Survival of Patients Older Than 60 Years With Kidneys Transplanted From Spanish Expanded Criteria Donors Versus Patients Continued on Hemodialysis

doi:10.1016/j.transproceed.2009.06.176

Transplantation Proceedings

Volume 41, Issue 6, July–August 2009, Pages 2376-2378

https://doi.org/10.1016/j.transproceed.2009.06.176 Get rights and content

Abstract

A retrospective study was performed in patients >60 years of age who had initiated hemodialysis (HD) at our hospital between 2000 and 2005 (n = 211). Of these, 47 were placed on the kidney transplantation waiting list and 164 were excluded and continued on HD. Cadaveric transplantation was performed in 31 patients using an expanded criteria donor organ (TR), while 16 remained on the waiting list (WL). We compared the 12-month survivals of patients in the 3 groups (TR/WL/HD), namely, 97%/78%/75% (P < .045). Survival at 24, 36, 48, and 60 months for TR/HD were 89%/57%; 86%/43%; 79%/32%; and 70%/16% (P < .001). HD patients showed greater comorbidity than TR patients: Charlson index >8 was 67.9% vs 19.4%. A total of 23.7% of patients were excluded solely due to advanced age. We compared survivals among the TR patients vs those excluded only because of age using paired comorbidity (Charlson index <8): 97%/95%, 89%/58%, and 86%/44% at 12, 24, and 36 months (P < .023). We concluded that kidney transplantation with an expanded criteria donor organ in elderly patients was a procedure that provided greater survival than HD for patients excluded from transplantation, for patients on the WL who did not receive a transplant, and for patients excluded solely due to advanced age who showed comorbidity comparable to the transplant recipients. According to our data, elderly patients with low comorbidity should be considered for inclusion on the WL for transplantation.

Section snippets

Patients and Methods

We performed this retrospective study of patients >60 years of age who initiated HD between 2000 and 2005 in area 11 of the Madrid community, collecting demographic as well as comorbidity and mortality data. The population was divided into 3 groups: 1 subjects on HD who were candidates for transplantation (WL); 2 individuals on HD who were not candidates for transplantation (HD); and 3 patients who underwent transplantation with an expanded criteria graft (TR). Measurement of the survival rate

Results

We analyzed 211 patients: 134 men (63.5%) and 77 women (36.5%) with a mean follow-up of 23 ± 18 months (range, 0.1–71.5 months; median, 18 months). A total of 47 patients (22.2%) were placed on the WL, including 31 (65.9%) who underwent transplantation. Twenty-five patients with Charlson index < 8 were excluded only because of advanced age.

Patients on HD showed a greater comorbidity index and ischemic heart disease in relation to those on the WL (P < .003) and to the transplant patients (P <

Discussion

Renal transplant leads to greater patient survival than HD,⁴ even among elderly patients who do not suffer great comorbidity.5, 6, 7 We sought to verify whether survival was also improved among elderly patients who received a kidney from an expanded criteria donor.8, 9, 10 Our data showed significantly increased survival of TR patients at 60 months follow-up beyond those of patients on HD or with advanced age. Survival of TR patients also displayed a better trend compared with those on the WL.

References (10)

G. Danovitch et al.
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A. Foss et al.
Should kidneys from older cadaveric donors be aged-matched to the recipient?
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E. Luna et al.
Evolution of suboptimal renal transplantations: experience of a single Spanish center
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H.C. Rayner et al.
Mortality and hospitalization in haemodialysis patients in five European countries: results from the dialysis outcomes and practice patterns study (DOPPS)
Nephrol Dial Transplant
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J. Macrae et al.
Live and deceased donor kidney transplantation in patients aged 75 years and older in the United States
Int Urol Nephrol
(2005)

There are more references available in the full text version of this article.

