Elderly Kidney Recipients Research Articles

P.164: Comparable graft survival of re-transplantation in elderly kidney recipients in regard to rejection.

P.164: Comparable graft survival of re-transplantation in elderly kidney recipients in regard to rejection.

Clinical outcomes of retransplantation in elderly kidney recipients

Clinical outcomes of retransplantation in elderly kidney recipients

A review of elderly transplantation regarding complications, outcomes, and survival

BackgroundRenal transplant adds survival benefits to end-stage renal disease patients over dialysis, and a similar concept applies to elderly patients. Some of the challenges of transplanting old patients may involve age-related cancers and comorbid conditions such as cardiovascular disease. Studies had shown that advanced age is associated with better outcomes compared to dialysis despite receiving poorer quality organs. AimThis extended literature review aims to identify the common complications, outcomes, and survival benefits of kidney transplantation in the elderly population. MethodsAn extended literature review was done to identify studies that compared elderly transplant recipients with the younger kidney transplant recipient population. The study population included elderly kidney recipients aged sixty and above and younger kidney recipients below the age of sixty. This literature review aims to discuss complications facing elderly kidney recipients and compare transplant outcomes to younger kidney recipients. PubMed, Midline, and google scholar databases were searched and papers meeting the pre-set inclusion criteria were identified. ResultsA total of 212 papers were identified. After screening the results, 12 papers met the inclusion criteria and were included for review. 10/12 papers included patients' age cutoff point, one paper had cut-off age between 60 and 80 years, while the last paper recruited patients with ages above 70. Most of the studies mentioned young group age as below 60, 2/12 papers divided the young group into further subgroups of age. Two studies used paired donor organs for both young and elderly groups to eliminate donor bias. While other studies used living, deceased, or both living and deceased donors for both elderly and young groups. One study matched donor type and gender in both groups. The studies looked at patient and graft survival and complications. Elderly transplant patients suffered more hospitalization, infections, cardiovascular complications, malignancy, and surgical complications. Post-transplant diabetes was higher in the young recipient group in one study. ConclusionIn the case of elderly renal transplant recipients, the cut-off point for age to perform renal transplant is not clear but studies showed better survival and cost-effectiveness in elderly patients compared to patients on the waiting list even in older patient cohorts

Influence of pretransplant class I and II non-donor-specific anti-HLA immunization on immunologic outcome and graft survival in kidney transplant recipients

BackgroundAnti-HLA immunization determined by Panel Reactive Antibody (PRA) is known to have a negative impact on patient and graft survival. The predictive value of peak PRA (pPRA) on immunologic outcome, however, and the individual effects of anti-HLA class I and II antibodies remain uncertain. MethodsThe influence of HLA immunization on immunologic outcome parameters and graft survival was investigated in 1150 adult patients without pretransplant donor-specific antibodies (DSA) and in a subgroup of elderly kidney recipients aged ≥ 65 (n = 264). Anti-HLA immunization was defined as a pPRA > 0%. We investigated the influence of class I and II pPRA by dividing all kidney recipients into four pPRA groups (0%, 1–20%, 21–80%, >80%). ResultsPatients with non-donor-specific pretransplant anti-HLA immunization were at a higher risk for developing de novo DSA (49.9% vs. 18.7% p < 0.001), antibody mediated rejections (ABMR) (15.7% vs. 5.1%; p < 0.001), had a poorer death censored graft survival (69.2% vs. 86.2%; p < 0.001) and a higher decline of the calculated GFR. In elderly patients anti-HLA immunization only had a significant influence on the development of DSA (40.5% vs. 27.4%; p = 0.004). A multivariate model adjusted for all relevant factors revealed only class I but not class II pretransplant HLA immunization as a significant independent risk factor for de novo DSA, ABMR and death censored graft loss (HR 2.76, p < 0.001, HR 4.16, p < 0.001 and HR 2.07, p < 0.001, respectively). ConclusionMainly non-donor-specific pretransplant HLA class I immunization is an independent risk factor for the development of de novo DSA, ABMR and graft loss.

