Wait-listed Dialysis Patients Research Articles

Deceased donor transplantation – Our experience in the last 4 years

Background: Kidney transplant is the best treatment option for end stage kidney disease. Deceased donor transplantation has helped in increasing the donor pool for waitlisted dialysis patients. We received seventy deceased donor kidneys through the Kerala Network of Organ Sharing (KNOS) over the past 4 years from August 2013 to August 2017 and transplanted sixty six with good outcome. Pre-implantation biopsy performed in marginal donors helped in decision making to take the kidney and increase the donor pool. Aims and Objectives: 1)To evaluate outcome of renal transplant recipients in deceased donor transplantation. 2)To evaluate the role of pre-implantation biopsy to improve donor selection for better long term outcome. Materials and Methods: Sixty-six deceased donor kidneys were transplanted into the recipients from our pool of 253 patients registered with the KNOS. Four cadaver kidneys were rejected based on pre-implantation biopsy. Fifty-nine transplants were done at VPS Lakeshore and seven were done at PVS Memorial Hospital, Kochi. Donors of age less than 65 years were considered. Pre-tranpslant evaluation of recipients on waiting list including lab and cardiac evaluation with PRA status was done. Cross match was done prior to transplant. Triple immunosuppression including cyclosporine, mychophenolate mofetil and prednisolone with basiliximab as induction agent was used in all cases. Low dose tacrolimus was introduced after the third month in some cases. Pre-implantation biopsy was done in marginal donors for better donor selection. Results: Of the 66 recipients, 52 (78.8%) were males and 14 (21.2%) were females. PRA status was negative in all recipients. Deceased donors 56% IFTA changes, and other had 30%–40% IFTA changes. Results at 4 years post-transplant showed graft survival in 55/66 (83.34%) and patient survival in 60/66 (90.91%) cases. Six patients died: two with pneumocystis carinii pneumonia (PCP) (at 9 months/3.3 years post-transplant), one with mucormycosis (at 16 months post-transplant), one with acute coronary syndrome (immediate post-transplant), and two patients with sepsis. The average serum creatinine was 2.4 mg/dl in 1 (1.8%) case. The surgical outcome was good in all (100%) patients with no intraoperative surgical complications. Delayed graft function was noted in 18% of patients. Prolonged cold ischemia time was noted in patients with acute tubular necrosis. Six patients had acute rejection, of which two were antibody mediated, and four had acute cellular rejection. One patient had tacrolimus toxicity on biopsy and was shifted to everolimus. Infections included one patient with surgical wound infection, 12 patients with urinary tract infections, one patient with invasive fungal infection, and two patients with PCP. At 4 years, deceased donor transplantation has good graft and patient outcomes. Conclusion: Deceased donor transplantation has good graft outcome which is comparable to live non related donors. It has minimal paper work and less costly than routine live transplant. Pre-implantation biopsy should be considered in marginal donors for appropriate donor selection and avoid organ wastage in doubtful cases. In our study we noted that transplant outcome was better in recipients receiving kidney from with in the city limits because of less cold ischemia time. Hence facilities for early transportation of organs with minimal procedural hurdles to minimize cold ischemia time should be carried out by the concerned authorities. Proactivity from the Government at state, zonal and national level is needed to improve deceased donor pool and cadaver transplantation in India.

Bone histomorphometry and indicators of bone and mineral metabolism in wait-listed dialysis patients

