Narrative Review
Kidney Transplantation in the Older Adult

https://doi.org/10.1053/j.ajkd.2012.08.049Get rights and content

The end-stage renal disease population is aging. Nearly half of all new patients are older than 65 years and one third are older than 70 years. Assessing the possibility of transplantation for older patients with end-stage renal disease often involves contemplating more complex issues, including cognitive impairment, decreased functional status, and frailty, which makes selecting appropriate candidates more difficult. Older transplant recipients have decreased patient and transplant survival compared with younger recipients. For example, 75% of deceased donor transplant recipients aged 30-49 years are alive after 5 years compared to only 61% for those older than 65 years. Despite poorer outcomes compared with younger recipients, older transplant recipients have a significant improvement in survival compared with similar patients who remain on the wait list, with decreases in mortality of 41%-61% depending on the study. Use of living donors, even older living donors, provides significantly better outcomes for elderly recipients compared with the use of deceased donors. However, in the absence of a living donor, survival is improved significantly by accepting an expanded criteria donor organ rather than waiting for a standard criteria deceased donor. Older transplant recipients experience more infectious complications and less acute rejection, but the risk of transplant loss from rejection is increased compared with younger patients. These immunologic issues, along with the fact that older patients often are excluded from transplant trials, have made selecting an ideal immunosuppressive regimen challenging. Prospective comparative trials of different agents in the elderly population are warranted to better define the risk-benefit profile. This review discusses transplantation outcomes, including patient and transplant survival, different donor types, quality of life, and immunosuppression for older dialysis patients.

Section snippets

Patient Survival

In their landmark report, Wolfe et al6 showed that transplant recipients had a 68% decrease in mortality compared with those who remained on the wait list. This survival advantage also was seen in older individuals. Patients aged 60-74 years had 61% lower mortality (relative risk [RR], 0.39; 95% confidence interval [CI], 0.33-0.47) compared with similar patients on the wait list.6 This survival advantage translated into a 4-year increase in life expectancy.

Rao et al7 reported outcomes for 5,567

Deceased Versus Living Donor

Historically, there has been reluctance to use living donor transplants for older adults given the inherent limited life span. However, recent data suggest that living donor kidneys might be the best treatment option for elderly transplant recipients, just as it is for younger individuals. Gill et al8 examined outcomes for transplant recipients older than 60 years by donor age (younger [≤55 years] or older [>55 years]) and source (living or deceased). During the time frame of this study

Quality of Life and Economics

Humar et al17 measured quality of life at 1-year posttransplantation using the 36-Item Short Form Health Survey (SF-36). In this analysis, there were 42 patients who were at least 65 years of age; mean age was 69 years. They found that for 5 of the 8 domains, older transplant recipients had similar or even higher quality-of-life scores than age-matched values from the general US population. The sole domains in which these patients scored lower than the national norms were bodily pain, role

Immunosuppression

The immune response, like other aspects of biology, is significantly affected by the aging process. Although there is heterogeneity among individual patients, in general terms, both innate and adaptive immunity show decreases with increased age.21, 22 These changes are believed to contribute to the observation of decreased acute rejection in elderly transplant recipients. In an analysis involving more than 70,000 kidney transplant recipients, Meier-Kriesche et al23 showed that the incidence of

Evaluation Issues in the Elderly

Older patients with ESRD who are assessing transplantation often have more complex issues to contemplate than their younger counterparts, including cognitive impairment, decreased functional status, and frailty.33, 34 Mild cognitive impairment and dementia occur with greater frequency in older individuals and this increase is even greater in patients with ESRD. For example, only 10%-30% of young and middle-aged dialysis patients have cognitive impairment compared with 30%-55% of those older

Acknowledgements

Support: This article was produced without direct financial support. Dr Knoll is supported by a University of Ottawa Chair in Clinical Transplantation Research.

Financial Disclosure: Dr Knoll has participated on advisory boards or received research funding from Astellas Canada, Roche Canada, Novartis Canada, Wyeth Canada, and Genzyme Canada.

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    Originally published online December 20, 2012.

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