Cited by (12)

Chronic kidney disease in the elderly patient
2017, Revista Espanola de Geriatria y Gerontologia
La enfermedad renal crónica (ERC) es altamente prevalente en la población mundial, con un especial impacto en los ancianos. Cerca de la mitad de los pacientes mayores de 75 años cumplen criterios para ser catalogados como enfermos renales crónicos según las últimas guías Kidney disease improving global outcomes (KDIGO) 2012 para la evaluación y manejo de la ERC. Sin embargo, el paciente geriátrico con ERC tiene una serie de características que no se extrapolan a las guías clínicas de la población general. Es imprescindible tener clara la evolución natural habitual de la ERC en el anciano, así como los síntomas y datos de alarma que orienten al clínico a valorar una derivación a Nefrología o la actitud terapéutica a seguir. En esta revisión presentaremos un abordaje completo desde el punto de vista fisiopatogénico, diagnóstico, terapéutico y evolutivo de la función renal en el anciano.
Chronic kidney disease (CKD) is widely prevalent worldwide, with a special impact on elderly population. Around half of people aged over 75 meet diagnostic criteria for CKD according to the recent ‘Kidney disease improving global outcomes’ (KDIGO) 2012 clinical practice guideline on the evaluation and management of CKD. However, geriatric patients have characteristics that may not be addressed by general guidelines. Therefore, it is important to know the natural history of the disease, symptoms, and ‘red-flags’ that could help in the management of these patients. In this review, a complete approach is presented on the pathophysiology, diagnosis, and treatment of CKD in the geriatric population.
Do elderly recipients really benefit from kidney transplantation?
2015, Transplantation Reviews
Data from the nineties showed that even older individuals had a survival advantage with kidney transplantation compared to dialysis. Consequently, we are increasingly wait-listing high-risk patients in terms of age and co-morbidities. However, times are changing. Due to severe organ shortage we now use more often expanded criteria donor kidneys with less favorable outcomes, while at the same time survival on dialysis is improving. The question therefore rises again if elderly patients really benefit from transplantation nowadays. At least for the U.S., recent data still suggest an overall survival benefit with transplantation in older recipients but the risks vary greatly with the health status of the recipient and with the type of donor. Especially for transplant centers outside of the U.S., recent large studies are lacking. Because of continuing changes in both donor and recipient characteristics as well as dialysis outcomes, a permanent area-specific reassessment of data is needed. In this review we describe the important evolutions in transplant and dialysis care over the last 20 years and provide an overview on recent data comparing survival on dialysis versus transplantation in the elderly.
Preemptive kidney transplantation in elderly recipients with kidneys discarded of very old donors: A good alternative
2015, Nefrologia
Citation Excerpt :
In recent years, the number of patients older than 65 years with end stage renal disease (ESRD) has increased1 and is now the fastest growing patient population requiring renal replacement therapy in both Europe and the United States. Kidney transplantation improves life expectancy and quality of life in patients of all ages with ESRD2,3 and is an attractive option for elderly patients, in whom it confers lower mortality rates and improved quality of life compared to dialysis.4,5 However, a vast majority of kidney transplants in elderly patients are performed after a period of chronic dialysis, and in those elderly patients in whom a preemptive kidney transplant (PKT) is performed the organ comes from a living donor.
The shortage of organs is a major hurdle in kidney transplantation, and one solution to the problem is to extend the age of the donor. However, organs from older donors are often discarded due to the macroscopic appearance of the parenchyma or major vessels. On the other hand, a large number of elderly patients are potential candidates for kidney transplantation, while many kidneys from elderly deceased donors are discarded due to a lack of age-matched recipients. In addition, a large number are often discarded due to the lack of compatible recipients among elderly patients undergoing chronic dialysis. A possible solution to avoid this wastage of kidneys potentially suitable for transplantation could be the performance of preemptive kidney transplantation (PKT) in carefully selected elderly patients. PKT improves graft and patient survival compared to other renal replacement therapy options. There is no information about PKT in elderly patients receiving kidneys from elderly deceased donors.
