Access to Kidney Transplantation in the Elderly

Abstract

Introduction: There is a concern that some, especially elderly ESRD patients, are not referred and could benefit from kidney transplantation. Methods: We retrospectively examined consecutive incident ESRD patients at our center from 1/2006 to 12/2009. At ESRD start patients were classified into those with or without contraindications using Canadian eligibility criteria (CMAJ 2005). Based on referral for transplantation patients were grouped as CANDIDATES (no contraindication and referred), NEITHER (no contraindication and not referred) and CONTRAINDICATION. The Charlson Comorbidity Index (CCI) was used to assess co-morbidity burden. Results: Of the 437 patients, 133 (30.4%) were CANDIDATES (mean age 50 and CCI 3.0), 59 (13.5%) were NEITHER (mean age 76 and CCI 4.4), and 245 (56.1%) were CONTRAINDICATIONS (mean age 65 and CCI 5.5). CANDIDATES were the youngest with least comorbidity. NEITHER were the oldest but had less co-morbidity than CONTRAINDICATIONS. Although 10% of patients between 70-79 were referred, age was the best discriminator between NEITHER and CANDIDATES (c-statistic 0.96, p< 0.0001) with CCI being less discriminative (0.707, p< 0.001). Figure 1 shows that CANDIDATES had the best survival (censored at transplantation) whereas both NEITHER and CONTRAINDICATION subjects had high mortality rates.[Figure 1]Figure 2 shows that NEITHER patients also had very high rates to death or to developing a contraindication. By 1.5 years 50% were no longer eligible for a transplant. Neither patients who developed contraindications were more likely to have ischemic heart disease (OR 3.1, p=0.011). Age and other comorbidities were not predictive.[Figure 2]Conclusions: There exists a relatively small population of incident patients not referred that have no contraindications. These are elderly patients with significant co-morbidity that have a small window of opportunity for a transplant. Other than vascular disease, identifying those most likely to survive the wait time to a deceased donor transplant will be a challenge. Rapid evaluation and access to pre-emptive transplantation is required.