Holistic Long-Term Care Over Elderly Kidney Transplant Recipients

Kidney transplantation is an optimal method of renal replacement therapy in patients with phase V chronic kidney disease. Elderly patients (older than 60 years) with a kidney transplant create a significant and constantly growing pool of patients with this type of organ transplantation. In this group of patients, long-term care should be particularly stringent and vigilant. Apart from typical conditions associated with chronic kidney disease and possible post-transplant complications as well as side effects of immunosuppressive treatment, the patient also experiences changes and limitations associated with the progress of age and diseases typical for old age, characterized by a higher risk of infection, and changed pharmacokinetics/pharmacodynamics. Undoubtedly, patients should remain under the medical care of qualified transplantologists, but constant cooperation with a general practitioner and geriatrician would be of added value. Study results show that although most of the elderly kidney recipients have constant contact with their general practitioners, and almost half of them use private care, contribution of the geriatrician to the transplant care system is unsatisfactory, and elderly kidney recipients would expect more extensive outpatient care.

How does age affect the outcome of kidney transplantation in elderly recipients?

The aging of the on-dialysis population raises the issue of whether to propose elderly patients for kidney transplantation and how to manage their immunosuppression. This study aimed to analyze the outcome of kidney transplantation on an Italian series of elderly recipients. We included in this retrospective study all patients over 60years, receiving a deceased-donor kidney transplantation from January 2004 to December 2014 in two north Italian Centers. We analyzed the correlation of recipient age with graft's and patient's survival, delayed graft function, acute cellular rejection (ACR), surgical complications, infections, and glomerular filtration rate. Four hundred and fifty-two patients with a median age of 65years were included in the study. One-, 3-, and 5-year patient's and graft's survival were, respectively, of 98.7%, 93%, 89% and 94.4%, 87.9%, 81.4%. The increasing recipient age was an independent risk factor only for the patient's (P=.008) and graft's survival (P=.002). ACR and neoplasia were also associated to a worse graft survival. The reduced graft survival in elderly kidney recipients seems to be related more to the increasing recipient's age than to the donor's features. In this population, the optimization of organ allocation and immunosuppression may be the key factors to endorse improvements.

Immunosuppression in the elderly renal allograft recipient: a systematic review.

The Elderly are the fastest growing part of kidney transplant recipients. The best immunosuppressive strategy is unknown. We performed a systematic search of randomized controlled trials and observational studies focused on safety and efficacy of different immunosuppression strategies in elderly kidney recipients. Data extraction and risk of bias evaluation were systematically performed. Ten studies were included: 2 randomized clinical trials and 8 observational. A marginal benefit was found for early renal function with delayed tacrolimus or complete tacrolimus avoidance using mycophenolate mofetil (MMF). Observational cohort studies looked at different antibody induction strategies, calcineurin-inhibitors based maintenance immunosuppression, calcineurin-inhibitor-free sirolimus-based therapy and use of MMF versus azathioprine. Treatment with interleukin-2 receptor antibody induction, calcineurin-inhibitor minimization with MMF and steroid minimization is advisable in the low immunologic risk elderly recipient, considering the increased risk of toxicities, infection and malignancies. In the high immunologic risk elderly recipient, taking into account the morbid consequences of acute rejection in the elderly, observational studies support antibody induction with depletive antibodies, calcineurin-inhibitor, MMF and steroids; calcineurin-inhibitor-minimization is not recommended. There is very limited evidence for the benefits and harms of different immunosuppression strategies in the elderly. Most of the published literature are observational studies, and randomized controlled trials are urgently needed.

Allocation strategies for elderly kidney transplant recipients.

In all modern societies, the percentage of elderly people is increasing. However, this does not necessary reflect the percentage of patients waiting for a new kidney and the availability of organs for this entity differs markedly between countries. Thus, allocation strategies for elderly kidney recipients should be based on the characteristics of the specific countries and take into account: access to the waiting list and availability of living as well as marginal and conventional post-mortem donors.