The aim of this study was to evaluate the associations between bone histomorphometry and bone volume measured by dual-energy X-ray absorptiometry (DXA) in wait-listed dialysis patients. Further, the circulating markers of mineral metabolism and bone turnover were compared. Bone biopsies were performed on 61 wait-listed dialysis patients. Plasma samples were obtained for indicators of mineral metabolism and bone turnover. Bone mineral density (BMD) was determined by DXA and bone histomorphometry was performed. Bone histomorphometry could be determined in 52 patients (72% men, 54% on hemodialysis and median dialysis vintage 18 months). Adynamic bone disease was present in 21% of patients and 4% had osteomalacia. High turnover bone disease (mixed uremic osteodystrophy and osteitis fibrosa) was observed in 48% of patients (17% and 31%, respectively). 10% of patients had normal bone histomorphometry while 17% had mild osteitis fibrosa. Mineralization defect was found in 33% of patients. There was a strong correlation between femoral neck (FN) T-score and histologically measured cancellous bone volume (p = 0.004), FN T-score having a good negative predictive value for low cancellous bone volume. Plasma osteocalcin levels were significantly higher in the high-turnover group and lower in the mineralization defect group (p = 0.014 and p = 0.02, respectively). Our study confirms the high frequency of abnormal bone histology in wait-listed dialysis patients. Low bone turnover was less common than previously reported. Noninvasive markers had a limited value for assessing bone histology, whereas femoral BMD reflected bone volume well.

Renal transplantation with expanded criteria donors: Which is the optimal immunosuppression?

The growing gap between demand and supply for kidney transplants has led to renewed interest in the use of expanded criteria donor (ECD) kidneys in an effort to increase the donor pool. Although most studies of ECD kidney transplantation confirm lower allograft survival rates and, generally, worse outcomes than standard criteria donor kidneys, recipients of ECD kidneys generally have improved survival compared with wait-listed dialysis patients, thus encouraging the pursuit of this type of kidney transplantation. The relative benefits of transplantation using kidneys from ECDs are dependent on patient characteristics and the waiting time on dialysis. Because of the increased risk of poor graft function, calcineurin inhibitor (CNI)-induced nephrotoxicity, increased incidence of infections, cardiovascular risk, and malignancies, elderly recipients of an ECD kidney transplant are a special population that requires a tailored immunosuppressive regimen. Recipients of ECD kidneys often are excluded from transplant trials and, therefore, the optimal induction and maintenance immunosuppressive regimen for them is not known. Approaches are largely center specific and based upon expert opinion. Some data suggest that antithymocyte globulin might be the preferred induction agent for elderly recipients of ECD kidneys. Maintenance regimens that spare CNIs have been advocated, especially for older recipients of ECD kidneys. CNI-free regimens are not universally accepted due to occasionally high rejection rates. However, reduced CNI exposure and CNI-free regimens based on mammalian target of rapamycin inhibitors have shown acceptable outcomes in appropriately selected ECD transplant recipients.

Impact of Peripheral Vascular Disease on Mortality in Wait Listed Dialysis Patients and Recipients of a First Kidney Transplant.

Introduction: There is lack of information whether waitlisted dialysis patients with peripheral vascular disease (PVD) benefit from kidney transplantation. Methods: We used a cohort of USRDS incident dialysis patients from 2001 to 2007, with follow-up through 2008. Patients with PVD and under the age of 70 were included and divided into three groups; PVD patients on dialysis, waitlisted and PVD patients who received a first transplant (deceased or living). We calculated the mean comorbidity risk score (CRS) to determine differences in health status inpatients on dialysis, waitlist and at transplantation. CRS comprised of history of diabetes mellitus, hypertension, hypercholesterolemia, myocardial infarction, cerebrovascular disease and age greater than 55 years, by assigning a value of 1 to each comorbidity at the time first service. The primary outcome was all cause mortality. Standardized Mortality Ratios (SMR) and hazard ratios of death were calculated for statistical comparisons between the 3 groups. Results: 23,699 incident dialysis patients met inclusion criteria; only 16.7% (n=3964) were waitlisted, of which 8.9 % (n=2121) were transplanted. The annual death rates per 100 patient years was 22.86 in PVD patients on dialysis, 4.98 in waitlisted PVD patients and 4.86 in kidney transplant recipients. There was significant differences in mean co-morbidity risk score (2.38± 0.018 vs. 2.30 ±0.020 p=0.003) but not in adjusted hazard ratio 1.10 (95% CI 0.89-1.33, p=0.41) vs. 1.05 (95% CI 0.79-1.39, p=0.75) between waitlisted and transplanted patients with PVD. Figure 1 shows patient survival in PVD patients.Figure: No Caption available.Conclusions: There was no survival advantage of transplantation compared to remaining on the waitlist in PVD patients.

