ReviewSolid organ transplantation: Technical progress meets human dignity a review of the literature considering elderly patients’ health related quality of life following transplantation
Highlights
► The number of studies on the transplantion of elderly people is limited and only focused on survival. ► Only 5 out of 1427 studies dealt with the special needs of this patient polulation. ► We evaluated those 5 studies regarding their accuracy concerning elderly patients. ► We found out, that even in those studies quality of life was only of inferior importance.
Introduction
Over the past decades progress has been made in the field of organ transplantation. Surgical techniques, intensive care management and immunosuppressive therapy have improved to high quality standards in numerous transplant centres all over the world. Due to improved individual patient outcome, organ transplantation has been offered in increasing numbers to high-risk patients including older, multi-morbid patients with concomitant functional limitations. As a result, upper age limits for recruitment of people undergoing organ transplantation has increased.
Elderly patients contribute increasingly to the kidney recipient patient pool and they show favourable outcomes concerning renal graft survival (Pascual et al., 2002, Cameron, 2000, Wu et al., 2008). It could be shown that graft survival itself was not negatively influenced by evolving patient age (Roodnat et al., 1999) and that older patients seem to derive a survival benefit from transplantation compared to those remaining on dialysis treatment (Schaubel et al., 1995, Saxena et al., 2009). There are several reports in the literature dealing with quality of life assessment as well as functional ability of elderly patients on haemodialysis and peritoneal dialysis (Lew and Piraino, 2005, Tamura et al., 2009), all of which show a progressive decline of personal well-being and functionality with prolonged time on dialysis treatment. This may be either attributed to haemodialysis procedure itself, or may be part of the bio-psychosocial effects attributed to chronic disease and multi-morbidity. Older transplant recipients’ functional capacities and their respective follow up concerning their mental, physical and psychosocial long-term outcome could answer these questions. So far, most of the studies published dealing with kidney transplantation in elderly patients have put special focus on survival and mortality rates as compared to that in younger patients. Very little data concerning post-transplant “quality of life parameters” could be found in the literature.
Chronic liver failure is a disease that affects quality of life as well as mental and physical well being in a very unfavourable way (Gutteling et al., 2006). The mean age of liver transplantation is steadily rising, 10% of the recipients were older than 60 years in 1990–1991, 21% were older than 60 years between 1997 and 1999 (Freeman et al., 2007). Overall short-term survival rates in seniors undergoing liver transplantation are comparable to survival rates of younger adults (Levy et al., 2001, Garcia et al., 2001, Jimenez et al., 1999, Rudich and Busuttil, 1999). Organ transplantation may improve health and functional parameters. It has been shown in various studies that long-term survival is worse specifically in older patients due to long-term complications, such as malignancy and heart disease (Cross et al., 2007, Keswani et al., 2004).
Older patients also constitute a significant and growing percentage in cardiac transplant recipients. Operative mortality and 1-year survival rates similar to that of the younger patients (<60 years old) were described (Coffman et al., 1997, Fonarow, 2000).
The outcome of lung transplantation is discussed in detail in the transplant community. Despite strict patient selection criteria, lung transplant recipients older than 60 years showed an increased mortality (Gutierrez et al., 2007, Mahidhara et al., 2008). Smith et al. (2006) are the only to describe comparable outcomes of elderly and survival rates in carefully selected patients >60 years.
In pancreas transplantation, age is known to be the major risk factor for adverse patient outcome following transplantation. Older transplant recipients had worse outcomes compared with those who received organs at a younger age (Foley et al., 2005). Ablorsu et al. (2008) showed similar 1-year patient and pancreas graft survival rates in carefully selected older recipients (>50 years and older) in comparison to younger recipients. The previously accepted maximum recipient age was 50 years (EBPG, 2000). Diabetes as a risk factor may further increase the risk of unfavourable outcome. This fact may be attributed to the accelerated bio-system damage occurring with diabetes. Transplantation in elderly diabetics is therefore questionable.
In the light of improving health and organ function results in elderly transplant recipients – one may ask whether there is any ethical background to refuse transplantation to elderly patients? Organs are a scarce resource and there is ongoing discussion about allocation priorities. Should organs be allocated to the patient with the best chance of long-term success? And how can long-term transplant success be determined?
Considering the improving perioperative results, there are less arguments for an age restriction for transplant recipients. A key consideration in the field of transplantation should be a thorough recipient selection. Quality of life and assessment parameters of the individual physical and psychosocial functionality for recruitment to transplantation could provide more individual and distinctive decision making.
It is the aim of this review to evaluate publications in the transplant literature dealing with the parameters “quality of life” and “physical and psychosocial functionality” specifically in elderly transplant recipients from 1960 to 2010.
Section snippets
Search strategy
A comprehensive literature search was performed for studies concerning transplantation in elderly patients. We used a combination of “transplantation”, “elderly patients”, “aged” and “old patients” as key-words. The following databases were searched: MEDLINE (1960–January 2010), EMBASE (1980–January 2010), the Cochrane Central Register of Clinical Trials and Pascal Biomed (2000–January 2010). The abstracts and references identified from the search were assessed against inclusion/exclusion
Results
The initially retrieved sample using the above mentioned keywords produced 1427 citations from electronic databases, 1178 of which were excluded after abstract review. 249 abstracts were selected for full review, 64 of them were excluded as duplicates. From the remaining 185 articles 95 were excluded due to low number of patients or age <60 years. We defined 90 articles (kidney transplantation: 55, liver transplantation: 18, heart transplantation: 13, lung transplantation: 4, pancreas
What can be learned from this?
Clinical organ transplantation has exploded in recent years and the current interest and controversies in the world of transplantation reflect the empathy of colleagues all over the world. So far, perioperative patient management, graft survival, secondary morbidity and mortality as well as immuno-suppression in the context of benefits and costs have filled the hit lists in international journal publications. Special focus has been put on the subgroup of patients developing diabetes mellitus
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