 0.003) or patient death (OR 3.1, 95 % CI 1.5-5.8, p < 0.001). CONCLUSIONS Within the limitations of sample size and short follow-up time, in this cohort of ECD kidney transplant recipients the severity of histological changes observed in preimplantation biopsies was independently associated with graft loss.
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Affiliation(s)
- Luciana Assis-Borba
- Transplant Division, Hospital do Rim e Hipertensão, UNIFESP, São Paulo, SP, Brazil
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23
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24
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Halldorson J, Roberts JP. Decadal analysis of deceased organ donation in Spain and the United States linking an increased donation rate and the utilization of older donors. Liver Transpl 2013; 19:981-6. [PMID: 23780795 DOI: 10.1002/lt.23684] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 05/28/2013] [Indexed: 02/07/2023]
Abstract
After the foundation of the National Transplant Organization, Spanish rates of deceased donor donation rapidly outpaced US growth over the decade from 1989 to 1999. An analysis of the following decade, 1999-2009, demonstrated a markedly flattened growth curve for Spanish deceased donor organ procurement, which increased only 2.4% from 33.6 to 34.4 donors per million population (pmp). In comparison, over the same decade in the United States, the rate of deceased donation increased from 20.9 to 26.3 donors pmp (25.8%). An age group comparison demonstrated a much higher donation rate among older donors in Spain. For example, the number of donors older than 70 years increased from 3.8 to 8.8 pmp (a 132% increase), and they now constitute 25.4% of all Spanish organ donors. In contrast, the number of US donors older than 70 years increased from 1.0 to 1.3 pmp, and they constitute only 4.4% of total deceased donors. Over the same decade, the number of younger donors (15-30 years old) decreased from 6.6 to 2.5 pmp (a 62% decrease) in Spain, and this contrasted with a slightly increased US donation rate for the same age subgroup (a 15.5% increase from 5.8 to 6.7 pmp). Although older donors were more rarely used in the United States, growth in donation over the 2 decades (1989-2009) was strongly associated with the utilization of donors aged 65 or older (P < 0.01). United Network for Organ Sharing regions demonstrated significant differences in utilization rates for older donors. In conclusion, strategies aimed toward achieving US donation rates equivalent to the Spanish benchmark should target improved utilization rates for older donors in the United States instead of emulating elements of the Spanish organ procurement system.
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Affiliation(s)
- Jeff Halldorson
- Department of Surgery, University of California San Diego, San Diego, CA
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25
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Friedersdorff F, Roller C, Klein G, Werthemann P, Cash H, Budde K, Slowinski T, Kempkensteffen C, Busch J, Fuller TF, Giessing M. Outcome of expanded criteria donor kidneys that were transplanted at other Eurotransplant centers after being rejected by our institution. World J Urol 2012; 31:947-52. [DOI: 10.1007/s00345-012-0929-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Accepted: 08/07/2012] [Indexed: 10/28/2022] Open
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26
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Gallinat A, Moers C, Treckmann J, Smits JM, Leuvenink HGD, Lefering R, van Heurn E, Kirste GR, Squifflet JP, Rahmel A, Pirenne J, Ploeg RJ, Paul A. Machine perfusion versus cold storage for the preservation of kidneys from donors >=65 years allocated in the Eurotransplant Senior Programme. Nephrol Dial Transplant 2012; 27:4458-63. [DOI: 10.1093/ndt/gfs321] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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27
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Lim WH, Dogra G, Chadban SJ, Campbell SB, Clayton P, Cohney S, Russ GR, McDonald SP. Lack of impact of donor age on patient survival for renal transplant recipients ≥60years. Transpl Int 2012; 25:401-8. [PMID: 22340432 DOI: 10.1111/j.1432-2277.2012.01429.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
There has been an increase in the number of older patients on the transplant waiting list and acceptance of older donor kidneys. Although kidneys from older donors have been associated with poorer graft outcomes, whether there is a differential impact of donor age on outcomes in older recipients remains unclear. The aim of this study was to evaluate the effect of donor age on graft and patient survival in renal transplant (RT) recipients ≥60years. Using the Australia and New Zealand Dialysis and Transplant Registry, outcomes of 1,037 RT recipients ≥60years between 1995 and 2009 were analyzed. Donor age groups were categorized into 0-20, >20-40, >40-60, and >60years. Compared with recipients receiving donor kidneys >60years, those receiving donor kidneys >20-40years had lower risk of acute rejection (odds ratio 0.46, 95% CI 0.27, 0.79; P<0.01) and death-censored graft failure (HR 0.37, 95% CI 0.19, 0.72; P<0.01). There was no association between donor age groups and death. With a corresponding growth in the availability of older donor kidneys and the observed lack of association between donor age and patient survival in RT recipients ≥60years, preferential allocation of older donor kidneys to RT recipients ≥60years may not disadvantage the life expectancy of these patients.
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Affiliation(s)
- Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia.