From 2007 to 2012, we performed a prospective observational study comparing 26 elderly patients receiving PKT with a control group of 26 elderly patients receiving a first transplant after prior dialysis.
Mean age of recipients was 74.3 ± 2.9 years and mean age of donors was 73.8 ± 4.1 years. Induction immunosuppression was similar in both groups. Death-censored graft survival was 96% in the PKT group and 68% in the control group (p = 0.02), at 5 years after transplantation. Immediate and delayed graft function occurred in 92% and 3.8%, respectively, of patients in the PKT group and 53% and 34.6% of patients in the control group (p = 0.005). Acute rejection was significantly more frequent in PKT patients (23.1% vs 3.8%, p = 0.043). At the end of follow-up time 35.5 ± 20.1 months, the glomerular filtration rate was similar in both groups (42.2 ± 11.7 vs 41.7 ± 11.2 ml/min, p-value = 0.72). Patient survival was similar in the two groups.
Elderly patients with end stage of renal disease non-dialysis may benefit from PKT elderly deceased donors whose kidneys were to be discarded for there are not patients in the waiting list.
La escasez de órganos constituye una importante dificultad para los trasplantes renales, y una posible solución del problema está en ampliar el margen de edad aceptado para los donantes. Sin embargo, los órganos de donantes de edad avanzada se desechan con frecuencia debido al aspecto macroscópico del parénquima o de los vasos sanguíneos principales. Por otro lado, hay un gran número de pacientes ancianos que son posibles candidatos a un trasplante renal, mientras que muchos riñones de donantes ancianos fallecidos se desechan porque no hay receptores de una edad similar. Además, a menudo se desecha un gran número de órganos a causa de la falta de receptores compatibles entre los pacientes ancianos en diálisis crónica. Una posible solución para evitar que se desperdicien estos riñones que pueden ser apropiados para un trasplante sería llevar a cabo un trasplante renal prediálisis (TRP) en pacientes ancianos cuidadosamente seleccionados. El TRP mejora la supervivencia del órgano trasplantado y del paciente, en comparación con otras opciones de terapia sustitutiva renal. No disponemos de información acerca del TRP en pacientes ancianos a los que se trasplantan riñones de donantes ancianos fallecidos.
De 2007 a 2012 llevamos a cabo un estudio prospectivo observacional en el que se compararon 26 pacientes ancianos que recibieron un TRP con un grupo de control formado por 26 pacientes ancianos a los que se practicó un primer trasplante después de una diálisis previa.
La media de edad de los receptores fue de 74,3 ± 2,9 años y la de los donantes de 73,8 ± 4,1 años. La inmunosupresión de inducción fue similar en los dos grupos de tratamiento. La supervivencia del órgano, con censura para el análisis estadístico a la muerte del paciente, fue del 96% en el grupo de TRP y del 68% en el grupo de control (p = 0,02), 5 años después del trasplante. Hubo una función inmediata y tardía del riñón trasplantado en el 92% y 3,8% de los pacientes, respectivamente, en el grupo de TRP, y en el 53% y 34,6% de los pacientes en el grupo de control (p = 0,005). El rechazo agudo fue significativamente más frecuente en los pacientes a los que se practicó un TRP (23,1% frente a 3,8%, p = 0,043). Al final del periodo de seguimiento de 35,5 ± 20,1 meses, la filtración glomerular fue similar en ambos grupos (42,2 ± 11,7 frente a 41,7 ± 11,2 ml/min, valor de p = 0,72). La supervivencia de los pacientes fue también similar en los dos grupos.
En los pacientes ancianos con una enfermedad renal terminal no dializados, puede resultar beneficioso un TRP de donantes ancianos fallecidos cuyos riñones se desecharían si no hubiera pacientes en lista de espera.
Preemptive kidney transplantation in elderly recipients with kidneys discarded of very old donors: A good alternative
2015, Nefrologia
Citation Excerpt :
