Renal transplantation and the older adult patient
- Daniel C Brennan, MD, FACP
Daniel C Brennan, MD, FACP
- Editor-in-Chief — Nephrology
- Section Editor — Renal Transplantation
- Professor of Medicine
- Washington University School of Medicine
- Emilio Ramos, MD, FACP
Emilio Ramos, MD, FACP
- Clinical Associate
- Johns Hopkins School of Medicine
Renal transplantation improves the long-term survival and quality of life of most patients with end-stage renal disease (ESRD), including older patients. However, individual older patients who have significant comorbidities may not live long enough to realize the benefits of transplantation, which are not observed until a number of months to years after transplantation. It is important to carefully evaluate older patients who are being considered for renal transplantation in order to avoid subjecting the patient to an invasive procedure from which he or she will not benefit and to avoid wasting a kidney that could provide years of benefit to another recipient.
This topic reviews issues surrounding renal transplantation among older adults.
The evaluation of potential kidney transplant donors and recipients, the kidney transplant waiting list, and the allocation of deceased-donor kidneys are discussed elsewhere. (See "Evaluation of the potential renal transplant recipient" and "Evaluation of the living kidney donor" and "The kidney transplant waiting list in the United States" and "Organ sharing in kidney transplantation".)
The age of renal transplant patients has increased over the past 20 to 25 years. Sixty percent of patients who enter end-stage renal disease (ESRD) are ≥60 years of age . The number of transplants performed annually among patients ≥65 years has tripled between 1998 and 2011 [1,2]. The percentage of candidates >50 years on the transplant waiting list increased from 53 to 64 percent between 2003 and 2013, with a corresponding decrease in younger patients .
A comprehensive evaluation of the prospective older transplant recipient includes the identification of significant comorbid disease that may preclude transplantation. Because the benefits of renal transplantation on patient survival are generally not realized until 1.5 to 2 years after transplantation, patients who are unlikely to survive this long should not undergo transplantation.
- http://srtr.transplant.hrsa.gov/annual_reports/2011/default.aspx (Accessed on May 17, 2013).
- Schaeffner ES, Rose C, Gill JS. Access to kidney transplantation among the elderly in the United States: a glass half full, not half empty. Clin J Am Soc Nephrol 2010; 5:2109.
- Matas AJ, Smith JM, Skeans MA, et al. OPTN/SRTR 2013 Annual Data Report: kidney. Am J Transplant 2015; 15 Suppl 2:1.
- Dusseux E, Albano L, Fafin C, et al. 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.
- Tso PL. Access to renal transplantation for the elderly in the face of new allocation policy: a review of contemporary perspectives on "older" issues. Transplant Rev (Orlando) 2014; 28:6.
- Reese PP, Bloom RD, Shults J, et al. Functional status and survival after kidney transplantation. Transplantation 2014; 97:189.
- Danovitch GM, Gill J, Bunnapradist S. Immunosuppression of the elderly kidney transplant recipient. Transplantation 2007; 84:285.
- Meier-Kriesche HU, Ojo A, Hanson J, et al. Increased immunosuppressive vulnerability in elderly renal transplant recipients. Transplantation 2000; 69:885.
- Martins PN, Pratschke J, Pascher A, et al. Age and immune response in organ transplantation. Transplantation 2005; 79:127.
- Velez RL, Brinker KR, Vergne-Marini PJ, et al. Renal transplantation with cyclosporine in the elderly population. Transplant Proc 1991; 23:1749.
- EBPG Expert Group on Renal Transplantation. European best practice guidelines for renal transplantation. Section IV: Long-term management of the transplant recipient. IV.12. Elderly (specific problems). Nephrol Dial Transplant 2002; 17 Suppl 4:58.
- Deluca L, Cardella CJ. How can the care of elderly dialysis patients be improved? Semin Dial 1992; 5:28.
- Brifkani Z, Alhamad T, Horwedel T, et al. Induction avoidance in 2-haplotype-matched white living kidney transplantation. Am J Transplant 2015.
- Gill J, Sampaio M, Gill JS, et al. Induction immunosuppressive therapy in the elderly kidney transplant recipient in the United States. Clin J Am Soc Nephrol 2011; 6:1168.
- Hurst FP, Altieri M, Nee R, et al. Poor outcomes in elderly kidney transplant recipients receiving alemtuzumab induction. Am J Nephrol 2011; 34:534.
- Smits JM, Persijn GG, van Houwelingen HC, et al. Evaluation of the Eurotransplant Senior Program. The results of the first year. Am J Transplant 2002; 2:664.
- Kasiske BL, Chakkera HA, Louis TA, Ma JZ. A meta-analysis of immunosuppression withdrawal trials in renal transplantation. J Am Soc Nephrol 2000; 11:1910.
- Fritsche L, Hörstrup J, Budde K, et al. Old-for-old kidney allocation allows successful expansion of the donor and recipient pool. Am J Transplant 2003; 3:1434.
- Meier-Kriesche HU, Friedman G, Jacobs M, et al. Infectious complications in geriatric renal transplant patients: comparison of two immunosuppressive protocols. Transplantation 1999; 68:1496.
- Johnson DW, Nicol DL, Purdie DM, et al. Is mycophenolate mofetil less safe than azathioprine in elderly renal transplant recipients? Transplantation 2002; 73:1158.
- Meier-Kriesche HU, Morris JA, Chu AH, et al. Mycophenolate mofetil vs azathioprine in a large population of elderly renal transplant patients. Nephrol Dial Transplant 2004; 19:2864.