Excess Risk of Death Increases with Time from First Dialysis for Patients on the Waiting List: Implications for Renal Allograft Allocation Policy

Background: Subgroups of patients registered on a kidney transplant waiting list have higher than usual mortality levels. This study used data from the French Renal Epidemiology and Information Network (REIN) Registry to quantify the impact over time of various comorbidities on the excess risk of death among patients on the waiting list. Methods: Lexis diagrams were used to analyze time since onset of end-stage renal disease and time since registration on the waiting list. The number of excess deaths was calculated by comparison with the number of expected deaths in the general population of the same age and sex. Results: During 45,013 person-years of follow-up, 7,224 patients died, 5,956 (82%) more than expected relative to the general population. There were 101 deaths among wait-listed dialysis patients, 76 more than expected. The excess risk of death increased by 45% per additional year on the waiting list (18-79%, p = 0.0005). Time from end-stage renal disease onset until list registration (p = 0.004), time since registration (p < 0.001), age >65 years (p = 0.008), the presence of a primary renal disease (p = 0.028), and the number of comorbidities (p = 0.035) were independent predictors of death while on the waiting list. Conclusions: The excess risk of death while on the waiting list increased faster in patients with comorbidities. These results require consideration of ways to accelerate access to transplantation in high-risk patients.

Quantification of the Early Risk of Death in Elderly Kidney Transplant Recipients

To inform decision making regarding transplantation in patients ≥ 65 years, we quantified the early posttransplant risk of death by determining the time to equal risk and equal survival between transplant recipients and wait-listed dialysis patients in the United States between 1995 and 2007 (total n = 25468). Survival was determined using separate multivariate nonproportional hazards analyses in low-, intermediate- and high-risk cardiovascular risk patients. Compared to wait-listed patients with similar cardiovascular risk, standard criteria (SCD) and expanded criteria (ECD) recipients had a higher risk of death in the perioperative and early-posttransplant period. In contrast, low and intermediate risk living donor (LD) recipients had an immediate survival advantage compared to similar risk wait-listed patients. In all risk groups, transplantation was associated with a long-term survival advantage compared to dialysis, but there were marked differences in time to equal risk of death, and time to equal survival by donor type. For example, survival in high-risk recipients of an LD, SCD and ECD transplant became equal to that in similar risk wait-listed patients 130, 368 and 521 days after transplantation. Early posttransplant mortality risk is eliminated in low- and intermediate-risk patients, and markedly reduced in high-risk patients with LD transplantation.

Transplantation in Obese Patient

Obesity is a worldwide epidemic leading to severe comorbidity that damages end-organ function. Overall transplant outcomes in this population are inferior to those in nonobese patients. Large population studies show decreased patient and graft survival in obese kidney transplant patients. Despite the poorer outcomes, kidney transplantation is considered because of the survival benefit as compared with the wait-listed dialysis patients. In liver transplantation, the benefit to transplantation as compared with remaining on the list is obvious, as there is no viable liver dialysis at this time. Obesity in potential organ donors impacts both medical and surgical issues. Obesity-related kidney disease affects both the remaining and transplanted kidney. Pancreas donor organs are associated with decreased early graft survival. Liver donor organs with significant steatosis lead to an increased risk for delayed or nonfunction of the organ. Immunosuppressive drugs with variable lipophilicity and altered volume of distribution can greatly affect the therapeutic usefulness of these drugs. Transplant candidates benefit from a multidisciplinary team approach to their care. As the epidemic progresses and less-invasive treatments for metabolic surgery evolve, we are likely to require more patients to lose weight prior to transplantation as we continue to strive for improved outcomes.

