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Renal Transplantation in Recipients over 65 Years Old

P. Eufrásio, P. Moreira, B. Parada, P. Nunes, A. Figueiredo, R. Alves, F. Macário, and A. Mota

ABSTRACT

Background and Purpose. Older patients on hemodialysis have become candidates forrenal transplantation, particularly in the period of increasing numbers of marginal donors.The purpose of this study was to evaluate short-term and long-term results of renaltransplantation among recipients �65 years old for comparison with these in youngerpatients.Patients and Methods. We retrospectively studied 1,796 renal transplantations per-formed between June 1991 and May 2010, dividing the sample into 2 groups: �65 years old(n � 89) versus �65 years old (n � 1,707).Results. The mean ages were 42.17 and 67.45 years for the younger and older groups,respectively. Time of pretransplantation dialysis was significantly greater among the oldergroup (52.76 vs 47.69 mo). There were no differences between the 2 groups regardingdonor age, donor renal function, or cold ischemia times. After a mean follow-up of 73.37versus 39.73 months for the younger versus older groups, respectively, we observeddifferences in initial graft function, with a greater rate of delayed graft function in the �65group (28.1% vs 17.8%), and in acute rejection rate, which was higher among the youngergroup (19.4% vs 10.1%). Initial creatinine was better for the older group (1.71 vs 2.10mg/dL), but similar between the groups at 10 years. Graft and patient survivals at 1, 5, and10 years were lower among the older group. When analyzing graft survival censored fordeath with a functioning kidney, there were no differences between the younger and oldergroups: It was at 1, 5, and 10 years, namely 93.6% versus 90.6%, 87% versus 80.8%, and76.7% versus 70.1%, respectively.Conclusions. Selected recipients �65 years of age show good outcomes of trans-

plantation.

The age of patients with end-stage renal disease (ESRD)requiring dialysis is increasing, owing to the longer life

expectancy. The best kidney substitute therapy for olderpatients is controversial, because of the greater incidence ofcardiovascular disease, shorter life expectancy, and organshortage for transplantation. In contrast, hemodialysis isassociated with significant morbidity and reduced quality oflife.1 Nevertheless, renal transplantation has demonstrated

clear advantage in survival, quality of life, and cost-ffectiveness compared with hemodialysis,2 thus represent-

ing the best treatment for ESRD. With the increasedavailability of marginal donor kidneys, elderly patients havebecome candidates for renal transplantation, with goodresults.3 Age is not a contraindication for this procedure.

ur purpose herein was to analyze the results of renal

ransplantation among patients �65 years old.

© 2011 by Elsevier Inc. All rights reserved.360 Park Avenue South, New York, NY 10010-1710

Transplantation Proceedings, 43, 117–119 (2011)

METHODS

We retrospectively analyzed the outcomes of 1,796 renal trans-plants performed between June 1991 and May 2010, which corre-sponds to the time of the first procedure in a recipient �65 yearsold, since the beginning of kidney transplantation at our center inJune 1980. The sample included 1,707 patients (95%) �65 yearsold and 89 (5%) recipients �65 years old. Immunosuppressiveprotocols have varied over time but did not differ between groups.All patients particularly older ones owing to higher cardiovascularrisk, underwent extensive screening.

From the Department of Urology and Renal Transplantation,Coimbra University Hospital, Coimbra, Portugal.

Address reprint requests to Pedro Eufrásio, Department ofUrology and Renal Transplantation, Coimbra University Hospital,

3000 Coimbra, Portugal. E-mail: pedrocotovio26@hotmail.com

0041-1345/–see front matterdoi:10.1016/j.transproceed.2010.12.036

117

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118 EUFRÁSIO, MOREIRA, PARADA ET AL

There was a male prevalence in both groups: of 62.4% among theyounger and 70.8% among the older samples. Mean ages was 42.17 �13.3 years in the �65 group and 67.45 � 2.12 years in the �65group. Mean time of pretransplantation dialysis was significantlylonger in the �65 group (47.69 � 44.7 mo vs 52.76 � 30.97 mo).Donor age was higher among the older group, although notreaching statistical significance, namely, mean values of 38.08versus 56.96 years. The rate of kidneys from a marginal donor wassignificantly different between the 2 samples: namely, 6.6% in the�65 and 46.1% in the �65 group. Donor renal function was similarbetween the groups: serum creatinines of 1.03 mg/dL versus 1.04mg/dL among the younger versus older cohorts. Mean cold isch-emia time did not differ at �19 hours. Overall follow-up was 73.37versus 39.73 months for the younger and older groups, respectively(Table 1).

