Access to kidney transplantation among the elderly in the United States: a glass half full, not half empty

Trends in Patient Characteristics on the Japanese Waiting Lists for Deceased-Donor Kidney Transplantation. Are There no Eligibility or Ineligibility Criteria for Registration and Renewal?

BACKGROUND

Controversial issues in registering candidates for deceased-donor kidney transplantation (DDKT) comprise various factors, including age, life expectancy, and dialysis duration. We investigated patient characteristics on the waiting list and discussed suitable criteria in Japan, which has a long waiting period.

METHODS

This study included 592 patients on the waiting list for DDKT at our institute between 1982 and 2023. We retrospectively reviewed patients' medical charts and obtained their clinical information. Patient characteristics according to outcomes and eligibility criteria for applying for or renewing registration were investigated. No prisoners were used in the study, and the participants were neither coerced nor paid.

RESULTS

Approximately 70%, 45%, and 14.5% of the registered patients were aged >60, >70, and 80 years, respectively. The number of patients aged ≥70 years gradually decreased over time. The median waiting periods of patients who underwent and interrupted DDKT were 13 and 7 years, respectively. Patients in their 70s with a >15-year dialysis period tended to have opportunities for DDKT. Living-donor kidney transplantation was performed in patients aged <60 years. Waiting patients were significantly younger and had a shorter dialysis duration. Advanced age at registration was associated with a significantly high risk of interruption.

CONCLUSIONS

Advanced age and longer dialysis periods were considered at registration because patients with these factors tended to experience interruptions despite the long waiting period and high cost. Although older patients can undergo DDKT, factors including surgical cost and risks are considered. Eligibility/ineligibility criteria should be established for DDKT waiting lists in Japan.

Organization of Post-Transplant Care and the 5-Year Outcomes of Kidney Transplantation

The outcomes of kidney transplantation depend on numerous factors and vary between transplant centers. The aim of this study is to assess the relationship between selected organizational factors, comorbidities, and patient and graft survival. This is a retrospective analysis of 438 renal transplant recipients (RTR) followed for 5 years. Patient and graft survival were evaluated in relation to hospitalization length, distance from the patient's residence to the transplant center, the frequency of outpatient transplant visits, and the number and type of comorbidities. Five-year patient and graft survival rates were 93% and 90%, respectively. We found significant associations of patient survival with the prevalence of pre-transplant diabetes, cardiovascular diseases, malignancies, the number of comorbidities, and the first post-transplant hospitalization length. The incidence of infections, cardiovascular diseases, and transplanted kidney diseases was 60%, 40%, and 33%, respectively. As many as 41% of RTR had unknown etiology of primary kidney disease. In conclusion, the organization of post-transplant care needs to be adapted to the multi-morbidity of contemporary RTR and include multi-specialist care, especially in the context of current problems related to the COVID-19pandemic. The high proportion of patients with undetermined etiology of their primary renal disease carry the risk for additional complications during their long-term follow-up.

The beneficial effect of providing kidney transplantation information on transplantation status differs between for-profit and nonprofit dialysis centers

Informing end-stage kidney disease patients about kidney transplantation options increases the likelihood of kidney transplant waiting list (WL) enrollment and live donor kidney transplant (LDKT) receipt. Patients in for-profit dialysis centers have lower rates of WL enrollment and LDKT receipt. This study examined if the ownership status of dialysis centers modified the association between informing patients about transplantation options and patients' transplantation status. Multilevel analysis using mixed-effect multinomial logistic regression was performed using the United States Renal Data System (USRDS) data (January 2005 to December 2017). The study showed that informing patients improved the odds of WL enrollment and LDKT receipt. However, the effect of informing patients on transplantation status was less pronounced at for-profit as compared with nonprofit centers (Nonprofit: WL enrollment OR: 2.23 [95% CI: 2.07-2.40], and LDKT receipt OR: 3.35 [95% CI: 2.65-4.25]. For-profit: WL enrollment OR: 1.73 [95% CI: 1.66-1.79], and LDKT receipt OR: 2.35 [95% CI: 2.08-2.66]), although the odds of informing patients was higher for for-profit centers, and type of patients informed were similar across both types of centers. Information provided by for-profit centers was potentially less effective than those provided by nonprofit centers. Standardized guidelines for transplantation information provision are needed in order to ensure similar informational quality across centers.

Frailty and Kidney Transplantation: A Systematic Review and Meta-analysis

Frailty is a multidimensional condition and is the result of the body's age-associated decline in physical, cognitive, physiological, and immune reserves. The aim of this systematic review is to assess the quality of evidence of the included studies, determine the prevalence of frailty among kidney transplant candidates, and evaluate the relationship between frailty and associated patient characteristics and outcomes after kidney transplantation.

METHODS

A systematic search was performed for relevant literature on frailty and kidney transplantation. This was followed by a meta-analysis for patient characteristics and outcomes reported by a minimum of 2 studies including mean age, gender, mean body mass index, type of kidney transplantation, dialysis, previous kidney transplantation, comorbidities, hypertension, race, preemptive kidney transplantation, delayed graft function, and length of stay.