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28
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Abstract
Kidney transplantation is the best possible treatment for many patients with end-stage renal failure, but progressive dysfunction and eventual allograft loss with return to dialysis is associated with increased mortality and morbidity. Immune injury from acute or chronic rejection and non-immune causes, such as nephrotoxicity from calcineurin inhibitors, ischaemia-reperfusion injury, recurrent glomerular disease, and allograft BK viral infection, are potential threats. Serial monitoring of renal function enables early recognition of chronic allograft dysfunction, and investigations such as therapeutic drug concentrations, urinalysis, imaging, and a diagnostic biopsy should be undertaken before irreversible nephron loss has occurred. Specific interventions targeting the pathophysiological cause of dysfunction include strengthening of immunosuppression for chronic rejection, or calcineurin inhibitor minimisation, substitution, or elimination if nephrotoxicity dominates. Recommended proactive preventive measures are control of hypertension, proteinuria, dyslipidaemia, diabetes, smoking, and other comorbidities. Strategies to maintain transplant function and improve long-term graft survival are important goals of translational research.
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Affiliation(s)
- Brian J Nankivell
- Department of Renal Medicine, University of Sydney, Westmead Hospital, Sydney, NSW, Australia.
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29
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Midtvedt K, Namtvedt T, Scott H, Abedini S, Rocke JC, Dørje C, Foss S, Christen U, Hagness M, Hartmann A. Single transplanted kidneys from a 90-year-old deceased donor perform acceptably at 1 year. Transplant Proc 2011; 43:2107-9. [PMID: 21693337 DOI: 10.1016/j.transproceed.2011.01.192] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Accepted: 01/19/2011] [Indexed: 11/29/2022]
Abstract
Most centers are reluctant to accept expanded criteria donors above 70 to 75 years of age. We accepted kidneys from a 90-year-old male and report the 1-year outcome. The kidneys were used as single transplants and both had immediate graft function. Recipient A was a 71-year-old male, with cold ischemia time of 4 hours 49 minutes. One rejection was successfully treated with intravenous methylprednisolone. At 1 year, serum creatinine was 146 μmol/L with estimated glomerular filtration rate (eGFR) 41 mL/min. Recipient B was a 79-year-old male with known panel-reactive antibody positivity prior to transplantation. Cold ischemia time was 10 hours 4 minutes. He experienced no rejections. At 1 year serum-creatinine was 99 μmol/L with eGFR 63 mL/min. Both recipients performed a surveillance biopsy at 1 year with identical findings: interstitial fibrosis and tubular atrophy grade 1 with moderate to severe arteriolosclerosis. We conclude that both kidneys performed acceptably 1 year after engraftment. The use of old kidneys in old recipients gives them a properly functioning kidney and improves quality of life. Longer observation is needed.
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Affiliation(s)
- K Midtvedt
- Department of Specialized Medicine and Surgery, Oslo University Hospital Rikshospitalet, Oslo, Norway.
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30
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Veroux M, Grosso G, Corona D, Mistretta A, Giaquinta A, Giuffrida G, Sinagra N, Veroux P. Age is an important predictor of kidney transplantation outcome. Nephrol Dial Transplant 2011; 27:1663-71. [PMID: 21926404 DOI: 10.1093/ndt/gfr524] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Donor and recipient age may have an impact on the renal transplant outcome. Kidney transplantation from older donors may result in a worse outcome, and the survival benefit of kidney transplantation compared with dialysis may be reduced. The aim of this study was to evaluate the impact of donor and recipient age on kidney transplant outcome. MATERIALS AND METHODS Two hundred and twenty-three recipients of kidney transplants performed at our institution between 2002 and 2007 were analysed. The role of donor and recipient age matching on survival rate were investigated performing the Kaplan-Meier survival time analysis by decades, considering the donor's age of 60 and 70 years. The Cox proportional hazard uni- and multivariate regressions were also performed. Finally, Kaplan-Meier survival time analysis was performed to assess survival rates of patients transplanted stratified by donor age compared with wait-listed renal transplant candidates. RESULTS Elderly recipients had a significant lower graft and patient survival as well as a significantly higher risk of graft loss and patient death. Recipients younger and older than 65 years of age were at higher risk of graft loss if they received grafts from donors>65 years [hazard ratio (HR)=2.59, 95% confidence interval (CI): 1.12-6 and HR=5.65, 95% CI: 2.31-13.79, respectively]. Elderly recipients displayed a worse survival compared with transplant candidates on the waiting list. CONCLUSIONS Age is an important predictor of kidney transplantation outcome. Kidney transplantation does not offer a significant survival benefit in the intermediate term, compared to the waiting list, to elderly recipients transplanted with grafts from older donors. However, it cannot be excluded that it is still possible that there is a long-term benefit of transplantation over dialysis in this group of patients.
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Affiliation(s)
- Massimiliano Veroux
- Department of Surgery, Transplantation and Advanced Technologies, Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, Catania, Italy.