Psychosocial variables are associated with being wait-listed, but not with receiving a kidney transplant in the Dialysis Outcomes and Practice Patterns Study (DOPPS)

Psychosocial factors are associated with clinical outcomes in patients with end-stage renal disease. It is not known if self-reported depression and quality of life influence the likelihood of being wait-listed and receiving a transplant. Prevalent cross section of 18- to 65-year-old hemodialysis (HD) patients in the USA (N = 2033) and seven European countries (N = 4350) from the Dialysis Outcomes and Practice Patterns Study phase II and III was analyzed. Wait-listed patients (N = 1838) were followed until kidney transplantation. Self-reported depressive symptoms were assessed by the Center for Epidemiologic Studies-Depression scale, 10-item version (CES-D) and health-related quality of life (HR-QoL) by the Kidney Disease Quality of Life Short Form 12 scale Physical Component Score (PCS). At study entry, 27% (USA) to 53% (UK) of patients were wait-listed in participating countries. Variables associated with lower odds of being on the waiting list included worse HR-QoL, more severe depressive symptoms, older age, fewer years of education, lower serum albumin, lower hemoglobin, shorter time on dialysis and presence of multiple comorbid conditions. Among wait-listed patients, significantly lower transplantation rates were seen for females, blacks, patients having prior transplantation and multiple comorbid conditions but not PCS or CES-D. Fewer depressive symptoms and better HR-QoL are associated with being on the waiting list in prevalent HD patients but not with receiving a kidney transplant among wait-listed dialysis patients. Regular assessment of subjective well-being may help identify patients with reduced access to wait-listing and kidney transplantation.

Kidney Transplantation From Donors After Cardiac Death: A 25-Year Experience

The shortage of organ donors presents a major obstacle for adequate treatment of patients with end-stage renal disease. Donation after cardiac death (DCD) has been shown to increase the number of kidneys available for transplantation. The present article reports on the first 25 years of our experience with DCD kidney transplantation. This observational cohort study included all DCD kidney transplantations recovered in our procurement area from January 1, 1981 until December 31, 2005 (n=297). Patients were followed up until the earliest of death or December 31, 2006. Clinical outcomes were compared with matched kidney transplantations from brain dead donors (DBD, n=594), using multivariable regression models to adjust for potential confounders. DCD activity resulted in a 44% increase in the number of deceased donor kidneys from our organ procurement area. After adjustment for potential confounders, the odds of primary nonfunction and delayed graft function were 7.5 (95% CI, 4.0-14.1; P<0.001) and 10.3 (95% CI, 6.7-15.9; P<0.001) times greater, respectively, for DCD kidneys compared with DBD kidneys. The high incidence of primary nonfunction of DCD kidneys resulted in an increased rate of graft loss (HR, 1.82; 95% CI, 1.37-2.42; P<0.001). However, DCD kidneys that did not experience primary nonfunction functioned as long as DBD kidneys (HR, 1.05; 95% CI, 0.73-1.51; P=0.79). Patient survival of DCD and DBD kidney recipients was equivalent (HR, 1.16; 95% CI, 0.87-1.54; P=0.32). The benefits of DCD kidney transplantation outweigh the increased risk of early graft loss. Expansion of the supply of DCD kidneys is likely to improve the treatment of wait-listed dialysis patients.

Challenges of Abdominal Organ Transplant in Obesity

Obesity is a worldwide epidemic and public health crisis associated with severe comorbidity leading to end organ dysfunction and poorer transplant outcome. Large population studies show decreased patient and graft survival in obese kidney transplant patients. Despite the poorer outcomes, kidney transplant is considered because of the survival benefit as compared to the wait-listed dialysis patients. In liver transplantation, the benefit of transplant as compared to remaining on the list is obvious because there is no viable liver dialysis at this time.Obesity in potential organ donors impacts both medical and surgical issues. Obesity-related kidney disease affects both the remaining and transplanted kidney. Pancreas donor organs are associated with decreased early graft survival. Liver donor organs with significant steatosis lead to an increased risk for delayed function or nonfunction of the organ.Immunosuppressive drugs with variable lipophilicity and altered volume of distribution can greatly affect the therapeutic usefulness of these drugs.Transplant candidates benefit from a multidisciplinary team approach to their care. As the epidemic progresses and less invasive treatments for metabolic surgery evolve, we are likely to see more patients lose weight before transplant as we continue to strive for improved outcomes.