RESULTS

A total of 18 studies were included in the systematic review and 14 of those studies were suitable for meta-analysis. The overall pooled prevalence of frailty before transplantation was estimated at 17.1% (95% confidence interval [CI], 15.4-18.7). Frailty was significantly associated with higher age (mean difference, 3.6; 95% CI, 1.4-5.9), lower rate of preemptive transplantation (relative risk, 0.60; 95% CI, 0.4-0.9), longer duration of delayed graft function (relative risk, 1.80; 95% CI, 1.1-3.0), and length of stay longer than 2 wk (odds ratio, 1.64; 95% CI, 1.2-2.3).

CONCLUSIONS

One in 6 kidney transplant recipients is frail before transplantation. The presence of frailty is associated with lower rates of preemptive transplantation, older recipient age, higher rates of delayed graft function, and longer length of stay. Future research is required to explore the association of frailty with other adverse outcomes after kidney transplantation and the effects of intervention programs to improve the different frailty domains.

Outcomes in Older Kidney Transplant Recipients After Prior Nonkidney Transplants

BACKGROUND

Recipients of nonkidney solid organ transplants (nkSOT) are living longer, and 11%-18% will develop end stage renal disease (ESRD). While our general inclination is to treat nkSOT recipients who develop ESRD with a kidney transplant (KT), an increasing number are developing ESRD at an older age where KT may not be the most appropriate treatment. It is possible that the risk of older age and prior nkSOT might synergize to make KT too risky, but this has never been explored.

METHODS

To examine death-censored graft loss and mortality for KT recipients with and without prior nkSOT, we used Scientific Registry of Transplant Recipients data to identify 42 089 older (age ≥65) KT recipients between 1995 and 2016. Additionally, to better understand treatment options for these patients and survival benefit of KT, we identified 5023 older (age ≥65) with prior nkSOT recipients listed for subsequent KT, of whom 863 received transplants.

RESULTS

Compared with 41 159 older KT recipients without prior nkSOT, death-censored graft loss was similar (adjusted hazard ratio [aHR]: 1.13, 95% CI: 0.93-1.37, P = 0.2), but mortality (aHR: 1.40, 95% CI: 1.28-1.54, P < 0.001) was greater for older KT recipients with prior nkSOT. Nonetheless, in a survival benefit model (survival with versus without the transplant), among older prior nkSOT recipients, KT decreased the risk of mortality by more than half (aHR: 0.47, 95% CI: 0.42-0.54, P < 0.001).

CONCLUSIONS

Older prior nkSOT recipients who subsequently develop ESRD derive survival benefit from KT, but graft longevity is limited by overall survival in this population. These findings can help guide patient counseling for this challenging population.

NK Cells Contribute to the Immune Risk Profile in Kidney Transplant Candidates

Background: A previously proposed immune risk profile (IRP), based on T cell phenotype and CMV serotype, is associated with mortality in the elderly and increased infections post-kidney transplant. To evaluate if NK cells contribute to the IRP and if the IRP can be predicted by a clinical T cell functional assays, we conducted a cross sectional study in renal transplant candidates to determine the incidence of IRP and its association with specific NK cell characteristics and ImmuKnow® value.

Material and Methods: Sixty five subjects were enrolled in 5 cohorts designated by age and dialysis status. We determined T and NK cell phenotypes by flow cytometry and analyzed multiple factors contributing to IRP.

Results: We identified 14 IRP+ [CMV seropositivity and CD4/CD8 ratio < 1 or being in the highest quintile of CD8+ senescent (28CD–/CD57+) T cells] individuals equally divided amongst the cohorts. Multivariable linear regression revealed a distinct IRP+ group. Age and dialysis status did not predict immune senescence in kidney transplant candidates. NK cell features alone could discriminate IRP– and IRP+ patients, suggesting that NK cells significantly contribute to the overall immune status in kidney transplant candidates and that a combined T and NK cell phenotyping can provide a more detailed IRP definition. ImmuKnow® value was negatively correlated to age and significantly lower in IRP+ patients and predicts IRP when used alone or in combination with NK cell features.

Conclusion: NK cells contribute to overall immune senescence in kidney transplant candidates.

Influence of gender and age on haemodialysis practices: a European multicentre analysis

Background

Women of all ages and elderly patients of both genders comprise an increasing proportion of the haemodialysis population. Worldwide, significant differences in practice patterns and treatment results exist between genders and among younger versus older patients. Although efforts to mitigate sex-based differences have been attempted, significant disparities still exist.

Methods

This retrospective cohort study included all 1247 prevalent haemodialysis patients in DaVita units in Portugal (five dialysis centres, n = 730) and Poland (seven centres, n = 517). Demographic data, dialysis practice patterns, vascular access prevalence and the achievement of a variety of Kidney Disease: Improving Global Outcomes (KDIGO) treatment targets were evaluated in relation to gender and age groups.

Results

Body weight and the prescribed dialysis blood flow rate were lower in women (P < 0.001), whereas treated blood volume per kilogram per session was higher (P < 0.01), resulting in higher single-pool Kt/V in women than in men (P < 0.001). Haemoglobin was significantly higher in men (P = 0.01), but the proportion of patients within target range (10–12 g/dL) was similar. Men more often had an arteriovenous fistula than women (80% versus 73%; P < 0.01) with a similar percentage of central venous catheters. There were no gender-specific differences in terms of dialysis adequacy, anaemia parameters or mineral and bone disorder parameters, or in the attainment of KDIGO targets between women and men >80 years of age.

