Download - How Old is Old for Transplantation?

American Journal of Transplantation 2004; 4: 2067–2074Blackwell Munksgaard

Copyright C© Blackwell Munksgaard 2004

doi: 10.1111/j.1600-6143.2004.00622.x

How Old is Old for Transplantation?

Gabriel C. Oniscua,∗, Helen Brownb

and John L. Forsythea

aTransplant Unit, The Royal Infirmary of Edinburgh, UK andbInformation and Statistics Division, Scottish NationalHealth Service, UK∗Corresponding author: Gabriel C. Oniscu,[email protected]

Elderly patients are the fastest growing group re-quiring renal transplantation. This study investigateswhether transplantation is worthwhile in the elderlyand whether there is evidence supporting an age limitfor transplantation.

One thousand ninety-five adults transplanted inScotland between 1 January 1989 and 31 December1999 were followed up to 11 years. Sociodemographic,comorbidity and transplant data were obtained fromthe national databases and patient’s notes. Patient andgraft survival, risk and causes of graft failure and pa-tient death were compared between four age groups(18–49, 50–59, 60–64 and >65).

All groups had similar gender, social deprivation andrenal disease distribution. The incidence of comorbid-ity increased with age. The groups had comparableHLA matching, but patients aged 18–49 years receivedtransplants from younger donors and with shorter coldischaemic times. Younger patients had more acute re-jection and less delayed graft function. Older patientshad a higher incidence of death with functioning graft.Patients over 65 years had an almost dialysis-free re-maining life, while the graft half-life was significantlyshorter than patient half-life in the youngest group.

Transplantation in elderly recipients is worthwhile de-spite a higher comorbidity. Careful selection ratherthan a fixed age limit should be used to ensure a sat-isfactory graft and patient survival.

Key words: Renal transplantation, elderly patients,outcome, comorbidity, survival, multivariate analysis,graft survival, clinical assessment

Received 13 March 2004, revised and accepted for pub-lication 22 July 2004

Introduction

The number of elderly patients accepted in renal replace-ment programmes is continuously increasing. In Scotland,

a country of five million people, the incidence of end stagerenal disease (ESRD) has risen dramatically from 61 permillion population (pmp) in 1990, to 109 pmp in 1999. Thepercentage of ESRD patients over 60 years has increasedfrom 42% in 1989, to 65% in 1999. In fact, patients agedover 65 years represented more than half of the total num-ber of new patients in 1999 (1). A similar trend was notedin the United States, where the number of patients over 65years requiring RRT doubled in the last decade (2), Australia(3), Japan, Canada and the rest of Europe (4).

On the basis of evidence that transplantation is safe andsuccessful (5,6) and survival with a transplant is better thanthat on dialysis (7,8) even in older patients, there is a gen-eral consensus that age per se should not represent abarrier to transplantation. And yet, many centers are stillreluctant to accept elderly patients onto the waiting list dueto their comorbid conditions (9) and shorter life expectancy.In addition, an increased age at the time of transplantationhas a significant impact on long-term graft survival (10) anddeath with a functioning graft is a common event duringthe follow-up (11).

Although in the United Kingdom there is no age limit foraccess to transplantation and the listing and transplanta-tion criteria are identical for all patients irrespective of theirage, only 7.2% of transplant recipients are aged over 65years (12). In the United States, where extended criteriadonors (ECD) are used increasingly in recent years, only9.9% of patients over 65 years are transplanted with non-ECD, while 22.9% receive an ECD kidney (13). In Scotland,where the UK national listing and transplantation criteria areapplied, significant inequities in access to the waiting listand renal transplantation according to patients’ age havebeen described (14). Only 26% of those aged 60–64 yearsand respectively 8.5% of those over 65 years are on thewaiting list for transplantation within 3 years of startingRRT. After listing, only 43% of the 60–64 years old pa-tients and respectively 29% of those over 65 years aretransplanted within 3 years. This is in stark contrast to over70% of patients aged 18–49 years listed within 3 years ofstarting RRT. More than 60% of those listed in this agegroup received a transplant within 3 years.

In the context of the current organ shortage, there is acontinuous debate whether elderly patients should go ontothe national waiting lists, or they should be part of speciallydesigned schemes to which older or marginal kidneys arepreferentially allocated. Currently in the United Kingdom,there are no such schemes and the selection criteria for

2067

Oniscu et al.

the transplant waiting list and subsequent transplantationare identical for all patients irrespective of their age.