In recent years, the number of patients older than 65 years with end stage renal disease (ESRD) has increased1 and is now the fastest growing patient population requiring renal replacement therapy in both Europe and the United States. Kidney transplantation improves life expectancy and quality of life in patients of all ages with ESRD2,3 and is an attractive option for elderly patients, in whom it confers lower mortality rates and improved quality of life compared to dialysis.4,5 However, a vast majority of kidney transplants in elderly patients are performed after a period of chronic dialysis, and in those elderly patients in whom a preemptive kidney transplant (PKT) is performed the organ comes from a living donor.
The shortage of organs is a major hurdle in kidney transplantation, and one solution to the problem is to extend the age of the donor. However, organs from older donors are often discarded due to the macroscopic appearance of the parenchyma or major vessels. On the other hand, a large number of elderly patients are potential candidates for kidney transplantation, while many kidneys from elderly deceased donors are discarded due to a lack of age-matched recipients. In addition, a large number are often discarded due to the lack of compatible recipients among elderly patients undergoing chronic dialysis. A possible solution to avoid this wastage of kidneys potentially suitable for transplantation could be the performance of preemptive kidney transplantation (PKT) in carefully selected elderly patients. PKT improves graft and patient survival compared to other renal replacement therapy options. There is no information about PKT in elderly patients receiving kidneys from elderly deceased donors.
From 2007 to 2012, we performed a prospective observational study comparing 26 elderly patients receiving PKT with a control group of 26 elderly patients receiving a first transplant after prior dialysis.
Mean age of recipients was 74.3 ± 2.9 years and mean age of donors was 73.8 ± 4.1 years. Induction immunosuppression was similar in both groups. Death-censored graft survival was 96% in the PKT group and 68% in the control group (p = 0.02), at 5 years after transplantation. Immediate and delayed graft function occurred in 92% and 3.8%, respectively, of patients in the PKT group and 53% and 34.6% of patients in the control group (p = 0.005). Acute rejection was significantly more frequent in PKT patients (23.1% vs 3.8%, p = 0.043). At the end of follow-up time 35.5 ± 20.1 months, the glomerular filtration rate was similar in both groups (42.2 ± 11.7 vs 41.7 ± 11.2 ml/min, p-value = 0.72). Patient survival was similar in the two groups.
Elderly patients with end stage of renal disease non-dialysis may benefit from PKT elderly deceased donors whose kidneys were to be discarded for there are not patients in the waiting list.
La escasez de órganos constituye una importante dificultad para los trasplantes renales, y una posible solución del problema está en ampliar el margen de edad aceptado para los donantes. Sin embargo, los órganos de donantes de edad avanzada se desechan con frecuencia debido al aspecto macroscópico del parénquima o de los vasos sanguíneos principales. Por otro lado, hay un gran número de pacientes ancianos que son posibles candidatos a un trasplante renal, mientras que muchos riñones de donantes ancianos fallecidos se desechan porque no hay receptores de una edad similar. Además, a menudo se desecha un gran número de órganos a causa de la falta de receptores compatibles entre los pacientes ancianos en diálisis crónica. Una posible solución para evitar que se desperdicien estos riñones que pueden ser apropiados para un trasplante sería llevar a cabo un trasplante renal prediálisis (TRP) en pacientes ancianos cuidadosamente seleccionados. El TRP mejora la supervivencia del órgano trasplantado y del paciente, en comparación con otras opciones de terapia sustitutiva renal. No disponemos de información acerca del TRP en pacientes ancianos a los que se trasplantan riñones de donantes ancianos fallecidos.
De 2007 a 2012 llevamos a cabo un estudio prospectivo observacional en el que se compararon 26 pacientes ancianos que recibieron un TRP con un grupo de control formado por 26 pacientes ancianos a los que se practicó un primer trasplante después de una diálisis previa.