Conclusions

This large, multicentre real-world analysis indicates that haemodialysis practices and treatment targets are similar for women and men, including the most elderly, in DaVita haemodialysis clinics in Europe.

A comparative analysis of survival of patients on dialysis and after kidney transplantation

Background

Kidney transplant survival benefits are not observed for around 8 months after transplantation because of a higher complications rate in early post-transplant periods. This study compares survival of patients awaiting transplantation with survival of transplant recipients and non-listed dialysis patients in Ireland.

Methods

In this retrospective analysis, the relative-risk (RR) of death was assessed with time-dependent, non-proportional hazards analysis, with adjustment for age, cause of end-stage kidney disease (ESKD), time from first treatment for ESKD to placement on the waiting list and year of initial placement on the list.

Results

A total of 3597 patients were included. Annual death rates per 100 patient-years at risk for all patients on dialysis, waiting-list patients and transplant recipients were 16.5, 2.4 and 1.2, respectively. Death rate was highest among diabetics. The relative risk of death for all patients on dialysis was five times higher than the waiting-list patients [RR, 4.90; 95% confidence interval (CI), 3.70–6.52; P < 0.001]. Time to survival equilibration was 1 year. Thereafter, the 5-year mortality risk was estimated to be 47% lower than that of the patients on the waiting list (RR, 0.53; 95% CI, 0.37–0.77; P = 0.001).

Conclusions

Transplant recipients had a higher risk of death initially, but a better long-term survival. Time to death risk equilibration was longer compared with other studies. This could be explained by better survival rates in our waiting-list cohort.

Perspectives of Older Kidney Transplant Recipients on Kidney Transplantation

BACKGROUND AND OBJECTIVES

Older kidney transplant recipients are susceptible to cognitive impairment, frailty, comorbidities, immunosuppression-related complications, and chronic graft failure, however, there has been limited focus on their concerns and expectations related to transplantation. This study aims to describe the perspectives of older kidney transplant recipients about their experience of kidney transplantation, self-management, and treatment goals to inform strategies and interventions that address their specific needs.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Face-to-face semistructured interviews were conducted with 30 kidney transplant recipients aged 65-80 years from five renal units in Australia. Transcripts were analyzed thematically.

RESULTS

Six themes were identified: restoring vitality of youth (with subthemes of revived mindset for resilience, embracing enjoyment in life, drive for self-actualization); persisting through prolonged recovery (yielding to aging, accepting functional limitations, pushing the limit, enduring treatment responsibilities); imposing sicknesses (combatting devastating comorbidities, painful restrictions, emerging disillusionment, anxieties about accumulating side effects, consuming treatment burden); prioritizing graft survival (privileged with a miracle, negotiating risks for longevity, enacting a moral duty, preserving the last opportunity); confronting health deterioration (vulnerability and helplessness, narrowing focus to immediate concerns, uncertainty of survival); and value of existence (purpose through autonomy, refusing the burden of futile treatment, staying alive by all means).

CONCLUSIONS

Older kidney transplant recipients felt able to enjoy life and strived to live at their newly re-established potential and capability, which motivated them to protect their graft. However, some felt constrained by slow recuperation and overwhelmed by unexpected comorbidities, medication-related side effects, and health decline. Our findings suggest the need to prepare and support older recipients for self-management responsibilities, clarify their expectations of post-transplant risks and outcomes, and provide assistance through prolonged recovery after kidney transplantation.

Prehabilitation in our most frail surgical patients: are wearable fitness devices the next frontier?

PURPOSE OF REVIEW

Frailty is the concept of accumulating physiologic declines that make people less able to deal with stressors, including surgery. Prehabilitation is intervention to enhance functional capacity before surgery. Frailty and prehabilitation among transplant populations and the role of wearable fitness tracking devices (WFTs) in delivering fitness-based interventions will be discussed.

RECENT FINDINGS

Frailty is associated with increased complications, longer length of hospital stay and increased mortality after surgery. Frail kidney transplant patients have increased delayed graft function, mortality and early hospital readmission. Frail lung or liver transplant patients are more likely to delist or die on the waitlist. Prehabilitation can mitigate frailty and has resulted in decreased length of hospital stay and fewer postsurgical complications among a variety of surgical populations. Increasingly, WFTs are used to monitor patient activity and improve patient health. Interventions using WFTs have resulted in improved activity, weight loss and blood pressure.

SUMMARY

Frailty is a measurable parameter that identifies patients at risk for worse health outcomes and can be mitigated through intervention. Prehabilitation to reduce frailty has been shown to improve postsurgical outcomes in a variety of populations. WFTs are being integrated in healthcare delivery for monitoring and changing health behavior with promising results.

Predialysis nephrology care and dialysis-related health outcomes among older adults initiating dialysis

BACKGROUND

Predialysis nephrology care is associated with lower mortality and rates of hospitalization following chronic dialysis initiation. Whether more frequent predialysis nephrology care is associated with other favorable outcomes for older adults is not known.

METHODS

Retrospective cohort study of patients ≥66 years who initiated chronic dialysis in 2000-2001 and were eligible for VA and/or Medicare-covered services. Nephrology visits in VA and/or Medicare during the 12-month predialysis period were identified and classified by low intensity (<3 visits), moderate intensity (3-6 visits), and high intensity (>6 visits). Outcome measures included very low estimated glomerular filtration rate, severe anemia, use of peritoneal dialysis, and receipt of permanent vascular access at dialysis initiation and death and kidney transplantation within two years of initiation. Generalized linear models with propensity score weighting were used to examine the association between nephrology care and outcomes.