Symptoms of Depression in Kidney Transplant Recipients: A Cross-sectional Study

Depression is associated with impaired quality of life and increased morbidity and mortality in patients with end-stage renal disease. Little is known about the prevalence and correlates of depression in kidney transplant recipients. In this study, we aimed to compare depressive symptoms between kidney transplant recipients and wait-listed dialysis patients and identify the correlates of depressive symptoms in the transplant recipient population. Observational cross-sectional study using the Center for Epidemiologic Studies Depression Scale (CES-D) to assess the severity of depressive symptoms. A cutoff score of 18 was used to identify the presence of depression. 1,067 kidney transplant recipients and 214 wait-listed dialysis patients were asked to participate; the final analysis included 854 kidney transplant and 176 wait-listed dialysis patients, respectively. Sociodemographic and clinical variables. Severity of depressive symptoms and presence of depression (CES-D score > or = 18). The prevalence of depression was 33% versus 22% in wait-listed versus transplant patients, respectively (P = 0.002). In multivariate regression, number of comorbid conditions, estimated glomerular filtration rate, perceived financial situation, and marital status were significant and independent predictors of depression in the transplant recipient group. Treatment modality was associated significantly with the presence of depression, even after adjustment for clinical and sociodemographic variables (OR, 2.01; 95% CI, 1.25-3.23; P = 0.004). Self-reported measurement of depressive symptoms. The prevalence of depression is lower in transplant recipients than in wait-listed patients. However, one-fifth of transplant patients are still at high risk of clinically significant depression. Comorbid conditions, socioeconomic status, and treatment modality predicted depressive symptoms in patients with end-stage renal disease.

Early Living-Donor Kidney Transplantation: A Review of the Associated Survival Benefit

Avoidance of dialysis-related morbidity, improvement in quality of life, and reduction of costs have been mentioned as advantages of preemptive kidney transplantation. However, this therapeutic option is underutilized. Previous studies assessing the patient survival benefit of preemptive kidney transplantation compared it with postdialysis kidney transplantation. These studies may have been subjected to lead-time bias. When comparing patient survival of preemptive kidney transplant patients with waitlisted dialysis patients, there is a clear patient survival advantage in favor of preemptive kidney transplantation. This benefit justifies encouragement of preemptive kidney transplantation.

High prevalence of patients with a high risk for obstructive sleep apnoea syndrome after kidney transplantation association with declining renal function

Obstructive sleep apnoea syndrome (OSAS) is much more prevalent in patients on dialysis than in the general population. Our aim was to assess for the first time the prevalence of patients with a high risk for OSAS and its clinical correlates in a large sample of kidney transplanted patients. We also wanted to compare the prevalence of the disorder between waitlisted dialysis patients (WL) and kidney transplanted patients (Tx). One thousand sixty-seven kidney transplanted patients were asked to participate in a cross-sectional survey ('TransQoL-HU Study'). Socio-demographic data, history of renal disease, medication, comorbidity and laboratory parameters were collected at enrolment. Patients completed a battery of self-administered questionnaires including the Berlin Sleep Apnoea Questionnaire to assess risk status of OSAS. The final analyses included 841 Tx and 175 WL patients. The prevalence of high risk for OSAS was similar in the transplanted group vs WL patients (27% vs 33%). In multivariate logistic regression analysis male gender, older age, lower educational status, worse kidney function, use of hypnotic drugs and comorbidity were independent predictors for high risk of OSAS in kidney transplanted patients. High risk for sleep apnoea is highly prevalent in the kidney transplanted population. In addition to the well-known risk factors of OSAS (male gender, obesity, use of hypnotic drugs, comorbidity), impaired kidney function was also independently associated with high risk for OSAS.