Elderly Kidney Recipients of Deceased Donors &gt;75y Show Reduced Short and Long Term Patient and Graft Survival But 2.2 Fold Better Survival Than Their Paired Wailisted Patients Remaining On Hemodialysis.

The purpose of this study is to compare the survival of elderly patients transplanted from deceased donors (dcd) older than 75y with that of comparable waitlisted patients remaining on HD. For validating the comparison, we paired the patients looking for identical characteristics patient by patient (age group, gender, end stage renal disease, year of HD onset, type of first vascular access, time on HD and accompanying morbidities: cardiovascular, diabetes, tumors and chronic liver and chronic respiratory diseases), using a parametric survival model and we calculated the proportional risk of death by the Cox model clustering for paired patients and robust estimation of the variance. Out of the total of the 4097 recipients (KT) of first grafts from dcd transplanted between 1997 and 2011 in six hospitals of our city, 281 KT (6.9%) received a graft >75y. Patient survival of the 281 KT was 90.7%, 73.7% and 50.9% at 1, 5 and 10 years, significantly lower than that of the 3244 KT of dcd <65y: 97.1%, 90.5% and 78.9% respectively (p=0.000) but not significantly worse than that of the 572 KT of dcd aged between 66y and 75y: 93.0%, 78.0% and 52.6% respectively (p=0.260). The graft survival of the KT of dcd >75y was also significantly lower (80.1%, 60.3% and 40.5%) than that of the KT of grafts of dcd <65y (92.2%, 81.1% and 64.2%; p=0.000) but not significantly worse than that of the KT of grafts of dcd aged between 66y and 75y (86.5%, 64.2% and 41.7%; p=o.171). We then compared the survival of the elderly recipients of grafts of dcd >75y with that of comparable waitlisted patients remaining on HD. Out of the 281 KT of grafts of dcd >75y, we were able to pair 148 of them with 282 patients that had remained on HD (132 KT had two HD pairs each and 16 KT one). Patient survival at 1, 3, 5 and 10 years was 92.8%, 87.5%, 80.8% and 53.5% for the 148 KT vs 92.8%, 72.4%, 58.8% and 27.7% for the 282 patients remaining on HD. The 148 paired KT did not show statistically better survival (p=0.122) than the 133 KT that we were not able to pair. We conclude that patients remaining on HD of similar characteristics of kidney recipients of deceased donors older than 75y have a risk of death 2.2 times increased.

Does Insurance Type Influence Risk Assessment in Elderly Kidney Candidates?

Introduction:Outcomes of elderly kidney recipients is of great interest. We analyzed OPTN database to assess unique outcome predictors. Methods:We evaluated first kidney recipients in OPTN database from 1987 to 2010 who received non-DCD, Standard Criteria Donor grafts only. Results:Two variables had significant interaction with age at transplant: donor type (living v. deceased) & insurance type at transplant (private (PI) v. gov (GI)) creating 4 unique recipient groups: living donor-govt (LD-G), living donor-private (LD-P), deceased donor-govt (DD-G), & deceased donor-private (DD-P). LD-P recipients had lowest risk of death & DDG the highest. In age over 60, differences in survival increase benefiting DD-P. Overall graft survival for those under 60 paralleled the above with LD-P the best & DD-G the worst. The LD-G and DD-P groups were similar until age 60 when the DD-P group had worsening graft survival. LD-G approached the best performing LD-P. Conclusion:Higher risk older patients with PI are more likely to undergo LD or DD kidney transplant than those with GI.Table: No Caption available.Figure: No Caption available.Figure: No Caption available.