RESULTS

Among 58,014 patients, 46 % had none, 22 % had low, 13 % had moderate, and 19 % had high intensity predialysis nephrology care. Patients with a greater intensity of predialysis nephrology care had more favorable outcomes (all p < 0.001). In adjusted models, patients with high intensity predialysis nephrology care were less likely to have severe anemia (RR = 0.70, 99 % CI: 0.65-0.74) and more likely to have permanent vascular access (RR = 3.60, 99 % CI: 3.42-3.79) at dialysis initiation, and less likely to die within two years of dialysis initiation (RR = 0.80, 99 % CI: 0.77-0.82).

CONCLUSION

In a large cohort of older adults treated with chronic dialysis, greater intensity of predialysis nephrology care was associated with more favorable outcomes.

'I feel stronger and younger all the time'-perspectives of elderly kidney transplant recipients: thematic synthesis of qualitative research

BACKGROUND

Kidney transplantation offers improved survival and quality of life to an increasing number of elderly patients with end-stage kidney disease. However, elderly kidney transplant recipients may face unique challenges due to a higher burden of comorbidity, greater cumulative risk of immunosuppression-related complications and increasing frailty. We aimed to describe the perspectives of elderly kidney transplant recipients.

METHODS

Electronic databases were searched to April 2015. Qualitative studies were eligible if they reported views from elderly kidney transplant recipients (≥60 years). Thematic synthesis was used to analyse the findings.

RESULTS

Twenty-one studies involving >116 recipients were included. We identified seven themes. 'Regaining strength and vitality' meant valuing the physical and psychosocial improvements in daily functioning and life participation. 'Extending life' was the willingness to accept any organ, including extended criteria kidneys, to prolong survival. 'Debt of gratitude' entailed conscious appreciation toward their donor while knowing they were unable to repay their sacrifice. 'Moral responsibility to maintain health' motivated adherence to medication and lifestyle recommendations out of an ethical duty to protect their gift for graft survival. 'Unabating and worsening forgetfulness' hindered self-management. 'Disillusionment with side effects and complications' reflected disappointment and exasperation with the unintended consequences of medications. 'Finality of treatment option' was an acute awareness that the current transplant may be their last.

CONCLUSIONS

Kidney transplantation was perceived to slow and even reverse the experience of aging among elderly recipients, especially compared with dialysis. However, some were frustrated over persistent limitations after transplant, struggled with the burden of medication side effects and worried about a possible return to dialysis if the transplant failed. Clarifying patient expectations of transplantation, providing support to alleviate the debilitating impacts of immunosuppression and addressing fears about deteriorating health and graft failure may improve satisfaction and outcomes in elderly kidney transplant recipients.

[Management of older patients following solid organ transplantation]

Due to a continuous expansion of transplantation registers, such as the old-for-old program in Europe, the number of older patients treated with transplantation is increasing. At the same time the perioperative survival rates show a clear increase even in this patient collective (older than 65 years); therefore, the probability that the care of older patients after organ transplantation will be undertaken in the routine practice increases. This article describes the medical characteristics of older patients following organ transplantation. Special emphasis is placed on the management of accompanying diseases as well as possible side effects and interactions of immunosuppressive therapy.

The changing trends and outcomes in renal replacement therapy: data from the ERA-EDTA Registry

BACKGROUND

This study examines the time trends in incidence, prevalence, patient and kidney allograft survival and causes of death (COD) in patients receiving renal replacement therapy (RRT) in Europe.

METHODS

Eighteen national or regional renal registries providing data to the European Renal Association-European Dialysis and Transplant Association Registry between 1998 and 2011 were included. Incidence and prevalence time trends between 2001 and 2011 were studied with Joinpoint and Poisson regression. Patient and kidney allograft survival and COD between 1998 and 2011 were analysed using Kaplan-Meier and competing risk methods and Cox regression.

RESULTS

From 2001 to 2008, the adjusted incidence of RRT rose by 1.1% (95% CI: 0.6, 1.7) annually to 131 per million population (pmp). During 2008-2011, the adjusted incidence fell by 2.2% (95% CI: -4.2, -0.2) annually to 125 pmp. This decline occurred predominantly in patients aged 45-64 years, 65-74 years and in the primary renal diseases diabetes mellitus type 1 and 2, renovascular disease and glomerulonephritis. Between 2001 and 2011, the overall adjusted prevalence increased from 724 to 1032 pmp (+3.3% annually, 95% CI: 2.8, 3.8). The adjusted 5-year patient survival on RRT improved between 1998-2002 and 2003-2007 [adjusted hazard ratio (HRa) 0.85, 95% CI: 0.84, 0.86]. Comparing these time periods, the risk of cardiovascular deaths fell by 25% (HRa 0.75, 95% CI: 0.74, 0.77). However the risk of malignant death rose by 9% (HRa 1.09, 95% CI: 1.03, 1.16) in patients ≥65 years.

CONCLUSION

This European study shows a declining RRT incidence, particularly in patients aged 45-64 years, 65-74 years and secondary to diabetic nephropathy. Encouragingly, the adjusted RRT patient survival continues to improve. The risk of cardiovascular death has decreased, though the risk of death from malignancy has increased in the older population.