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Single-center experience with kidney transplantation using deceased donors older than 75 years. Transplantation 2011; 92:76-81. [PMID: 21546867 DOI: 10.1097/tp.0b013e31821d2687] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Gavela E, Pallardó LM, Avila A, Sancho A, Beltrán S, Kanter J, Crespo JF. Renal allografts from donors older than 70 years are useful for single transplantation. Transplant Proc 2010; 41:2047-9. [PMID: 19715828 DOI: 10.1016/j.transproceed.2009.05.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Kidney transplantation has been related in elderly recipients to a greater longevity compared with dialysis. Due to the scarcity of donors, transplantation of older patients depends on the acceptance of older donors. We compared the characteristics and evolution of transplants from donors >or=70 years (n = 53) with those from donors >55-<70 years (n = 201). Group D >or=70 included older recipients (65.37 +/- 4.9 vs 55.92 +/- 9.66 years; P = .000) and more women (62.3% vs 45.3%; P = .02), with more peripheral arterial disease (10.9% vs 2.4%; P = .011). No differences in donor characteristics were observed. Induction treatment with thymoglobulin or basiliximab was more common in D >or=70 (81.1% vs 57.3%; P = .006), with no differences in other immunosuppressive drugs. The incidence of delayed graft function (DGF) was similar (P = .82), with a trend to a lower incidence of acute rejection episodes among D>or=70 (11.8% vs 22.5%; P = 0.09). Serum creatinine and proteinuria levels did not differ during follow-up (P > .05). Patients in D >or=70 displayed more episodes of urinary sepsis (19.1% vs 6.4%; P = .008), but no differences were observed in cytomegalovirus (CMV) infection (P = .629), neoplasia (P = .118), ischemic cardiopathy (P = .642), or hospital readmission due to infections (P = .567). Graft survivals at 5 years were 70% and 75% (P = .279) among groups D >or=70 and D>55-<70, respectively, and patient survivals at 5 years were 88% and 88% (P = .63), respectively. In conclusion, our study showed that selected kidneys from donors older than 70 years were followed with excellent graft and patient survivals, permitting older patients on renal replacement therapy to benefit from renal transplantation.
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Affiliation(s)
- E Gavela
- Nephrology Department, Hospital Universitario Dr Peset, Valencia, Spain.
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Heldal K, Hartmann A, Grootendorst DC, de Jager DJ, Leivestad T, Foss A, Midtvedt K. Benefit of kidney transplantation beyond 70 years of age. Nephrol Dial Transplant 2009; 25:1680-7. [PMID: 20038521 PMCID: PMC2856560 DOI: 10.1093/ndt/gfp681] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background. Kidney transplantation generally improves long-term survival in patients with end-stage renal disease. However, in patients older than 70 years of age, only limited data are available that directly compare the potential survival benefit of transplantation versus dialysis. Methods. All patients aged above 70 years who started dialysis between 1990 and 2005 and were waitlisted for kidney transplantation were included in the study. They were categorized according to time periods of inclusion (1990–99 vs 2000–05). Survival rates of altogether 286 dialysis patients were analyzed with a Kaplan–Meier model, as well as with a time-dependent Cox model. Comparisons were made between those who received a transplant and those who did not, and further between the two time periods. Results. Median age at inclusion was 73.6 years (interquartile range 72.3–75.6). Two hundred and thirty-three patients (81%) received a kidney transplant during follow-up. Transplant recipients experienced an increased mortality in the first year after transplantation when compared to waitlisted patients. Patients starting dialysis between 1990 and 1999 had no significant long-term benefit of transplantation; HR for death 1.01 (0.58–1.75). In contrast, there was a substantial long-term benefit of transplantation among those starting dialysis after 2000; HR for death 0.40 (0.19–0.83), P = 0.014. Conclusions. Survival after kidney transplantation in patients over 70 years has improved during the last decade and offers a survival advantage over dialysis treatment. Our experience supports the use of kidney transplantation in this age group if an increased early post-operative risk is accepted. This transplant policy may be challenged for priority reasons.
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Affiliation(s)
- Kristian Heldal
- Section of Nephrology and Endocrinology, Clinic of Internal Medicine, Sykehuset Telemark, Norway.
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Bayat S, Kessler M, Briancon S, Frimat L. Survival of transplanted and dialysed patients in a French region with focus on outcomes in the elderly. Nephrol Dial Transplant 2009; 25:292-300. [DOI: 10.1093/ndt/gfp469] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Schlanger LE, Bailey JL, Sands JM. Geriatric Nephrology: Old or New Subspecialty. Clin Geriatr Med 2009; 25:311-24. [DOI: 10.1016/j.cger.2009.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Over the last 5 years, a number of utility-based allocation systems have been proposed in an effort to increase the life-prolonging potential of deceased donor kidneys in the United States. These have included various adaptations of age-matching and net benefit, including the Eurotransplant Senior Program, Life Years From Transplant, and several systems for avoiding extreme donor/recipient mismatch. However, utility-based allocation is complex and raises issues regarding choice of metric, appropriateness of certain factors for use in allocation, accuracy of prediction models, transparency and perception, and possible effects on donation rates. Changing the role of utility in kidney allocation will likely cause changes to efficiency, equity, predictability, autonomy, controversy, trust and live donation. In this manuscript, various allocation systems are discussed, and a framework is proposed for quantifying the goals of the transplant community and evaluating options for utility-based kidney allocation in this context.
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Affiliation(s)
- D L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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