Trends in Kidney Transplant Outcomes in Older Adults

Mara A. McAdams-DeMarco, PhD; Nathan James, MSc; Megan L. Salter, PhD; Jeremy Walston, MD; Dorry L. Segev, MD, PhD

Disclosures

J Am Geriatr Soc. 2014;62(12):2235-2242. 

In This Article

Abstract and Introduction

Abstract

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

Design Cohort study.

Setting The Scientific Registry of Transplant Recipients (SRTR).

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

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

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

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

Introduction

In 2011, there were more than 230,000 older adults (aged ≥65) with end-stage renal disease (ESRD), a substantial rise from approximately 50,000 in 1990.[1] The incidence of ESRD is highest in older adults, and individuals with ESRD are living longer, further increasing the prevalence of ESRD in older adults disproportionately to the incidence,[2] but few older adults undergo kidney transplantation (KT) relative to the burden of ESRD in this population.[3] It has previously been identified that 76% of older adults with ESRD estimated to be excellent candidates for KT (in the highest quintile of KT outcomes, with predicted 3-year post-KT survival exceeding 87%) lack access to transplantation.[4] In the past, KT outcomes were poor for older adults,[5–8] and it was hypothesized that these historically poor outcomes have contributed to regressive attitudes toward transplantation in older adults and lack of pursuit of KT by older adults and their providers.

It is critical to understand trends in this population, especially in light of the rapid, profound expansion of older KT candidates and recipients and recent changes to kidney allocation policy. Older adults who undergo KT are likely to have many comorbidities (including cardiovascular disease, which registries do not capture) and likely to receive kidneys that are associated with worse outcomes, such as an expanded criteria donor (ECD) or donation after cardiac death (DCD) kidneys.[3] Quantifying changes in mortality and graft loss for older KT recipients is important not only for clinical decision-making, but also for informing policy changes. The new organ allocation policy considers candidate age (among other variables) in allocation priority.[9] Understanding changes in survival over time will be important for organ allocation in older KT candidates, a group that has recently experienced longer survival after KT. If organ allocation priority for older candidates is based on old, outdated data (in other words, if the risk associated with age in the prediction model is estimated based on outdated data), older KT candidates may be denied organs because this population had poor survival in the past.

To inform clinical practice and policy changes, the main goals of this study were to characterize the changing landscape of transplantation in older adults, to evaluate trends in KT mortality and death-censored graft loss for older adults over time, and to identify risk factors unique to older adults.

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