Chronic Insomnia in Kidney Transplant Recipients

Recent studies confirmed that sleep disorders have a significant impact on various aspects of health in patients at different stages of chronic kidney disease. At the same time, there is an almost complete lack of information on the prevalence and correlates of insomnia in kidney transplant recipients. In a cross-sectional study, the Athens Insomnia Scale was used to assess the prevalence of insomnia in a large sample of kidney transplant recipients compared with wait-listed dialysis patients and also a matched group obtained from a nationally representative sample of the Hungarian population. The prevalence of insomnia was 15% in wait-listed patients, whereas it was only 8% in transplant recipients (P < 0.001), which, in turn, was not different from the prevalence of this sleep problem in the sample of the general population (8%). Prevalences of insomnia in the transplant group were 5%, 7%, and 14% for the groups with glomerular filtration rates (GFRs) greater than 60 mL/min (> 1.00 mL/s), 30 to 60 mL/min (0.50 to 1.00 mL/s), and less than 30 mL/min (< 0.5 mL/s), respectively (P < 0.01). However, estimated GFR was no longer associated significantly with insomnia in the transplant population after statistical adjustment for several covariates. In a multivariate model, insomnia was significantly and independently associated with treatment modality (transplantation versus wait listing), as well as the presence of depression, restless legs syndrome, and high risk for obstructive sleep apnea syndrome, and with self-reported comorbidity. The prevalence of insomnia was substantially less in the transplant group than in wait-listed dialysis patients and similar to that observed in the general population. Because this condition potentially is treatable, attention should be directed to the appropriate diagnosis and management of insomnia in the kidney transplant recipient population.

Restless legs syndrome in patients after renal transplantation

There is an almost complete lack of information on the epidemiology of sleep disorders in kidney-transplanted patients. In this report the authors assess the prevalence and clinical correlates of restless legs syndrome (RLS) in kidney-transplanted (Tx) patients. They also analyze the impact of declining renal function on this condition in the Tx population. Finally, the prevalence of RLS was compared between waitlisted dialysis patients (WL), and the Tx group. In a cross-sectional study enrolling 992 patients (816 Tx and 176 WL), the presence of RLS was assessed using the Restless Legs Syndrome Questionnaire. Clinical and sociodemographic data were collected from the patients' medical records. In transplanted patients, the prevalence of RLS was 4.8%. RLS was associated strongly with declining renal function. In groups formed on the basis of estimated glomerular filtration rate (eGFR), the prevalence of RLS was 1.8%, 5.1%, 6.5%, and 23.5% in patients with eGFR greater than 60 mL/min/1.73 m 2 ; eGFR 30 to 59 mL/min/1.73 m 2 ; eGFR 15 to 29 mL/min/1.73 m 2 ; and eGFR less than 15 mL/min/1.73 m 2 , respectively (P < 0.001). There was also a significant association between RLS and lower serum hemoglobin, higher number of self-reported comorbid conditions, and higher prevalence of iron deficiency. RLS was significantly less frequent in patients taking steroids than in patients not taking this medication (4% versus 9%, P < 0.05). In multivariate analysis, not taking steroids, eGFR, self-reported comorbidity, and iron deficiency were significant and independent predictors of RLS. Dialysis treatment was associated with increased odds for RLS (odds ratio 2.2; 95% confidence interval 1.11 to 4.35; P < 0.05) even after adjusting for serum hemoglobin and comorbidity. The prevalence of RLS is significantly lower in Tx patients than in patients on maintenance dialysis. Declining renal function is associated with increasing prevalence of the condition.

Shared frailty models for recurrent events and a terminal event.

There has been an increasing interest in the analysis of recurrent event data (Cook and Lawless, 2002, Statistical Methods in Medical Research 11, 141-166). In many situations, a terminating event such as death can happen during the follow-up period to preclude further occurrence of the recurrent events. Furthermore, the death time may be dependent on the recurrent event history. In this article we consider frailty proportional hazards models for the recurrent and terminal event processes. The dependence is modeled by conditioning on a shared frailty that is included in both hazard functions. Covariate effects can be taken into account in the model as well. Maximum likelihood estimation and inference are carried out through a Monte Carlo EM algorithm with Metropolis-Hastings sampler in the E-step. An analysis of hospitalization and death data for waitlisted dialysis patients is presented to illustrate the proposed methods. Methods to check the validity of the proposed model are also demonstrated. This model avoids the difficulties encountered in alternative approaches which attempt to specify a dependent joint distribution with marginal proportional hazards and yields an estimate of the degree of dependence.

