When Are You Too Old to Get a Kidney Transplant?

Lavanya Kodali; Alexandra Turner

Disclosures

Curr Opin Nephrol Hypertens. 2019;28(6):593-599. 

In This Article

Abstract and Introduction

Abstract

Purpose of review: With the increasing incidence and prevalence of ESRD in the elderly, we are now transplanting more elderly patients. Although we know from previous reports that transplantation provides increased survival advantage and/or quality of life when compared to being on dialysis, we also know that transplantation is not the best option for all patients. In this review, we try to identify the upper age limit (if any) for deceased donor renal transplantation, predictive factors that can identify the risks for transplant outcomes, frailty, and immunosenescence.

Recent findings: Review of data over the last 5 years have identified certain risk predictors and outcomes that might be helpful in evaluation of the elderly transplant recipient, which we aim to summarize in this review.

Summary: Identifying predictors to risk stratify elderly patients and promote transplantation is much needed. Modifiable risks should be addressed to ensure more candidates become transplantable. A combination of physical, medical, and immunological markers to better identify recipients is imperative for future research gearing towards precision medicine.

Introduction

The average life expectancy in the United States has increased over time. In 2017, the life expectancy at birth was 78.6 years for the U.S. Population.[1] The prevalence of end-stage renal disease (ESRD) in the U.S. population has consequently increased. Per the USRDS annual report in 2018, ESRD is most prevalent in adults over 65, whereas incident ESRD is highest in adults 75 years or older. In the elderly population over age 65, kidney disease accounted for the top 10 causes of death in 2017.[2]

Renal transplantation is the preferred modality of treatment for ESRD when compared with dialysis because of improved survival benefit and quality of life.[3,4] Reports from the 1990s by Wolfe et al.[3] noted a survival benefit for transplantation across all age groups when compared with waitlisted patients on dialysis. Rao et al.[4] specifically looked at the benefit of transplantation in patients older than 70 years of age during the early 2000s. The authors concluded that elderly recipients had a 41% lower risk of death compared with the waitlisted dialysis patients (RR = 0.59; P < 0.0001). Elderly patients must survive the operation itself, however, to benefit from transplant. The risk of death at 45 days posttransplant was 2.26 times greater than risk of death on dialysis, with equivalent mortality at 125 days. Improved survival occurred at 548 days posttransplant. Legeai et al.[5] queried the French registry between 2002 and 2013, to compare the mortality risk in patients aged at least 70 years on dialysis, waitlist and posttransplantation. They reported a similar 3-year mortality rate of 17.6% in the 877 transplant recipients and 17.5% in the 342 waitlisted patients of the same age. The authors report that the risk of death was 3-fold higher in KTRs compared with the waitlisted group in the first 3 months, and subsequently halved by month 9, but was still not offset by month 36. These studies emphasize the need for better patient selection to improve early patient survival in the elderly KTRs.

It is well known that death with a functioning graft is the leading cause of graft loss in elderly recipients. Cardiovascular disease, infections and malignancy are the common causes of mortality in the elderly transplant recipients. Gill et al.[6] examined perioperative transplant mortality in the elderly compared to waitlisted patients on dialysis by donor type. Patients were matched for cardiovascular risk. Living donor recipients demonstrated an almost immediate survival benefit over dialysis; whereas deceased donor recipients had increased mortality compared to patients on dialysis. Recipients of extended criteria donor (ECD) kidneys had the highest rate of perioperative mortality, especially in the high cardiovascular risk group. Delayed graft function (DGF) is recognized as an important risk factor for early mortality, with cardiovascular disease being the most common cause of death, emphasizing the need to identify strategies to minimize DGF.

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