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Renal Transplantation in OCTOGENARIANS—A Real Proposition?

Sutherland, Andrew Ian MB, ChB, DPhil, FRCS

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doi: 10.1097/TP.0000000000001364
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In Brief

As the average life expectancy continues to rise, we have seen the number of patients older than 65 years on hemodialysis increase 3-fold over the last 20 years.1 In the United Kingdom, the highest incidence of patients on dialysis is in the 75- to 79-year age group, with the second highest incidence in the 80- to 84-year group.1 There is continued debate as to whether we should be transplanting this group of patients. Although most transplant units do not specify an upper age limit, transplantation in patients older than 80 years is very rare. In this issue of Transplantation, Lønning et al2 report their single-center experience of transplanting octogenarians over the last 22 years. Although the overall number of patients included in the study is small, outcomes were good and compared favorably with a group of patients aged 70 to 79 years who were transplanted during the same period. Although this is a highly selected group of octogenarians, as the authors suggest, it is these fitter patients that we should be considering for transplantation and biological age rather chronological age should be the criteria. The recipients in this study only received organs from donors after brain death, and the results may therefore not be applicable to donors after circulatory death or indeed living donors. Two- and 5-year patient survival rates were 78% and 47% in octogenarians versus 85% and 67% in aged 70 to 79 years, respectively. Death-censored 5-year graft survival was 89% in the octogenarian group. These results are comparable with registry studies of older recipients that show that “death with a functioning graft” is the commonest cause of graft loss, but that death-censored survival is similar in older recipients.3,4 It should be noted, however, that registry data have also shown that although overall survival in elderly transplant recipients is higher than dialysis, posttransplant mortality is increased perioperatively, and the survival benefit of older recipients is not realized until 1.5 years posttransplantation.5

Lønning et al's study will rightly stimulate debate on whether we should be more open to listing octogenarians. However, even if we can demonstrate a benefit for selected patients, we also need to consider whether it is appropriate to transplant octogenarians when there is a limited donor pool. UK guidelines recommend that potential recipients should have a greater than 50% 5-year survival.6 In this study, 5-year survival was 47%, although when limited to transplants after the year 2000, the 5-year survival was 55%, only just meeting this criterion. To alleviate the pressure on the donor pool, kidneys from older donors could be used, which would not be suitable for younger recipients because of reduced predicted graft survival and function. Although there is concern about using extended criteria organs for extended criteria recipients, a number of units have had excellent results adopting this strategy, most notably the European “old for old” scheme.7 Indeed, in Lønning et al's study, 57% of donors were from extended criteria donors.

When considering whether we start listing selected octogenarians, we also need to ensure that we are not raising “false hope.” Stevens et al8 showed that only 8% of older than 65 years patients that are listed for deceased donor transplant go on to be transplanted. Similarly, low transplantation rates for elderly recipients have been reported in the United States.9 The importance of early transplantation in elderly recipients is also recognized, and often older recipients wait longer and are at higher risk of dying while on the waiting list.9 The alternative, to achieve transplant in a timely fashion is living donor transplantation. However, this is not without its own problems, and donor surgeons may be reticent to put potential donors at risk for older recipients with a relatively short life expectancy. Nevertheless, with the changing demographics of our population and shifting attitudes within the transplant community, it is not difficult to anticipate a time when transplanting octogenarians will become common practice.

REFERENCES

1. https://www.renalreg.org/wp-content/uploads/2015/12/Chapter-01_v3.pdf.
2. Lønning K, Midtvedt K, Leivestad T, et al. Are octogenarians with end stage renal disease candidates for renal transplantation? Transplantation. 2016;100:2705–2709.
3. Huang E, Poommipanit N, Sampaio MS, et al. Intermediate-term outcomes associated with kidney transplantation in recipients 80 years and older: an analysis of the OPTN/UNOS database. Transplantation. 2010;90:974–979.
4. Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med. 1999;341:1725–1730.
5. Sener A, Schweitzer EJ, Munivenkatappa R, et al. Deceased-donor renal transplantation in the geriatric population demonstrates equal graft survival compared with younger recipients. Transplantation. 2009;87:1549–1554.
6. http://www.odt.nhs.uk/pdf/kidney_selection_policy.pdf.
7. Boesmueller C, Biebl M, Scheidl S, et al. Long-term outcome in kidney transplant recipients over 70 years in the eurotransplant senior kidney transplant program: a single center experience. Transplantation. 2011;92:210–216.
8. Stevens KK, Woo YM, Clancy M, et al. Deceased donor transplantation in the elderly—are we creating false hope? Nephrol Dial Transplant. 2011;26:2382–2386.
9. Schaeffner ES, Rose C, Gill JS. Access to kidney transplantation among the elderly in the United States: a glass half full, not half empty. Clin J Am Soc Nephrol. 2010;5:2109–2114.
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