Incidence and Cost of New Onset Diabetes Mellitus Among U.S. Wait-Listed and Transplanted Renal Allograft Recipients

This study sought to determine 1) the incidence and costs of new onset diabetes mellitus (NODM) associated with maintenance immunosuppression regimens following renal transplantation and 2) whether the mode of dialysis pretransplant or the type of calcineurin inhibition used for maintenance immunosuppression affected either the incidence or cost of NODM. The study examined the United States Renal Data System's clinical and financial records from 1994 to 1998 of all adult, first, single-organ, renal transplantations in either 1996 or 1997 with adequate financial records. It used the second diagnosis of diabetes in previously nondiabetic patients to identify NODM. While NODM had an incidence of approximately 6% per year among wait-listed dialysis patients, NODM over the first 2 years post-transplant had an incidence of almost 18% and 30% among patients receiving cyclosporine and tacrolimus, respectively. By 2 years post-transplant, Medicare paid an extra $21 500 per newly diabetic patient. We estimated the cost of diabetes attributable to maintenance immunosuppression regimens to be $2025 and $3308 for each tacrolimus patient and $1137 and $1611 for each cyclosporine patient at 1 and 2 years post-transplant, respectively.

Geriatric issues in renal transplantation.

There are an increasing amount of data which are compelling us to consider the issue of age in dealing with decisions regarding both renal transplant recipients and donors. These geriatric issues in transplantation can be summarized as follows: (1) The explosion of a geriatric population of patients with ESRD, in association with data showing a survival advantage of transplantation over wait-listed dialysis patients, demands an increase in expertise in transplantating patients over 60 years old. (2) The critical shortage in cadaveric organ supply is creating a variety of solutions including expanding the donor pool with older kidneys in which long term survival may be shorter than in kidneys from younger donors. (3) The donor shortage, in association with data demonstrating improved survival of living related and unrelated donor transplants, is generating an increased number of older (> 60 years old) individuals who want to donate to a relative, spouse or friend. Future efforts should be directed toward continued research designed to evaluate the efficacy and safety of these trends. We also need to provide improved training in geriatrics for nephrologists so that we and transplant surgeons can deliver better medical care to an aging population of patients with ESRD.

Comparison of Survival Probabilities for Dialysis Patients vs Cadaveric Renal Transplant Recipients

To compare mortality risk among cadaveric renal transplant recipients vs transplant candidates on dialysis in the cyclosporine era. Patient mortality risk was analyzed by treatment modality for a completed statewide patient population. All Michigan residents younger than age 65 years who started endstage renal disease (ESRD) therapy between January 1, 1984, and December 31, 1989, were included. Patients were followed up from ESRD onset (n = 5020), to wait-listing for renal transplant (n = 1569), to receiving a cadaveric first transplant (n = 799), and to December 31, 1989. Mortality rates. Using a time-dependent variable based on the waiting time from date of wait-listing to transplantation and adjusting for age, sex, race, and primary cause of ESRD, the relative risk (RR) of dying was increased early after transplantation and then decreased to a beneficial long-term effect, given survival to 365 days after transplantation (RR, 0.36; P < .001). This lower long-term risk was most pronounced (RR, 0.25) among diabetic transplant recipients compared with diabetic wait-listed dialysis patients (P < .001) and not observed among patients with glomerulonephritis as cause of ESRD (P > .05). Overall, the estimated times from transplantation to equal mortality risk was 117 +/- 28 days and to equal cumulative mortality was 325 +/- 91 days. The overall mortality risk following renal transplantation was initially increased, but there was a long-term survival benefit compared with similar patients on dialysis. These analyses allow improved description of comparative mortality risks for dialysis and transplant patients and allow advising patients regarding comparative survival outcomes.