- Tullius SG, Tran H, Guleria I, et al. The combination of donor and recipient age is critical in determining host immunoresponsiveness and renal transplant outcome. Ann Surg 2010; 252:662.
- McAdams-DeMarco MA, James N, Salter ML, et al. Trends in kidney transplant outcomes in older adults. J Am Geriatr Soc 2014; 62:2235.
- Huang E, Poommipanit N, Sampaio MS, et al. Intermediate-term outcomes associated with kidney transplantation in recipients 80 years and older: an analysis of the OPTN/UNOS database. Transplantation 2010; 90:974.
- Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med 1999; 341:1725.
- Hunsicker LG. A survival advantage for renal transplantation. N Engl J Med 1999; 341:1762.
- Johnson DW, Herzig K, Purdie D, et al. A comparison of the effects of dialysis and renal transplantation on the survival of older uremic patients. Transplantation 2000; 69:794.
- Oniscu GC, Brown H, Forsythe JL. How great is the survival advantage of transplantation over dialysis in elderly patients? Nephrol Dial Transplant 2004; 19:945.
- Giessing M, Budde K, Fritsche L, et al. "Old-for-old" cadaveric renal transplantation: surgical findings, perioperative complications and outcome. Eur Urol 2003; 44:701.
- Rao PS, Merion RM, Ashby VB, et al. Renal transplantation in elderly patients older than 70 years of age: results from the Scientific Registry of Transplant Recipients. Transplantation 2007; 83:1069.
- Savoye E, Tamarelle D, Chalem Y, et al. Survival benefits of kidney transplantation with expanded criteria deceased donors in patients aged 60 years and over. Transplantation 2007; 84:1618.
- Trouillhet I, Benito N, Cervera C, et al. Influence of age in renal transplant infections: cases and controls study. Transplantation 2005; 80:989.
- Kappes U, Schanz G, Gerhardt U, et al. Influence of age on the prognosis of renal transplant recipients. Am J Nephrol 2001; 21:259.
- The 2010 SRTR report on the state of transplantation www.ustransplant.org/annual_reports (Accessed on February 12, 2012).
- Meier-Kriesche HU, Cibrik DM, Ojo AO, et al. Interaction between donor and recipient age in determining the risk of chronic renal allograft failure. J Am Geriatr Soc 2002; 50:14.
- Weng FL, Reese PP, Mulgaonkar S, Patel AM. Barriers to living donor kidney transplantation among black or older transplant candidates. Clin J Am Soc Nephrol 2010; 5:2338.
- Gill J, Bunnapradist S, Danovitch GM, et al. Outcomes of kidney transplantation from older living donors to older recipients. Am J Kidney Dis 2008; 52:541.
- Knoll GA. Kidney transplantation in the older adult. Am J Kidney Dis 2013; 61:790.
- Gill JS, Gill J, Rose C, et al. The older living kidney donor: Part of the solution to the organ shortage. Transplantation 2006; 82:1662.
- Chang P, Gill J, Dong J, et al. Living donor age and kidney allograft half-life: implications for living donor paired exchange programs. Clin J Am Soc Nephrol 2012; 7:835.
- Ferrari P, Lim W, Dent H, McDonald SP. Effect of donor-recipient age difference on graft function and survival in live-donor kidney transplantation. Nephrol Dial Transplant 2011; 26:702.
- Schold J, Srinivas TR, Sehgal AR, Meier-Kriesche HU. Half of kidney transplant candidates who are older than 60 years now placed on the waiting list will die before receiving a deceased-donor transplant. Clin J Am Soc Nephrol 2009; 4:1239.
- Keith DS, Demattos A, Golconda M, et al. Effect of donor recipient age match on survival after first deceased donor renal transplantation. J Am Soc Nephrol 2004; 15:1086.
- Chavalitdhamrong D, Gill J, Takemoto S, et al. Patient and graft outcomes from deceased kidney donors age 70 years and older: an analysis of the Organ Procurement Transplant Network/United Network of Organ Sharing database. Transplantation 2008; 85:1573.
- Molnar MZ, Streja E, Kovesdy CP, et al. Age and the associations of living donor and expanded criteria donor kidneys with kidney transplant outcomes. Am J Kidney Dis 2012; 59:841.
- Cohen B, Smits JM, Haase B, et al. Expanding the donor pool to increase renal transplantation. Nephrol Dial Transplant 2005; 20:34.
- Rudge C. Long-term patient and graft survival in the eurotransplant senior program: a single-center experience. Transplantation 2005; 80:571.
- Fabrizii V, Kovarik J, Bodingbauer M, et al. Long-term patient and graft survival in the eurotransplant senior program: a single-center experience. Transplantation 2005; 80:582.
- Frei U, Noeldeke J, Machold-Fabrizii V, et al. Prospective age-matching in elderly kidney transplant recipients--a 5-year analysis of the Eurotransplant Senior Program. Am J Transplant 2008; 8:50.
- Giessing M, Fuller TF, Friedersdorff F, et al. Outcomes of transplanting deceased-donor kidneys between elderly donors and recipients. J Am Soc Nephrol 2009; 20:37.
- Tan JC, Alfrey EJ, Dafoe DC, et al. Dual-kidney transplantation with organs from expanded criteria donors: a long-term follow-up. Transplantation 2004; 78:692.
- Moore PS, Farney AC, Sundberg AK, et al. Dual kidney transplantation: a case-control comparison with single kidney transplantation from standard and expanded criteria donors. Transplantation 2007; 83:1551.