Cost of renal replacement: how to help as many as possible while keeping expenses reasonable?

The treatment of kidney diseases consumes a substantial amount of the health budget for a relatively small fraction of the overall population. If the nephrological community and society do not develop mechanisms to contain those costs, it will become impossible to continue assuring optimal outcomes and quality of life while treating all patients who need it. In this article, we describe several mechanisms to maintain sustainability of renal replacement therapy. These include (i) encouragement of transplantation after both living and deceased donation; (ii) stimulation of alternative dialysis strategies besides classical hospital haemodialysis, such as home haemodialysis, peritoneal dialysis or self-care and necessitating less reimbursement; (iii) promotion of educational activities guiding the patients towards therapies that are most suited for them; (iv) consideration of one or more of cost containment incentives such as bundling of reimbursement (if not affecting quality of the treatment), timely patient referral, green dialysis, start of dialysis based on clinical necessity rather than renal function parameters and/or prevention of CKD or its progression; (v) strategically planned adaptations to the expected growth of the ageing population in need of renal replacement; (vi) the necessity for support of research in the direction of helping as large as possible patient populations for acceptable costs; and (vii) the need for more patient-centred approaches. We also extend the discussion to the specific situation of kidney diseases in low- and middle-income countries. Finally, we point to the dramatic differences in accessibility and reimbursement of different modalities throughout Europe. We hope that this text will offer a framework for the nephrological community, including patients and nurses, and the concerned policy makers and caregivers on how to continue reaching all patients in need of renal replacement for affordable expenses.

Optimizing outcomes in the elderly with end-stage renal disease--live long and prosper

BACKGROUND

The elderly form an expanding proportion of patients with chronic kidney disease and end-stage renal disease worldwide. The increased physiological frailty and functional morbidity associated with the aging process pose unique challenges when planning optimal management of an older patient needing renal replacement therapy (RRT).

AIMS

This position paper discusses current evidence regarding the optimal management of end-stage renal disease in the elderly with an emphasis on hemodialysis since it is the most common modality used in older patients. Further research is needed to define relevant patient-reported outcome measures for end-stage renal disease including functional assessments and psychological impacts of various forms of RRT. For those older patients who have opted for dialysis treatment, it is important to study the strategies that encourage greater uptake of home-based dialysis therapies and optimal vascular access.

CONCLUSIONS

The management of advanced chronic kidney disease in the elderly can be challenging but also extremely rewarding. The key issue is adopting a patient-focused and individualized approach that seeks to achieve the best outcomes based on a comprehensive holistic assessment of what is important to the patient.

Renal Transplantation in Recipients Older Than 65 Years: Retrospective Analysis of the Results of a 4-year (2008-2012) Experience

BACKGROUND

We analyze the results of renal transplantation among recipients older than 65 years old over a 4-year period (2008-2012) from a single renal transplantation unit and compare results with younger recipients.

METHODS

We retrospectively analyzed the outcomes of 2018 renal transplantations performed between November 2008 and December 2012. The χ(2) test was used for the comparison of categorical data, and the Student t test was used for the analysis of continuous variables. Patient and graft cumulative actuarial survivals were calculated using the Kaplan-Meier analysis and we tested for differences with the Mantel-Cox log-rank test.

RESULTS

Seventy-five (3.7%) recipients were aged ≥ 65 years with a median age of 68 (range, 65 to 82) years. Actuarial graft survivals at 1, 2, and 3 years were 93.8%, 92.5%, and 90.3%, respectively, for the <65 group and 89.7%, 88.1%, and 83.1%, respectively, for the ≥ 65 group (P < .03). Actuarial patient survivals at 1, 2, and 3 years were 96.3%, 95.5%, and 94.7%, respectively, for the younger and 91.8%, 90.2%, and 88%, respectively, for the older samples (P < .03). When graft survival was censored for patient death with a functioning kidney at 1, 2, and 3 years, the results were similar between groups with 95.5%, 94%, and 92.8%, respectively, for recipients aged <65 years and 94.7%, 89.2%, and 89.2%, respectively, for recipients aged ≥ 65 years (P = .213).

CONCLUSIONS

Our results showed that renal transplantation in selected patients older than 65 years was associated with good outcomes; this indicates that it seems safe and effective to treat end-stage renal disease in the elderly knowing there are acceptable rates of graft and patient survival.

Rates of renal transplantations in the elderly-data from Europe and the US

The demography in most part of the world is changing with an increasing proportion of elderly persons. This is expected to reflect demography of patients accepted for renal replacement therapy both in the form of dialysis and transplantation. Based on this, the intention of the present review is to collect and describe available data on rates of transplantation with focus on the elderly patients in both Europe and the US. Data were collected from available sources including activity reports from national and supranational registries on uremia, organ procurement, waiting lists, and transplantations. Since 1990 both absolute numbers and proportions of elderly patients starting renal replacement therapy have increased dramatically in both Europe and the US. Although the pattern of changes is similar in Europe and the US, the incidence and prevalence rates for renal replacement therapy in the elderly are 3-4 times higher in the US. In the same period, the rates of renal transplantations in the elderly patient group have increased in both Europe and the US with increased access to the waiting list and to transplantation. Data from the United States Renal Data System on incidence of transplantation document a substantial increase in proportion of elderly transplant recipients (65+ years) from 4.2% in 1990 to 17.2% in 2012 and an increase in proportion of prevalent elderly renal transplant patients from 3.8% in 1992 to 23.3% in 2012. Similar changes have been seen in Europe. Due to these alterations in the demography of the transplant patients in both Europe and the US it is concluded that the elderly transplant patient from being a rare patient has now become a common patient necessitating increased focus on this group in order to optimize treatment results.