Therefore, the aim of this paper was to compare the resultsof kidney transplantation in different age groups and toinvestigate whether transplantation is worthwhile in theelderly or we should set an age limit for access onto thewaiting list.

Methods

All adult patients who started dialysis between 1 January 1989 and31 December 1999 and were transplanted with a cadaveric kidney (firstgraft) until 31 December 2000 (n = 1095) were grouped according to theirage at grafting (18–49 years, 50–59 years, 60–64 years and >65 years). Thekidneys were distributed according to the national criteria set by the UKTransplant. They are based on closeness of HLA with three tiers (tier 1 =no HLA mismatch, tier 2 = one mismatch for HLA-A and/or HLA-B and nomismatches for HLA-DR, tier 3 = one or two HLA-DR mismatches and/ortwo mismatches for HLA-A and/or HLA-B). At each level, priority is given topediatric over adult recipients, highly sensitized over non-sensitized, localversus national recipients. If more than one recipient is identified, a pointscoring mechanism is used as a discriminator based on the following crite-ria: recipient age, donor/recipient age difference, waiting time, matchability,sensitization and balance of exchange between centers. Although the al-gorithm has been revised several times throughout this study, all criteriacontinued to apply to all patients, irrespective of their age.

The sociodemographic and extensive comorbidity data, as well as the levelof HLA matching, the length of the cold ischaemic time, patient and graft

Table 1: Comparison of baseline characteristics of transplanted patients according to the age at transplantation

18–49 years 50–59 years 60–64 years >65 years(n = 686) (n = 252) (n = 82) (n = 75) p-value

Male:Female ratio 57.9:42.1 67.5:32.5 64.6:35.4 66.7:33.3 0.033a

Primary renal disease (%) 0.174Glomerulonephritis 28.7 30.2 23.2 34.7Interstitial nephritis 35.0 34.9 31.7 25.3Multisystem disease 11.2 13.5 17.1 18.7Diabetes 13.7 8.3 11.0 8.0Other 11.4 13.1 17.1 13.3

Deprivation category (%) 0.621 (least deprived) 5.0 5.2 6.1 4.02 12.0 13.1 14.6 18.73 22.6 21.8 23.2 30.74 26.1 26.6 29.3 29.35 15.3 16.3 15.9 6.76 12.6 11.5 8.5 9.37 (most deprived) 6.4 5.6 2.4 1.3

HD as 1st RRT (%) 56.5 59.9 62.2 58.6 0.785Median duration of pre-transplant dialysis (years) 1.3 1.33 1.62 1.92 0.031a,b

Number of switches between dialysis modalities (%) 0.034a

0 65.7 64.5 61.7 76.01 21.3 21.6 29.6 13.3>2 13.0 13.9 8.7 10.7

Listing center (%) <0.0001a

Center 1 56.5 23.2 6.5 13.7Center 2 49.5 25.3 7.4 17.9Center 3 62.1 26.0 7.8 4.1Center 4 66.9 21.2 7.7 4.3

aStatistically significant.bKruskal-Wallis test, all other chi-square tests.

survival, the incidence of acute rejection episodes and delayed graft func-tion and the causes of death and graft failure were obtained from theScottish Renal Registry and UK Transplant databases and case notes, andcompared between the four groups. Social deprivation was assessed withthe Carstairs score, a combination of four variables (male unemployment,car ownership, social class and overcrowding), derived from the census, cal-culated for each postcode and classified into seven categories from 1 (leastdeprived) to 7 (most deprived) (15). Patient and graft half-life were calcu-lated assuming a constant death rate beyond a year after transplantationand compared according to patients’ age using a Log-rank test.

The risks of death and graft failure were calculated after adjustment for co-morbidity and other sociodemographic variables for each group of patients,using a Cox proportional hazards model. Further comparisons were per-formed using chi-square, t-test, Mann-Whitney U test, Kruskal-Wallis andANOVA test where appropriate.

Results

The demographic characteristics of the study populationaccording to the age at transplantation are shown in Table 1.