Clinical Outcomes in Elderly Kidney Transplant Recipients are Related to Acute Rejection Episodes Rather Than Pretransplant Comorbidity

Deciding whether an elderly patient with end-stage renal disease is a candidate for kidney transplantation can be difficult. We aimed to evaluate pre- and early posttransplant risk factors that could predict outcome in elderly kidney recipients. Data from all elderly (>or= 70 years, n=354), senior (60-69 years, n=577), and control (45-54 years, n=563) patients receiving their first kidney transplant at our center from 1990 to 2005 were retrieved. Patient and graft survival were analyzed in a Cox model addressing the common risk factors including Charlson comorbidity index (CCI), pretransplant dialysis time, and early acute rejection episodes. Acute rejection in the first 90 days, Hazard ratio (HR) 1.74 (1.34-2.25); time on dialysis, HR 1.02 (1.01-1.03) per month; and donor age more than 60 years, HR 1.52 (1.14-2.01) predicted mortality in the elderly. CCI score did not predict mortality in the elderly, HR 1.05 (0.98-1.12); but did so both in senior, HR 1.17 (1.08-1.27) and control recipients, HR 1.33 (1.19-1.48). Delayed graft function, HR 3.69 (2.01-6.79); donor age more than 60 years, HR 2.42 (1.30-4.49); and presence of human leukocyte antigen antibodies, HR 3.96 (1.38-11.37) were independent predictors for death-censored graft loss in the elderly. Adequate immunosuppression with low frequency of rejection episodes improves the outcome for elderly kidney recipients as does a reduction of time on dialysis. CCI score at transplantation does not seem helpful in the selection of elderly patients for kidney transplantation but plays a significant role in patients under 70 years of age.

Are All Domains of Quality of Life Poor Among Elderly Kidney Recipients?

Background This study sought to answer whether all domains of HRQoL are low among elderly kidney recipients. Methods A cross-sectional study of 162 renal transplanted subjects included group I (age < 40 years, n = 85), group II (age between 40 and 55 years, n = 55), and group III (age > 55 years, n = 22). We compared the total score of the Short Form health survey (SF-36) and its eight subscales, including physical functioning (PF), social functioning (SF), role limitations due to physical health problems (RPh), role limitations due to emotional problems (REm), mental health (MH), vitality (VT), bodily pain (BP), and general health perceptions (GH) between the study groups. Results As compared to groups II and I, group III, showes significantly lower scores of REm (49.12 ± 23.22, 63.03 ± 26.33, 64.36 ± 26.54, P = .08), PF (48.94 ± 27.41, 72.69 ± 25.54, 72.14 ± 22.79, P = .001) and SF-36 total score (46.79 ± 10.52, 54.77 ± 10.66, 54.09 ± 9.35, P = .01). There were no significant differences among SF, RPh, MH, VT, and BP. Group III reported better GH than groups II and I (52.36 ± 9.18, 48.71 ± 12.01, 43.50 ± 14.81, P = .020). Conclusions Increasing age did not result in poor health-related quality of life in all domains. The general health perception was better in the elderly, which might be due to their better coping ability.