A simple clinical tool to inform the decision-making process to refer elderly incident dialysis patients for kidney transplant evaluation

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.

Dialysis facility and network factors associated with low kidney transplantation rates among United States dialysis facilities

Variability in transplant rates between different dialysis units has been noted, yet little is known about facility-level factors associated with low standardized transplant ratios (STRs) across the United States End-stage Renal Disease (ESRD) Network regions. We analyzed Centers for Medicare & Medicaid Services Dialysis Facility Report data from 2007 to 2010 to examine facility-level factors associated with low STRs using multivariable mixed models. Among 4098 dialysis facilities treating 305 698 patients, there was wide variability in facility-level STRs across the 18 ESRD Networks. Four-year average STRs ranged from 0.69 (95% confidence interval [CI]: 0.64-0.73) in Network 6 (Southeastern Kidney Council) to 1.61 (95% CI: 1.47-1.76) in Network 1 (New England). Factors significantly associated with a lower STR (p < 0.0001) included for-profit status, facilities with higher percentage black patients, patients with no health insurance and patients with diabetes. A greater number of facility staff, more transplant centers per 10 000 ESRD patients and a higher percentage of patients who were employed or utilized peritoneal dialysis were associated with higher STRs. The lowest performing dialysis facilities were in the Southeastern United States. Understanding the modifiable facility-level factors associated with low transplant rates may inform interventions to improve access to transplantation.

Kidneys at higher risk of discard: expanding the role of dual kidney transplantation

Half of the recovered expanded criteria donor (ECD) kidneys are discarded in the United States. A new kidney allocation system offers kidneys at higher risk of discard, Kidney Donor Profile Index (KDPI)>85%, to a wider geographic area to promote broader sharing and expedite utilization. Dual kidney transplantation (DKT) based on the KDPI is a potential option to streamline allocation of kidneys which otherwise would have been discarded. To assess the clinical utility of the KDPI in kidneys at higher risk of discard, we analyzed the OPTN/UNOS Registry that included the deceased donor kidneys recovered between 2002 and 2012. The primary outcomes were allograft survival, patient survival and discard rate based on different KDPI categories (<80%, 80-90% and >90%). Kidneys with KDPI>90% were associated with increased odds of discard (OR=1.99, 95% CI 1.74-2.29) compared to ones with KDPI<80%. DKTs of KDPI>90% were associated with lower overall allograft failure (HR=0.74, 95% CI 0.62-0.89) and better patient survival (HR=0.79, 95% CI 0.64-0.98) compared to single ECD kidneys with KDPI>90%. Kidneys at higher risk of discard may be offered in the up-front allocation system as a DKT. Further modeling and simulation studies are required to determine a reasonable KDPI cutoff percentile.

Older patients/older donors: choosing wisely

Two lingering problems regarding transplantation in older adults have been how to select patients appropriately and whether to use older sibling donors. Allogeneic hematopoietic cell transplantation (HCT) of older patients may result in long-term survival due to GVL, but the data remain observational and mostly restricted to those 50 to 69 years of age. Patients with excellent performance status and low comorbidity have the best long-term survival after HCT. Novel measures of health status such as self-report or performance-based functional measures allow “staging the age” and may inform candidacy for less robust patients. Older matched sibling donors should be preferred over matched unrelated donors (MUDs) because outcomes are equivalent to superior for matched sibling donors compared with MUD. However, MUDs also achieve acceptable outcomes and long-term disease control. An alternative donor can be considered based on institutional protocols and expertise. Very limited information is available in patients or related donors 70 years of age and older. Future efforts to more completely characterize patient health status before transplantation will allow better application of HCT in older adults.

Access to renal transplantation for the elderly in the face of new allocation policy: a review of contemporary perspectives on "older" issues

The benefits of renal transplantation have been demonstrated to extend to the elderly. As a result, more seniors have been placed on the kidney transplant wait list and have received renal allografts in recent years. In June 2013 significant amendments to deceased donor kidney allocation policy were approved to be instituted in 2014 with the goal of increasing overall life years and graft years achieved compared to the current system. Going forward, it is conceivable that transplant centers may perceive a need to adjust practice patterns and modify evaluation and listing criteria for the elderly as the proportion of kidneys distributed to this segment of the wait list would potentially decrease under the new system, further increasing wait times. This review examines contemporary perspectives on access to transplantation for seniors and pertinent issues for this subgroup such as wait time, comorbidity, and evaluation and listing practices. Potential approaches to improve the evaluation of elderly patients being considered for transplant and to increase availability of expanded criteria donor (or higher kidney donor profile index) and living donor organ transplant opportunities while maintaining acceptable outcomes for seniors are explored.

Comorbidities and kidney transplant evaluation in the elderly

BACKGROUND/AIMS

The elderly are the fastest growing subpopulation with end-stage renal disease. The goal of our study was to define characteristics of elderly patients who were considered ineligible for transplantation compared to those who were listed.