More men were transplanted in the youngest age group,but there was a comparable representation of all social de-privation categories in all four groups in the study. Therewas a similar prevalence of diabetes as a cause of re-nal failure, and almost 60% of the patients in each agegroup started renal replacement therapy on haemodialysis.The time spent on dialysis until transplantation increased

2068 American Journal of Transplantation 2004; 4: 2067–2074


Table 2: Comparison of comorbidity characteristics of transplanted patients according to the age at transplantation

18–49 years 50–59 years 60–64 years >65 years p-value

Peripheral vascular disease (%) 5.0 11.9 16.3 27.3 <0.0001a

Arrhythmias (%) 1.6 4.4 6.8 7.3 0.021a

Left ventricular hypertrophy (%) 24.9 32.7 39.0 44.4 0.005a

Pulmonary embolism (%) 0.2 2.5 2.3 7.3 <0.0001a

Valvular disease (%) 6.5 10.0 8.9 21.8 0.002a

Ischaemic heart disease (%) 5.9 23.8 40.0 27.3 <0.0001a

Heart failure (%) 3.7 7.0 16.7 7.3 0.003a

Gastrointestinal disorders (%) 12.7 27.5 38.5 34.5 <0.0001a

Respiratory disease (%) 10.3 15.7 26.7 12.7 0.009a

CMV +ve (%) 27.8 48.1 50.0 47.3 <0.001a

Smoker (%) 61.9 49.3 53.7 60.0 <0.001a

aStatistically significant, chi square tests.

significantly with patient’s age (p = 0.031, Kruskal-Wallistest), from a median of 1, 3 years for those aged 18–49years to almost 2 years for patients aged over 65 years. Onaverage, almost one third of all patients switched betweendialysis modalities until transplantation. This occurred sig-nificantly more frequently in the younger patients (p =0.034, chi square), while 76% of patients aged over 65years remained on the initial RRT modality until grafting(haemodialysis or peritoneal dialysis).

Significant differences were noted between centers, el-derly patients being more likely to be listed in centers 1and 2.

The most important differences in comorbidity condi-tions between transplant recipients according to their ageat grafting are illustrated in Table 2. There was a sig-nificant increase in the incidence of peripheral vascu-lar disease, arrhythmias and left ventricular hypertrophywith increased age. Ischaemic heart disease, heart fail-ure and gastrointestinal disorders were more commonly

Table 3: Comparison of donor characteristics, level of HLA matching, cold ischaemic time and transplant outcome according to recipient’sage at transplantation


Tier (%) 0.11 10.8 6.4 14.6 3.82 37.1 44.3 43.9 53.83 52.1 49.3 41.5 42.3

Donor age <0.0001a,b

Mean (S.D.) 38.0 (14.8) 43.4 (15.2) 48.0 (15.3) 48.2 (16.2)Donor gender 0.4

Male/Female 54.0/46.0 50.3/49.7 63.6/36.4 57.4/42.6Cold ischaemic time 0.004a,b

Mean (min) 1126 1295 1416 1326(S.D.) (602.5) (550.4) (482.4) (648.5)Acute rejection episodes (%) 34.7 25.2 27.9 23.6 0.09Chronic rejection (%) 11.9 8.5 7.0 9.1 0.4Delayed graft function (%) 19.2 27.7 20.9 32.7 0.05a

aStatistically significant.bOne way ANOVA test, all other chi-square tests.

seen in patients over 50 years compared with those aged18–49 years.

Valvular diseases and pulmonary embolism were mostcommon among patients over 65 years, respiratory dis-eases were more often seen in patients aged 60–64years, while patients in the 18–49 year-old group had halfthe prevalence of CMV compared with all other groups.The overall prevalence of comorbid conditions seemed tobe higher in patients aged 60–64 years rather than in thoseaged over 65 years. This indicates, that the eldest patientswho were eventually transplanted underwent a tight as-sessment process and only those with fewer comorbidconditions were selected.

All transplants had comparable levels of HLA matching ir-respective of the recipient’s age (Table 3). Between 48%and 58% of patients were well matched (tier 1 [000 mis-matches] or tier 2 [maximum 2 A and/or B mismatchesbut no DR mismatches]). Overall, there was a tendencyto offer fewer fully matched kidneys (000 mismatches) to

American Journal of Transplantation 2004; 4: 2067–2074 2069

Oniscu et al.