Pharmacokinetic Considerations Relating to Tacrolimus Dosing in the Elderly

Relaxation of the upper age limits for solid organ transplantation coupled with improvements in post-transplant survival have resulted in greater numbers of elderly patients receiving immunosuppressant drugs such as tacrolimus. Tacrolimus is a potent agent with a narrow therapeutic window and large inter- and intraindividual pharmacokinetic variability. Numerous physiological changes occur with aging that could potentially affect the pharmacokinetics of tacrolimus and, hence, patient dosage requirements. Tacrolimus is primarily metabolised by cytochrome P450 (CYP) 3A enzymes in the gut wall and liver. It is also a substrate for P-glycoprotein, which counter-transports diffused tacrolimus out of intestinal cells and back into the gut lumen. Age-associated alterations in CYP 3A and P-glycoprotein expression and/or activity, along with liver mass and body composition changes, would be expected to affect the pharmacokinetics of tacrolimus in the elderly. However, interindividual variation in these processes may mask any changes caused by aging. More investigation is needed into the impact aging has on CYP and P-glycoprotein activity and expression. No single-dose, intense blood-sampling study has specifically compared the pharmacokinetics of tacrolimus across different patient age groups. However, five population pharmacokinetic studies, one in kidney, one in bone marrow and three in liver transplant recipients, have investigated age as a co-variate. None found a significant influence for age on tacrolimus bioavailability, volume of distribution or clearance. The number of elderly patients included in each study, however, was not documented and may have been only small. It is likely that inter- and intraindividual pharmacokinetic variability associated with tacrolimus increase in elderly populations. In addition to pharmacokinetic differences, donor organ viability, multiple co-morbidity, polypharmacy and immunological changes need to be considered when using tacrolimus in the elderly. Aging is associated with decreased immunoresponsiveness, a slower body repair process and increased drug adverse effects. Elderly liver and kidney transplant recipients are more likely to develop new-onset diabetes mellitus than younger patients. Elderly transplant recipients exhibit higher mortality from infectious and cardiovascular causes than younger patients but may be less likely to develop acute rejection. Elderly kidney recipients have a higher potential for chronic allograft nephropathy, and a single rejection episode can be more devastating. There is a paucity of information on optimal tacrolimus dosage and target trough concentration in the elderly. The therapeutic window for tacrolimus concentrations may be narrower. Further integrated pharmacokinetic-pharmacodynamic studies of tacrolimus are required. It would appear reasonable, based on current knowledge, to commence tacrolimus at similar doses as those used in younger patients. Maintenance dose requirements over the longer term may be lower in the elderly, but the increased variability in kinetics and the variety of factors that impact on dosage suggest that patient care needs to be based around more frequent monitoring in this age group.

HIGH MORTALITY IN THE FIRST YEAR AFTER GRAFT LOSS IN ELDERLY KIDNEY RECIPIENTS

HIGH MORTALITY IN THE FIRST YEAR AFTER GRAFT LOSS IN ELDERLY KIDNEY RECIPIENTS

HIGH MORTALITY IN THE FIRST YEAR AFTER GRAFT LOSS IN ELDERLY KIDNEY RECIPIENTS

HIGH MORTALITY IN THE FIRST YEAR AFTER GRAFT LOSS IN ELDERLY KIDNEY RECIPIENTS

Successful Liver Transplantation in Older Patients Raises New Hopes, Challenges, Ethics Questions

BEING in one's 60s or even 70s is no longer reason enough to be denied orthotopic liver transplantation, two new studies suggest. The latest findings indicate that patients in their seventh or eighth decades of life do as well as younger adults. Moreover, similar success has been recorded with elderly kidney recipients in the last several years ( Transplantation . 1989;47:259 and 1989;48:689, Am J Kidney Dis . 1988;12:516, Transplant Proc . 1989;21:2018, 2020, 2024). While donor organ shortages unfortunately persist, the positive results recorded for older recipients of livers are likely to confound even more the decision as to who should receive a liver transplant. That is, when both young and older adults face similar chances for success, who should receive the scarce organs? Our data make the debate even more difficult, says John Pirsch, MD, assistant professor of medicine and transplant physician at the University of Wisconsin Hospital and Clinics, Madison. It's

Successful liver transplantation in older patients raises new hopes, challenges, ethics questions

BEING in one's 60s or even 70s is no longer reason enough to be denied orthotopic liver transplantation, two new studies suggest. The latest findings indicate that patients in their seventh or eighth decades of life do as well as younger adults. Moreover, similar success has been recorded with elderly kidney recipients in the last several years (<i>Transplantation</i>. 1989;47:259 and 1989;48:689,<i>Am J Kidney Dis</i>. 1988;12:516,<i>Transplant Proc</i>. 1989;21:2018, 2020, 2024). While donor organ shortages unfortunately persist, the positive results recorded for older recipients of livers are likely to confound even more the decision as to who should receive a liver transplant. That is, when both young and older adults face similar chances for success, who should receive the scarce organs? "Our data make the debate even more difficult," says John Pirsch, MD, assistant professor of medicine and transplant physician at the University of Wisconsin Hospital and Clinics, Madison. "It's