METHODS

984 patients were referred for evaluation during a 2-year period. Records of patients ≥65 years of age (n = 123) were reviewed. Patients who were listed versus not listed were characterized. Factors associated with waitlisting were determined using standard statistical tools.

RESULTS

Half of elderly transplant candidates were accepted for listing compared to 75.4% of those aged <65 years. In multivariable logistic regression, older age (OR 1.29 per year ≥65, 95% CI 1.14-1.45), coronary artery disease (OR 8.57, 95% CI 2.41-30.53), and poor mobility (OR 13.97, 95% CI 4.76-41.00) were independently associated with denial of listing. The receiver operating characteristic curve showed good discrimination for denial of listing (area under the receiver operating characteristic curve of 0.88).

CONCLUSION

Elderly candidates carry a heavy burden of comorbidities and over half of those evaluated are deemed unsuitable for waitlisting. Better delineation of characteristics associated with suitability for transplant candidacy in the elderly is warranted to facilitate appropriate referrals by physicians and management of expectations in potential candidates.

Quantification of the early risk of death in elderly kidney transplant recipients

To inform decision making regarding transplantation in patients ≥ 65 years, we quantified the early posttransplant risk of death by determining the time to equal risk and equal survival between transplant recipients and wait-listed dialysis patients in the United States between 1995 and 2007 (total n = 25 468). Survival was determined using separate multivariate nonproportional hazards analyses in low-, intermediate- and high-risk cardiovascular risk patients. Compared to wait-listed patients with similar cardiovascular risk, standard criteria (SCD) and expanded criteria (ECD) recipients had a higher risk of death in the perioperative and early-posttransplant period. In contrast, low and intermediate risk living donor (LD) recipients had an immediate survival advantage compared to similar risk wait-listed patients. In all risk groups, transplantation was associated with a long-term survival advantage compared to dialysis, but there were marked differences in time to equal risk of death, and time to equal survival by donor type. For example, survival in high-risk recipients of an LD, SCD and ECD transplant became equal to that in similar risk wait-listed patients 130, 368 and 521 days after transplantation. Early posttransplant mortality risk is eliminated in low- and intermediate-risk patients, and markedly reduced in high-risk patients with LD transplantation.

Older patients/older donors: choosing wisely

Two lingering problems regarding transplantation in older adults have been how to select patients appropriately and whether to use older sibling donors. Allogeneic hematopoietic cell transplantation (HCT) of older patients may result in long-term survival due to GVL, but the data remain observational and mostly restricted to those 50 to 69 years of age. Patients with excellent performance status and low comorbidity have the best long-term survival after HCT. Novel measures of health status such as self-report or performance-based functional measures allow "staging the age" and may inform candidacy for less robust patients. Older matched sibling donors should be preferred over matched unrelated donors (MUDs) because outcomes are equivalent to superior for matched sibling donors compared with MUD. However, MUDs also achieve acceptable outcomes and long-term disease control. An alternative donor can be considered based on institutional protocols and expertise. Very limited information is available in patients or related donors 70 years of age and older. Future efforts to more completely characterize patient health status before transplantation will allow better application of HCT in older adults.

Clinical practice guidelines on wait-listing for kidney transplantation: consistent and equitable?

BACKGROUND

Apparent variability in wait-listing criteria globally has raised concern about inequitable access to kidney transplantation. This study aimed to compare the quality, the scope, and the consistency of international guidelines on wait-listing for kidney transplantation.

METHODS

Electronic databases and guideline registries were searched to December 2011. The Appraisal of Guidelines for Research and Evaluation II instrument and textual synthesis was used to assess and compare recommendations.

RESULTS

Fifteen guidelines published from 2001 to 2011 were included. Methodological rigor and scope were variable. We identified 4 major criteria across guidelines: recipient age and life expectancy, medical criteria, social and lifestyle circumstances, and psychosocial considerations. Whereas some recommendations were consistent, there were differences in age cutoffs, estimated life expectancy (2-5 years), and glomerular filtration rate at listing (15-20 mL/min/1.73 m). Cardiovascular contraindications were broadly defined. Recommended cancer-free periods also varied substantially, and whereas uncontrolled infections were universally contraindicated, human immunodeficiency virus thresholds and adherence to highly active antiretroviral therapy were inconsistent. Most guidelines recommended psychological screening but were not augmented with specific clinical assessment tools.

CONCLUSIONS

Wait-listing recommendations in current guidelines are based on life expectancy, comorbidities, lifestyle, and psychosocial factors. Some recommendations are different across guidelines or broadly defined. There is a case for developing comprehensive, methodologically robust, and regularly updated guidelines on wait-listing for kidney transplantation.