Patient survival following transplantation (years)

121086420

Cum

ulat

ive

surv

ival

1.2

1.0

.8

.6

.4

.2

Age groups

>65 years

60–64 years

50–59 years

18–49 years

Age group 1 year 3 years 5 years 8 years

18–49 50–59 60–64 >65

98 92 87 91

93 88 76 77

91 81 59 66

82 61 49 33

Figure 1: Patient survival following

transplantation (p < 0.0001, Log-rank

test).

recipients aged >65 years, but this was compensated bya higher proportion of tier 2 (010, 010 or 110 mismatches)grafts.

As expected, the donor age increased, the older the recip-ient, from 38 years in the younger recipients, to 48 yearsin those >65 years, but with a comparable gender distri-bution.

Younger patients (18–49 years) were transplanted within ashorter cold ischaemic time (mean 1126 min), but had ahigher incidence of acute rejection episodes, while elderlypatients (>65 years) had a higher incidence of delayed graftfunction.

All patients had an excellent 1-year survival rate (Figure 1).There were no significant differences between the sur-vival curves in the first year post-transplantation, but asexpected, there were substantial differences in the long-term survival between those younger and those older than60 years. It was noted that up to 5 years post-transplant,those aged >65 years had a better survival than patientsaged 60–64 years. At 8 years post-transplant, half of thepatients in the 60–64 years old group were alive comparedwith one third in the >65 group.

Similar differences were noted for the graft survival(Figure 2), 60% of the transplants performed in patientsyounger than 60 years functioning at 8 years, in contrastwith only 30–40% in those over 60 years. However, graftsurvival in patients aged >65 years was comparable withthat seen in the 50–59 years group for the first 5 yearspost-transplant. When the two groups of elderly recipientswere compared, patients over 65 years had a better graftsurvival throughout the study period.

This advantage persisted when graft survival was censoredfor death with functioning graft (Figure 3). In fact, the oldergroup had the best graft survival at all time points, butoverall, the differences between the study groups werenot statistically significant (p = 0.2685, Log-rank test).

An examination of the crude death rate (Table 4) showeda fourfold increase from 2.4 per 100 years of patientfollow-up in the 18–49 years group to 10.35 in those aged>65 years. This was further illustrated by the differencesin the proportion of patients from each group, dying withinthe study period. Patient half-life showed a significantreduction in the life expectancy, from 37 years in theyoungest group to less than 8 years in patients >65 years(p = 0.0001, chi-square). Nevertheless, it is important to



Graft survival (years)

121086420

Cum

ulat

ive

surv

ival

1.2

1.0

.8

.6

.4

.2

Age groups

>65 years

60–64 years

50–59 years

18–49 years


18–49 50–59 60–64 >65

88 82 75 88

78 76 62 76

70 68 53 63

60 55 43 31 Figure 2: Graft survival (p < 0.0001,

Log-rank test).

highlight that the death rate noted in patients over 60 yearswho were transplanted, was significantly lower than thatobserved in similar aged patients who were listed but re-mained on dialysis (16 per 100 years of patient follow-up).When the risk of death on dialysis on the waiting list wascompared with the risk of death following transplantation(not adjusted for graft failure), it was observed that despitean initial (30 days) higher risk of death following transplan-tation (RR = 1.52, CI = 0.2–11.81), patients over 60 yearshave a 70% lower risk of death (RR = 0.30, CI = 0.16–0.56)beyond a year post-transplant.

When the relative risk of death, adjusted for comorbidityconditions, was determined for all transplant recipients,those over 50 years had a largely increased risk of deathcompared with the baseline represented by those aged18–49 years (Table 4). A similar tendency was observedfor graft failure, more than 40% of the grafts in the eldestgroup being lost throughout the 11 years of follow-up, alarge proportion of these due to death with functioninggraft. Despite a significant disproportion in the graft half-lifebetween the four groups, a kidney allograft transplanted inpatients under 60 years was likely to function for at least9 years (one quarter of the estimated patient half-life), while

patients over 65 years enjoyed an almost entire dialysis-free life following transplantation (graft half-life 6.96 andpatient half-life 7.88, respectively).

A comparison of the relative risk of graft failure adjustedfor the confounding comorbidity, showed no significant dif-ferences between the four groups of transplanted patients(p = 0.201, Cox regression analysis, Table 4).

The incidence of death with functioning graft was threetimes higher in patients aged >65 years compared withthose aged 18–49 years, in contrast to immunological fail-ures, which had an entirely opposite trend and were mostfrequent in the youngest age group (Table 5). However, asignificant proportion of the causes of graft failure in the18–49 years old group were unaccounted for.