To evaluate outcomes, we considered initial graft function, ratesof acute rejection episodes, causes of graft loss and patient death,and graft and patient survivals. For statistical analyses, we usedSPSS for Windows version 16.0. Categoric parameters were com-pared by �2 testing and continuous variables by Student t test.Patient and graft cumulative actuarial survivals calculated by usingKaplan-Meier analysis were tested for differences with the Mantel-Cox log-rank test. We considered statistically significance to bewhen the P value was �.05.

RESULTS

Assessing initial graft function, we observed that the ma-jority of patients in both groups displayed immediate diure-sis: 79.6% and 67.4% for the younger and older groups,respectively. There were significant differences in delayedgraft function: 17.8% in the �65 and 28.1% in the �65samples. The prevalence of never-functioning grafts waslow in both cohorts: 2.6% in �65 and 4.5% in �65. The rateof acute rejection episodes was not similar between the 2groups: 19.4% among the younger versus 10.1% among theolder (Table 2).

Graft function as evaluated by the serum creatinine (inmg/dL) at 1 month as well as 5 and 10 years, and lastmeasurement during follow-up showed, for the youngerversus older groups, respectively, 1.71 versus 2.1 (1 mo),1.43 versus 1.52 (1 y), 1.50 versus 1.57 (5 y), 1.54 versus 1.36(10 y), and 2.41 versus 2.08 (last creatinine). The onlysignificant difference between samples was the first-monthvalue (P � .05); all the others were similar.

Table 1. Demographic

Group Recipient age (y)Pretransplantation

hemodialysis time (mo) Donor age (y)

�65 y 42.17 � 13.3 47.69 � 44.70 38.08 � 16.38�65 y 67.45 � 2.12 52.76 � 30.97 56.96 � 15.67P value — �.05 NS

Table 2. Initial Graft Function Assessment

Age �65 y Age �65 y P Value

Immediate diuresis 79.6% 67.4% NSDelayed graft function 17.8% 28.1% �.05

Never-functioning kidney 2.6% 4.5% NS N

The causes of graft loss were similar between the 2groups, except for chronic rejection (Table 3). The maincause among both samples was death with a functioningkidney (40.4% for �65 vs 53.6% for �65). Other causes,such as surgical complications, infections, recurrence ofrenal disease, acute rejection, and noncompliance, did notdiffer significantly between the 2 groups. Chronic rejectionrates did show a significant difference, namely, 33.9% foryounger versus 17.9% for older recipients (P � .05).

Causes of patient death also were similar between the 2groups. Values for the younger versus older samples forcardiovascular diseases were 42.3% versus 31.2%, infectiousproblems 28.6% versus 37.5%, hepatic insufficiency 3.8%versus 6.2%, and neoplasia 13.7% versus 6.2%, respectively.Unknown causes showed a prevalence of 11.5% versus 18.8%.

Actuarial graft survivals at 1, 5, and 10 years were, respec-tively, 91%, 79.3%, and 64% for the �65 group and 82.3%,69.3%, and 55.1% for the �65 group (P � .001). Actuarialpatient survivals at 1, 5, and 10 years were, respectively, 95%,88%, and 78.5% for the younger and 87%, 76.1%, and 69.8%for the older samples (P � .002). Considering graft survivalcensored for patient death with a functioning kidney at 1, 5,and 10 years, the results were, respectively, 93.6%, 87%, and76.7% for �65 cohort and 90.6%, 80.8%, and 70.1% for �65patients (P � .276; NS) (Fig 1).

DISCUSSION

Renal transplantation is considered to be the standardtreatment for ESRD. It is well established that comparedwith hemodialysis, this procedure increases patient survivaland quality of life, even at older ages. Costs are becomingmore important, and transplantation is cheaper than renalsubstitute techniques. Traditionally, this surgery was onlyavailable for younger patients with ESRD, owing to thegreater morbidity and mortality related to age and thescarcity of organs for transplantation. However, in recentyears, as a result of increased life expectancy, more patientsof advanced age are accepted to enter hemodialysis. In parallel,

a in the Two Groups

Kidney from arginal donor (%)

Donor creatinine(mg/dL)

Cold ischemiatime (h) Follow-up (mo)

6.6 1.03 � 0.42 19.01 � 6.45 73.37 � 60.2846.1 1.04 � 0.36 19.87 � 5.61 39.73 � 49.27�.05 NS NS �.05

Table 3. Causes of Graft Loss

Age �65 y Age �65 y P Value

Surgical complications 8.8% 10.7% NSChronic rejection 33.9% 17.9% �.05nfections 3.2% 3.6% NSecurrence of renal disease 0.6% 0% NScute rejection 2.8% 0% NSeath with a functioning graft 40.4% 53.6% NS

Dat

ma

oncompliance 1.8% 0% NS

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OLDER RENAL TRANSPLANT RECIPIENTS 119

the expanding ages of cadaver kidney donors and an “old-for-old” allocation algorithm made it possible for elderly patients tobecome transplantation candidates, particularly in areas withextensive availability of older-donor kidneys.4 The choice of theideal renal replacement treatment for this population is contro-versial, owing to their increased cardiovascular, infectious, andneoplastic risks, which parallel a shorter life expectancy. It is alsoimportant to note that the use of expanded-criteria donor kidneyshas been associated with worse renal function and reduced graftsurvival compared with standard donors.5,6 Other data3,7 havehown good results of renal transplantation in elderly patients.