La media de edad de los receptores fue de 74,3 ± 2,9 años y la de los donantes de 73,8 ± 4,1 años. La inmunosupresión de inducción fue similar en los dos grupos de tratamiento. La supervivencia del órgano, con censura para el análisis estadístico a la muerte del paciente, fue del 96% en el grupo de TRP y del 68% en el grupo de control (p = 0,02), 5 años después del trasplante. Hubo una función inmediata y tardía del riñón trasplantado en el 92% y 3,8% de los pacientes, respectivamente, en el grupo de TRP, y en el 53% y 34,6% de los pacientes en el grupo de control (p = 0,005). El rechazo agudo fue significativamente más frecuente en los pacientes a los que se practicó un TRP (23,1% frente a 3,8%, p = 0,043). Al final del periodo de seguimiento de 35,5 ± 20,1 meses, la filtración glomerular fue similar en ambos grupos (42,2 ± 11,7 frente a 41,7 ± 11,2 ml/min, valor de p = 0,72). La supervivencia de los pacientes fue también similar en los dos grupos.
En los pacientes ancianos con una enfermedad renal terminal no dializados, puede resultar beneficioso un TRP de donantes ancianos fallecidos cuyos riñones se desecharían si no hubiera pacientes en lista de espera.
Prostate specific antigen levels and prostate cancer detection rates in patients with end stage renal disease
2012, Journal of Urology
Citation Excerpt :
Its clinical benefit has been the source of considerable debate.15 Patients with ESRD add further complexity to PCa screening since 5-year disease specific mortality for PCa in the general population is approximately 2%16,17 compared to 84%3 for those with ESRD. However, a solid organ tumor excludes patients with ESRD from candidacy for a transplant at most institutions.
Patients with end stage renal disease plus prostate cancer are ineligible to receive a renal transplant at most centers until an acceptable cancer-free period is demonstrated. To our knowledge previously established prostate specific antigen reference ranges have not been validated in patients with end stage renal disease. We determined age stratified 95th percentile prostate specific antigen reference ranges and the prostate cancer detection rate at specific prostate specific antigen intervals for patients with end stage renal disease.
We retrospectively reviewed the records of 775 male patients with end stage renal disease on the waiting list for a renal transplant who had undergone a serum prostate specific antigen test. Prostate specific antigen was stratified by age at the time of the blood test and 95th percentile reference ranges were calculated for each decade. A total of 80 patients underwent prostate biopsy for increased prostate specific antigen and/or abnormal digital rectal examination. The cancer detection rate was calculated for specific prostate specific antigen reference ranges.
The age specific 95th percentile prostate specific antigen references ranges were 0 to 4.0 ng/ml for ages 40 to 49 in 137 patients, 0 to 5.3 ng/ml for ages 50 to 59 in 257, 0 to 10.5 ng/ml for ages 60 to 69 in 265 and 0 to 16.6 ng/ml for ages 70 to 79 years in 69. The cancer detection rate was 44%, 38% and 67% for prostate specific antigen 2.5 to 4.0, 4 to 10 and greater than 10 ng/ml, respectively.
In our study population of patients with end stage renal disease age stratified prostate specific antigen was higher than in the general population. The cancer detection rate was increased in our patients with end stage renal disease compared to that in patients with normal renal function at specific prostate specific antigen intervals. Lower prostate specific antigen cutoffs may be appropriate to recommend prostate biopsy in patients with end stage renal disease.
Age is an important predictor of kidney transplantation outcome
2012, Nephrology Dialysis Transplantation

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: This work was partially supported by a grant from AETER.

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Kidney transplantationOutcomeSurvival of Patients Older Than 60 Years With Kidneys Transplanted From Spanish Expanded Criteria Donors Versus Patients Continued on Hemodialysis

Abstract

Section snippets

Patients and Methods

Results

Discussion

Am J Kidney Dis

Transplant Proc

Transplant Proc

Mortality and hospitalization in haemodialysis patients in five European countries: results from the dialysis outcomes and practice patterns study (DOPPS)

Nephrol Dial Transplant

Live and deceased donor kidney transplantation in patients aged 75 years and older in the United States

Int Urol Nephrol

Kidney transplantation
Outcome
Survival of Patients Older Than 60 Years With Kidneys Transplanted From Spanish Expanded Criteria Donors Versus Patients Continued on Hemodialysis