Significant differences in the proportion of patients dyingdue to infection or vascular causes were noted betweenthe four groups (Table 6), but it is important to note thatthere was no difference in cardiac death between all agegroups. Nevertheless, between one in four and one in fivedeaths were not known in each group. If we considerthese unknown cases to represent sudden deaths, and


Oniscu et al.

Graft survival censored for death with functioning graft (years)

121086420

Cum

ulat

ive

surv

ival

1.1

1.0

.9

.8

.7

.6

.5

Age groups

>65 years

60–64 years

50–59 years

18–49 years


18–49 50–59 60–64 >65

89 88 82 93

81 84 74 90

75 78 72 81

70 75 72 70

Figure 3: Graft survival censored for

death with functioning graft (p =0.2685, Log-rank test).

therefore have a cardiac origin, this would increase thecardiac causes of death to 50% of all kidney transplantsperformed in Scotland, irrespective of the recipient age.

Discussion

The demographics of ESRD demonstrate a constant in-crease in the age of new patients starting replacement

Table 4: Comparison of patient and graft outcome according to recipient’s age at transplantation


Crude death rate (per 100 years 2.4 5.55 10.04 10.35of patient follow-up)

Deaths (%) 10.3 24.6 35.4 40.0 <0.0001a

Patient half-life 37.62 17 9.62 7.88 0.0001a

Adjusted RR of death (95% CI) 1 2.37 (1.28–4.39) 2.84 (1.12–7.18) 4.19 (3.54–4.59) <0.0001a

Graft failure (%) 28.3 34.1 43.9 41.3 0.004a

Graft failure censored for death 22.6 19.4 23.2 16.0 0.457with functioning graft (%)

Graft half-life 9.71 9.00 5.54 6.96 <0.0001a

Adjusted RR of graft failure (95% CI) 1 0.91 (0.59–1.38) 0.63 (0.28–1.42) 1.51 (0.86–2.41) 0.2012aStatistically significant, chi-square tests.

therapy every year. Currently in Scotland, as in many otherparts of the world (3,4), more than half of the new pa-tients are aged 65 years or more, but only few of them willever be transplanted. These patients represent a particu-lar controversial category (5) and therefore in this analy-sis we decided to investigate the outcome of transplan-tation in those over 65 separately from patients aged60–64 years.



Table 5: Comparison of causes of graft failure according to recipient’s age at transplantation

18–49 years 50–59 years 60–64 years >65 yearsCause of graft failure (n = 686) (n = 252) (n = 82) (n = 75) p-value

Death with functioning graft (%) 20.6 43.0 47.2 61.3 <0.001a

Immunological failures (%) 34.5 22.1 19.5 16.1 <0.001a

Vascular problems (%) 10.8 9.3 11.2 6.5 0.647Unknown (%) 22.7 16.3 19.4 6.5 0.002a

aStatistically significant, chi-square tests.

Despite a general agreement that age should not repre-sent a contraindication for transplantation, the proportion ofkidney transplants performed in elderly patients in UnitedKingdom has not changed much in the last decade (12,16)and many units are still reluctant to accept older patients astransplant candidates. This is clearly illustrated in this anal-ysis by 10% lower transplant rates in two of the centers,compared with the national average.

Elderly transplant recipients spend a longer time on dialy-sis and this may be partly due to a lengthier assessmentperiod necessary to confirm suitability for transplantation.It is fairly clear from the present analysis that elderly trans-plant recipients have a higher index of comorbidity and se-rious conditions, which shorten the life expectancy, suchas cardiovascular and respiratory conditions, are more of-ten present in those aged over 60 years. This does indicatethat the lower transplant rates may be a result of the highprevalence of comorbid conditions in this particular agegroup, which renders most of the patients unsuitable fortransplant candidacy.