We have been performing kidney transplants in patients65 years old since 1991. In our department, age is not a

ontraindication to this surgery, although few of the olderSRD patients benefit from the procedure. The inclusion

riteria onto a waiting list for transplantation are restrictiveor these patients, namely, a rigorous, especially cardiovas-ular, examination. Correct patient selection is crucial,hich is the main reason for our modest sample of 89

ubjects within these inclusion conditions, which was only% of the total patients transplanted in this period, owingo the high prevalence of symptomatic cardiovascular dis-ases in our country. Like other workers,3 we have followed

a policy of transplanting elderly patients with older-donorkidneys (old-for-old allocation), to allow younger recipientsto have kidneys from young donors.

Our data, show good results. The 5-year graft and patientsurvivals were, respectively 69.3% and 76.1%, compared with79.3% and 88% for patients �65 years. As expected, thisdifference was significant, as it would be in the generalpopulation, mainly because of shorter life expectancy andgreater comorbidity. So far, longer-term graft survival isdecreased among older transplant recipients also becausepatient death with a functioning kidney is the major cause ofgraft loss, accounting for more than a one-half of all cases, aswe observed among our data. When analyzing graft survivalcensored for death with a functioning kidney, we noted

Fig 1. Graft survival censored for death with a functioningkidney.

excellent results with 5-year survivals of 80.8% among the

older and 87% among the younger groups. Considering 10-year survivals, the outcomes were similar namely, 70.1% and76.7% for the �65 and �65 groups, respectively, showing thatenal transplantation was effective in the middle- and long-erm follow-ups for elderly subjects.

Initial graft function was acceptable: 67.4% of patients65 years old showed immediate diuresis compared with

9.6% of younger recipients (P � NS). Based on themeasured serum creatinine, renal function over timeshowed no difference except for the first-month creatinine-mia, which was better among the �65 group. Regardingacute rejection episodes, as expected and mentioned byothers,8 we observed fewer episodes among the older group

wing to the well known impairment of the immune systemn the elderly.9 This fact may explain in part the good

performance of grafts in older patients though there wereno differences in the immunosuppressive regimens.

It is important to note that these favorable results werepossible with an “old-for-old” policy regarding the donors.Possibly better outcomes could be reached if we routinelyused young kidneys in these patients. Our data showed thatthe difference in donor age, was not significant (38.08 vs56.96 y for �65 and �65 groups, respectively). So far, therewere only 6.6% marginal donors among the younger,compared with 46.1% among the older sample.

In conclusion, our results showed overall good results ofrenal transplantation in selected patients over �65 years old.t was safe and effective to treat ESRD in the elderly, withcceptable rates of graft and patient survival. Our policy ofcceptance of selected older patients into a transplant list andn “old-for-old” allocation seems to be adequate.

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2. Ojo AO, Hanson JA, Meier-Kriesche H, et al: Survival inrecipients of marginal cadaveric donor kidneys compared withother recipients and wait-listed transplant candidates. J Am SocNephrol 12:589, 2001

3. Herrero JC, Gutiérrez A, Martinez A, et al: Results of kidneytransplantation in recipients over 70 years of age: experience at asingle center. Transplant Proc 35:1675, 2003

4. Andrés A, Morales JM, Herrero JC, et al: Long-term resultsof renal transplantation in elderly cadaver donor recipients 65 yearsold or older. Transplant Proc 69:2060, 2000

5. López-Navidad A, Caballero F: Extended criteria for organacceptance. Strategies for achieving organ safety and for increasingorgan pool. Clin Transplant 17:308, 2003

6. Schnitzler MA, Whiting JF, Brennan DC: The expandedcriteria donor dilemma in cadaveric renal transplantation. Trans-plantation 75:308, 2003

7. Segoloni GP, Messina M, Giraudi R, et al: Renal transplan-tation in patients over 65 years of age: no more a contraindicationbut a growing indication. Transplant Proc 37:721, 2005

8. Nunes P, Mota A, Parada B, et al: Do elderly patients deservea kidney graft? Transplant Proc 37:2737, 2005

9. Saudan P, Berney T, Leski M, et al: Renal transplantation inthe elderly: a long-term, single-centre experience. Nephrol Dial

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