Counselling the elderly between hope and reality

Abstract

In the Western world, nowadays, senior citizens (i.e. those 65 years) constitute ~16% of the general population, a proportion predicted to increase to 23% in 2030 and >30% by 2050. The past decades have already witnessed significant changes in the demographic characteristics of patients with end-stage renal disease (ESRD), mainly due to an increase in elderly patients over the age of 65 years and, in more recent years, >75 years of age [1]. Transplantation is considered the preferred treatment option for ESRD, because it is relatively safe and offers survival advantage over dialysis for the majority of patients [2]. This benefit is extended to all causes of ESRD (e.g. glomerulonephritis, hereditary renal disease, diabetes mellitus and hypertension) and all age categories of patients. After the first year, including excess initial mortality, the projected increase in life span of patients aged 60–74 was 4 years with a 61% decrease in their long-term risk of death. Also, recipients >65 years of age who received expanded criteria kidneys lived on average 3.8 years longer than their wait-listed counterparts, despite lower graft outcomes [3]. Clearly, the magnitude of improved patient survival is not uniform across patient subgroups such as the elderly and/or those with diabetes mellitus [2]. Nevertheless, several studies have reported acceptable outcomes for selected patients over the age of 70 years or even 80 years [4, 5]. In this issue of Nephrology, Dialysis and Transplantation, Stevens et al. used their incident dialysis population between 1992 and 2009 to study access to transplantation among elderly patients as defined by the cumulative probability of being wait-listed for kidney transplantation and actually receiving a transplant. The likelihood of being listed for renal transplantation fell with increasing age. Within the first year after initiation of dialysis, only 4% of patients 65 years and 0.8% of those 75 years were listed. Only 8% of listed patients between 65 and 74.9 years received a deceased donor kidney transplant within 5 years. The results of this single centre analysis by Stevens et al. are a concern in that they suggest a disadvantage for transplantation in the elderly, but they are also in contrast with experience in other European countries. Results of the Eurotransplant Senior Programme (ESP) show that the numbers of transplants performed in the elderly increased significantly in recent years. Between 1991 and 2007, there has been an increase in the proportion of kidney transplant recipients 65 years from 3.6 to 19.7% [6]. A significant, >5-fold increase, since the proportions of transplant recipients aged 46–64 years remained the same and those <46 years decreased. Since 1999, the ESP preferentially allocates kidneys from older ( 65 years) deceased donors, without prospective matching for human leucocyte antigens (HLAs), to older ( 65 years), local or regional, transplant candidates. The programme also includes repeat transplants or sensitized patients, provided that unacceptable antigens are identified and excluded. The ESP allocation principle encouraged the use of older donor organs that otherwise might have been discarded and expedited the chance of the elderly to receive a kidney transplant (Figure 1). Within the same period of time, however, there has also been a substantial decrease in the numbers of kidney donors under the age of 46 years [6]. Stevens et al. [7] rightfully address the apparent disadvantage for the elderly, including lower referral rates and chances for placement on the waiting list, even in the absence of absolute contraindication for transplantation in comparison to younger counterparts. First of all, it is relevant to note that a significant proportion of the elderly may no longer desire a kidney transplant. Nevertheless, inadequate counselling for renal replacement therapy, delayed pre-transplant workup or referral while already on dialysis will all play a role. Preclusion based on age alone is considered not fair, but the difficulty of selection, taking biological age and co-morbid conditions along with the increased operative risk into account, continues to pose a significant challenge to the nephrology and transplant community. These views are supported by the observed excess initial mortality with an increased time to equal risk from 95 to 148 days in recipients aged 40–59 and 60–74 years, respectively [2]. Furthermore, there is the need for lifelong immunosuppressive therapy, while in the elderly infectious causes are among the leading primary causes of death [8]. To improve safety, the Eurotransplant Senior DR-compatible Programme (ESDP) was recently launched [6]. The important perspective remains that a successful transplantation with either a regular or even a marginal donor kidney is associated with a substantial improvement in longevity and in quality of life [2, 4, 5]. An allocation policy based on waiting time, however, carries the unintended consequence of a disadvantage