Diagnosis and management of chronic kidney disease in the elderly: a field of ongoing debate

Chronic kidney disease (CKD) is rather common in elderly adults who comprise the fastest growing subset of patients with end-stage renal disease (ESRD). At present, there are no specific guidelines and recommendations regarding early identification and management of elderly with CKD and the current CKD classification system may overestimate its exact prevalence. Screening strategies based either in a more accurate formula of estimation of GFR alone, or preferably in combination with proteinuria are urgently needed in order to raise awareness and to promote early diagnosis of CKD in the elderly. The number of elderly dialysis patients is also increasing and may lead to severe socio-economic problems worldwide. Both hemodialysis and peritoneal dialysis can sustain life, but present various disadvantages. There is a trend for home based dialysis therapies but the results are based on a small number of patients. Recent reports indicate that dialysis may not provide a clear benefit over non-dialysis regarding survival and quality of life issues, especially in the presence of extensive comorbidities. Current practices around the world regarding access to dialysis in the elderly are rather controversial, reflecting each country's health policies and ethical patterns. Although advanced age should not be considered as an absolute contraindication for kidney transplantation, it is not frequently offered in elderly ESRD patients due to the shortage of renal grafts. Global judgment of all physical and mental/psychological issues and full informed consent regarding possible complications are mandatory before listing elderly ESRD patients for kidney transplantation. As scientific evidence is rather scarce, there is an urgent need for prospective studies and an individualized approach for the diagnosis and treatment of the elderly CKD patients, in order to optimize care and improve quality of life in this special population.

Solid-organ transplantation in older adults: current status and future research

An increasing number of patients older than 65 years are referred for and have access to organ transplantation, and an increasing number of older adults are donating organs. Although short-term outcomes are similar in older versus younger transplant recipients, older donor or recipient age is associated with inferior long-term outcomes. However, age is often a proxy for other factors that might predict poor outcomes more strongly and better identify patients at risk for adverse events. Approaches to transplantation in older adults vary across programs, but despite recent gains in access and the increased use of marginal organs, older patients remain less likely than other groups to receive a transplant, and those who do are highly selected. Moreover, few studies have addressed geriatric issues in transplant patient selection or management, or the implications on health span and disability when patients age to late life with a transplanted organ. This paper summarizes a recent trans-disciplinary workshop held by ASP, in collaboration with NHLBI, NIA, NIAID, NIDDK and AGS, to address issues related to kidney, liver, lung, or heart transplantation in older adults and to propose a research agenda in these areas.

Time trend in access to the waiting list and renal transplantation: a comparison of four European countries

BACKGROUND

To examine the time trend and international differences in access to the waiting list and renal transplantation of patients with end-stage kidney disease.

METHODS

We included all patients (n = 30 961) from Austria, Norway, the Netherlands and Scotland who started renal replacement therapy (RRT) between 1995 and 2003 with their kidney transplant waiting list data (until 31 December 2005) and follow-up data on RRT and mortality (until 31 December 2007). The outcome measure was access to the waiting list within 2 years and to a first renal transplant within 4 years from the start of RRT, expressed as incidence per million age-related population (p.m.a.r.p.) per year. To estimate trends over time, mean percentage annual change (MPAC) and 95% confidence interval (CI) were calculated.

RESULTS

In each country, the number of patients starting RRT > 65 years increased significantly over time, whereas the number of renal transplants did not increase to the same extent. Only in Norway were almost all patients on the waiting list transplanted within 4 years of RRT start if they were < 65 years. In patients who started RRT > 65 years, the access to renal transplantation was high in Norway (49 p.m.a.r.p.) and low in Austria ( < 26 p.m.a.r.p.), the Netherlands and Scotland (both < 10 p.m.a.r.p.) but increased significantly in Austria (MPAC = 9.8%; 95% CI = 3.9-16.9) and the Netherlands (MPAC = 9.0%; 95% CI = 3.2-15.0).

CONCLUSION

Only in Norway, virtually all patients on the waiting list < 65 years received a transplant within 4 years after the start of RRT and, remarkably, also most of those > 65 years of age.

With respect to elderly patients: finding kidneys in the context of new allocation concepts

The elderly have benefited from increased access to renal transplantation in recent years. New allocation concepts would shift distribution of kidneys to younger recipients, making expanded criteria and living donor kidneys more relevant for seniors. Current issues impacting expanded criteria donor kidney availability and living donor transplant opportunities for the elderly are explored. It is hoped that the kidney donor profile index will improve risk assessment and utilization of marginal kidneys. The usefulness of procurement biopsy remains controversial. Dual kidney transplantation and machine perfusion appear to be effective mechanisms to increase organ availability. "Old-for-old" allocation systems, donation service area variation and regulatory and reimbursement issues highlight disparities and disincentives affecting expanded criteria donor organ utilization, and considerations for the way forward are discussed. Living donor transplantation, even with older donors, may provide the best option for elderly recipients, and careful expansion of the living donor pool appears appropriate. In light of new allocation concepts, it will be important to understand issues pertinent to seniors and develop effective strategies to maintain or improve their access to the benefits of transplantation.

Optimizing renal replacement therapy in older adults: a framework for making individualized decisions

It is often difficult to synthesize information about the risks and benefits of recommended management strategies in older patients with end-stage renal disease since they may have more comorbidity and lower life expectancy than patients described in clinical trials or practice guidelines. In this review, we outline a framework for individualizing end-stage renal disease management decisions in older patients. The framework considers three factors: life expectancy, the risks and benefits of competing treatment strategies, and patient preferences. We illustrate the use of this framework by applying it to three key end-stage renal disease decisions in older patients with varying life expectancy: choice of dialysis modality, choice of vascular access for hemodialysis, and referral for kidney transplantation. In several instances, this approach might provide support for treatment decisions that directly contradict available practice guidelines, illustrating circumstances when strict application of guidelines may be inappropriate for certain patients. By combining quantitative estimates of benefits and harms with qualitative assessments of patient preferences, clinicians may be better able to tailor treatment recommendations to individual older patients, thereby improving the overall quality of end-stage renal disease care.