Older recipients receive kidneys from older donors, but thedonor age range is comparable between the four groups,with an upper limit as high as 75 years. Donor age is a con-troversial point in kidney transplantation, as graft failurerates are higher with increased donor age (17,18). Never-theless, the use of older donors is considered acceptabledue to the scarcity of cadaveric kidneys and good resultshave been reported when such kidneys were transplantedin aged matched recipients (19). If kidneys from donors asold as 75 years can be accepted for implantation, there isno real justification why an increased number of elderlypatients could not receive a kidney graft in elderly-for-elderly programmes (20,21), which would eliminate poten-

Table 6: Comparison of causes of death according to patients’ age at transplantation

18–49 years 50–59 years 60–64 years >65 yearsCause of death (n = 686) (n = 252) (n = 82) (n = 75) p-value

Cardiac (%) 29.2 33.9 21.4 36.7 0.098Vascular (%) 11.1 16.1 25.0 3.3 <0.001a

Infection (%) 22.2 12.9 17.9 23.3 0.018a

Cancer (%) 8.3 8.1 3.6 10.0 0.407Unknown (%) 23.6 24.2 21.4 20.0 0.876aStatistically significant, chi-square tests.

tial allocation obstacles as well as shifting younger donorkidneys to younger recipients.

All groups have excellent 1-year patient-survival rates, rang-ing between 87% and 98% and it is worth noting thatthe 91%, 1-year patient survival in the >65 years group, iscomparable with that seen in patients aged 50–59 years.Beyond 3 years, there is a substantial survival benefit foryounger patients, while the two groups of patients agedover 60 years have comparable, but diminished survivalrates, two thirds being alive at 5 years and between 30–50% at 8 years. A similar trend is noticed for the graftsurvival, with comparable 1-year figures (75% to 88%) anda long-term advantage for younger recipients. The cruderate of graft loss increases with age, a significant propor-tion of the grafts in elderly patients being lost due to pa-tient death. This should not necessarily be interpreted as awaste of kidneys, especially if the survival rates and the lifeexpectancy noted in this study are set in the context of a2.1 years median survival for all patients >65 years on renalreplacement therapy (1) and a higher risk of death on dialy-sis on the waiting list. It is also important to note that whilein the youngest group, the estimated graft half-life is nearly10 years, against an estimated patient half-life of 37 years,a 7 years graft half-life in the eldest group ensures adialysis-free life in the context of a half-life of 8 years, of-fering a substantial improvement in the quality of life.

The patient and graft survival probabilities noted here arecomparable with those noted in the United States (13) andelsewhere (5,18,22–24). In addition, the comparison per-formed in this study has shown that results in patientsover 65 years are similar to those obtained in patients aged60–64 years and therefore these patients should be consid-ered for transplantation. One question which still remains


Oniscu et al.

unanswered is whether these patients should be placedon the national waiting lists and hence compete for or-gans with younger candidates or whether they should beenrolled in special programmes such as ’old-for-old’, whichmay allow a quicker access to a graft, but are yet to demon-strate sustainable results (25).

A critical issue for the success of transplantation in the el-derly is the assessment process and there is evidence thatwith a strict evaluation, 80%, 5-year patient and graft sur-vival in these patients is achievable (26). The incidence ofdeath due to cardiovascular diseases was not significantlydifferent in the four groups in this study, but this may be areflection of the higher incidence of cardiovascular diseasein the general population in Scotland. However, it also sug-gests that elderly patients, despite a higher prevalence ofthese conditions, when correctly assessed and selected,may not exhibit a higher risk of death as a direct result ofthem.

In conclusion, older patients with ESRD present health careprofessionals with a significant challenge and many man-agement issues remain subject to debate. The results ofthis paper seem to indicate the need for a review of the as-sessment process in order to maximize the use of the avail-able donor kidneys. With a prevailing shortage of organs,kidney transplantation should not be used indiscriminatelyin the elderly, nor should the elderly be denied access sim-ply on the basis of age. Careful assessment of ’biological’rather than ’chronological’ age should be used on an indi-vidual basis instead of applying rigid age limits and perhapssurvival prognostic models with applicability in the assess-ment clinic (27) will allow us to select the most appropriatecandidates in order to maximize the benefit for the elderlypatients and the society.

References

1. 2000 Annual Report. The Scottish Renal Registry 2001. Glasgow.2. Braun WE. Allocation of cadaver kidneys: New pressures, new

solutions. Am J Kidney Dis 1994; 24: 526–530.3. Australia and New Zealand Dialysis and Transplant Registry (ANZ-

DATA). The 23rd Annual Report, 2000. www.anzdata.org.au.4. US Renal Data System. USRDS 2001 Annual Data Report: Atlas

of end-stage renal disease in the United States 2001. Bethesda,MD, National Institute of Health, National Institute of Diabeticsand Digestive and Kidney Diseases.

