Kidney Transplant: A Realistic Chance for Elderly Patients

1. Kidney Transplant: A Realistic Chance for Elderly Patients Reference: Munnapradist S, Danovitch GM. Kidney transplants for the elderly: Hope or hype? Clin J Am Soc Nephrol. 2010;5:1910–1911.

2. The number of elderly end stage renal disease (ESRD) patients is increasing globally and in United States, ESRD prevalence is mostly observed in nearly half of the patients who are over 60 years of age. • In elderly patients, kidney transplantation offers an improved life span and quality of life, and it has been reported that reasonable outcomes were obtained in selected patients in the 70s and even in the 80s age group. • The percentage of elderly patients on the transplant waiting list and receiving subsequent transplants remains comparatively small (approximately 9% of patients 65 years and older were on the transplant waiting list in 2008). • Among these patients ≥65 years, in 1999, the number of active candidates on the waiting list was found to be 3,695, whereas, in 2008 the number increased more than double to 8,606.

3. In parallel, the number of “inactive” candidates (those placed on the waiting list yet not considered to be current candidates, usually because of comorbidities) aged 65 years or more on the waiting list showed an increase up to approximately nine-fold from 507 to 4,584 in the same period of time. • Therefore, as a result of this, the difference between the number of transplant candidates and organ supply has unavoidably resulted in increased waiting time and deaths on the waiting list. • These issues are more distinct in elderly patients because of their higher mortality rates on dialysis.

4. Access to Transplantation • The US Renal Data System database was used to study the “access to transplantation” among 60 years and older incident ESRD patients in US as defined by the cumulative probability of transplantation (living, standard criteria, and expanded criteria donor (ECD)) according to the year of ESRD onset. • Using this definition it was observed that access to transplantation has increased two-fold at 2 years among the elderly patients from 1995 to 2006. • The likely explanation for this increased transplantation rate are, • There was an increase in elderly candidates wait-listed over the course of the study period • There was an increase in preemptive transplantation, living donation, and ECD transplantation.

5. Based on these observations, the study revealed that suitable elderly ESRD patients should not be dissuaded from pursuing transplantation. • In the latter part of the study period, it was observed that the absolute probability of transplant remained quite small (from 2003 to 2006, only 3.4% at 1 year and 7.3% at 3 years for incident ESRD patients) and the cumulative probability of transplant at 10 years was in the low teens. • Furthermore, the transplant probability numbers were censored for death, thus overestimating the true probability. • Given the high yearly mortality rate on dialysis for the elderly, it was reported that censoring for death would lead to over inflation of the transplant rates. • The probability of transplant was very low.

6. “Access to transplantation” was also estimated by the proportion of incident ESRD patients transplanted over time. • This study cohort included incident ESRD patients who are interested and not interested in transplantation as well as those who are medically unsuitable. • By including only those on the waiting list, those who were not referred but would otherwise be suitable for transplantation would be excluded, thus overestimating the probability of transplant. • The ideal cohort to study access to transplantation includes all of those patients who desire a transplant.

7. Another study using “Scientific Registry for Transplant Research data” has shown that even among wait-listed patients over the age of 60 years, including those eager to get a transplant and considered to be a suitable candidate, the estimated proportion of candidates expected to die before getting a transplant was overall 56 and 35% when those who were temporarily inactive at the time of placement on the waiting list were excluded.

8. The study concluded that individuals older than 60 years of age, are at a significant risk for not surviving to receive a deceased donor transplant. • However, this does not necessarily imply that pursuing transplant in the elderly is ineffective, as approximately 50% of wait-listed patients ultimately undergo transplantation. • One of the most essential findings in this study was that the probability of receiving a transplant varied greatly, in part because of recipient factors including blood type, high levels of preformed antibodies, existence of diabetes and geographic location. • Approximately 80% of wait-listed patients were estimated to die before receiving a deceased donor transplant in those listed in the United Network for Organ Sharing (UNOS) region 5 (including Arizona, California, Nevada, New Mexico, and Utah) compared with less than 10% among those listed in UNOS region 6 (Alaska, Hawaii, Idaho, Montana, Oregon, and Washington).

9. One of the main limitations of this study was that the subjects were censored in the events of living donor transplantation, delisting, and death. • Censoring for living donor transplant would underestimate the possibility of the candidate on the wait list to be transplanted, thus over inflate the death rate on the waiting list. • In recent years, it has been evident that transplant rates has increased among the incident elderly ESRD population and in the United States, the overall number of transplantations were performed on the elderly. • The yearly mortality rate on dialysis exceeds greatly than the transplant rates. • Thus, it is necessary to understand and address the barriers in access to transplant, which includes (see Table 1) failure of adequate renal replacement therapy counseling, medical, and psychosocial incompatibility, failure to complete the transplant workup, and referral and listing criteria among nephrologists and transplant centers. These issues play a very distinct role in elderly candidates.

11. Transplantation rate among elderly incident ESRD patients has increased in recent years, although it remains quite low. • Given the increase in preemptive transplantation, an opportunity exists to encourage earlier consideration of transplantation by early referral to transplant centers as well as increased importance on living donor transplantation in the elderly. • The elderly are often unwilling to accept younger family members as potential donors, but since the last decade there had been a four-fold rise in the percentage of living donor transplants to recipients aged 65 years and older. • In 2009, 12% of all living donor transplantations were carried out in recipients of this age group and elderly patients must be counseled regarding the ECD transplant option and the relative benefit of a prolonged wait for a transplant compared with receiving a kidney, the characteristics of which may be less than ideal.

12. Practitioners must consider in a careful and very compassionate manner whether transplantation is a realistic option for each elderly ESRD candidate. Considering the comparatively predictable nature of the UNOS kidney allocation algorithm, each transplant program should carefully consider the most costeffective and clinically rational manner on which their elderly patients are estimated and managed while on the waiting list. • The best possible efforts must be put by the transplant programs, nephrologists, dialysis staff, and the patients themselves to invest health maintenance, and to minimize mortality and to maximize the benefit of the transplant when the patients’ long wait for a transplant comes, at last, to an end.