5. Fehrman I, Brattstrom, C, Duraj F, Groth CG. Kidney transplanta-tion in patients between 65 and 75 years of age. Transplant Proc1989; 21: 2018–2019.

6. Schulak JA, Mayes JT, Johnston KH, Hricik DE. Kidney transplan-tation in patients aged sixty years and older. Surgery 1990; 108:726–731.

7. Schnuelle P, Lorenz D, Trede M, Van Der Woude FJ. Impact of re-

nal cadaveric transplantation on survival in end-stage renal failure:Evidence for reduced mortality risk compared with hemodialysisduring long-term follow-up. J Am Soc Nephrol 1998; 9: 2135–2141.

8. Wolfe RA, Ashby VB, Milford EL et al. Comparison of mortality inall patients on dialysis, patients on dialysis awaiting transplanta-tion, and recipients of a first cadaveric transplant. N Engl J Med1999; 341: 1725–1730.

9. Mallick L, Marasi A. Dialysis in the elderly, to treat or not to treat?Nephrol Dial Transplant 1999; 14: 37–39.

10. Woo YM, Jardine AG, Clark AF. Early graft function and patientsurvival following cadaveric renal transplantation. Kidney Int 1999;55: 692–699.

11. Ojo AO, Hanson JA, Wolfe RA, Leichtman AB, Agodoa LY, PortFK. Long term survival in renal transplant recipients with graftfunction. Kidney Int 2000; 57: 307–313.

12. UK Transplant. Transplant activity report 2000. 2001. Bristol, UKTransplant.

13. 2003 Annual Report of the U.S. Scientific Registry of TransplantRecipients and the Organ Procurement and Transplantation Net-work: Transplant Data 1993–2002. (2003, August 1). Rockville,MD and Richmond, VA: HHS/HRSA/OSP/DOT and UNOS.

14. Oniscu GC, Schalkwijk AH, Johnson RJ, Brown H, Forsythe JLR.Equity of access to renal transplant waiting list and renal trans-plantation in Scotland: Cohort study. BMJ 2003; 327: 1261–1265.

15. Carstairs V, Morris R. Deprivation and mortality: An alternative tosocial class. Community Med 1989; 11: 210–219.

16. UK Transplant. Renal transplant audit 1990–1998. 1999. Bristol,UK Transplant.

17. Lee CM, Carter JT, Randall HB et al. The effect of age and pro-longed cold ischemia times on the national allocation of cadavericrenal allografts. J Surg Res 2000; 91: 83–88.

18. Morris PJ, Johnson RJ, Fuggle SV, Belger MA, Briggs JD. Analysisof factors that affect outcome of primary cadaveric renal trans-plantation in the UK. Lancet 1999; 354: 1147–1152.

19. Cecka JM, Terasaki P. Optimal use for older donors kidneys: Olderrecipients. Transplant Proc 1995; 27: 801–802.

20. Gjertson DW, Terasaki PI, Cecka JM, Takemoto S, Cho YW. Seniorcitizens pool for aged kidneys. Transplant Proc 1997; 29: 129.

21. Frei U, Smits JM, de Vries E, Persijn GG. The Eurotransplant se-nior program: 2-year results from the old-for-old renal allocationsystem [abstract]. Transplantation 2002; 74: 76.

22. Benedetti E, Matas AJ, Hakim RM. Renal transplantation for pa-tients 60 years of age or older: A single institution experience.Ann Surg 1994; 220: 445–460.

23. Pirsch JD, Stratta RJ, Armbrust MJ et al. Cadaveric renal trans-plantation with cyclosporine in patients more than 60 years ofage. Transplantation 1989; 47: 259–261.

24. Tesi RJ, Elkhammas EA, Davies EA, Mitchell LH, Ferguson RM.Renal transplantation in older people. Lancet 1994; 343: 461–464.

25. Fritsche L, Horstrup J, Budde K et al. Old-for-old kidney allocationallows successful expansion of the donor and reicipient pool. AmJ Transplant 2003; 3: 1434–1439.

26. Cantarovitch D, Baatard R, Baranger T et al. Cadaveric renal trans-plantation after 60 years of age. Transpl Int 1994; 7: 34–38.

27. Oniscu GC, Brown H, Forsythe JL. Predicting patient survival inthe renal transplant assessment clinic. A practical application [ab-stract]. Am J Transplant 2003; 3: 314.


Download - How Old is Old for Transplantation?

Top Related