———————————————————————————————————
ABSTRACT: So far, kidney transplantation has generally not been offered to elderly patients (>75 years) because of the perioperative risks. Nor has it been clearly established whether transplanted patients in this age benefit significantly. In a new study published in NDT [1], the graft survival proved to be excellent, and nearly all patients remained dialysis-free. Is it time to rethink established common practice?
—————————————————————————————————–
People in the industrialized counties are getting older and are very often in good health as a result of good nutrition, a healthier lifestyle and a higher level of education. More people nowadays know how to keep fit and prevent diseases. Screening programs have increased the survival rates of many illnesses such as cancer, national vaccination programs have completely eradicated many diseases, and better safety standards such as traffic regulation, risk management and safe work procedures have helped to reduce the number of accidents.
In a nutshell, people are getting older and healthier, but the prevention of chronic kidney disease (CKD) is lagging behind, with the number of patients on the rise. In 2016, 121 pmp started renal replacement, in 2017 this number rose to 127 pmp – according to figures released by the ERA-EDTA Renal Registry [2]. Most patients are elderly people, because the risk of chronic kidney disease increases with age. The mean age of patients starting RRT was 63.4 years.
The best available treatment of end-stage renal disease is kidney transplantation. “We know that patients benefit immensely from this treatment, survival and quality of life are significantly better compared to dialysis patients”, explains Professor Ron Gansevoort, Press Officer of the ERA-EDTA. This can be easily explained: After successful kidney transplantation, the detoxification function can return almost completely to normal, and there is no accumulation of toxins and water in the body, as in dialysis patients between dialysis treatments. Furthermore, patients are not dependent on the blood washing procedure (usually 3 times a week for 4 hour), which greatly impacts “normal life”.
However, due to the scarcity of donor organs, which is dramatic in many European countries, it is not possible for large numbers of people to receive transplants. When it comes to elderly patients, this scarcity produces a moral dilemma. Would it be correct to implant an organ into an elderly patient when a younger patient is also waiting for an organ and has a much longer life span ahead of him/her? One solution is the “old-to-old” donation, in which elderly patients receive the organs of deceased elderly patients. This raises the questions as to whether this kind of transplantation was “worth” being done, e.g. whether the old organs would work properly and whether the transplanted patient would derive a significant benefit.
These questions have now been answered by a new study published in NDT [1]. 138 recipients (≥75 years) who received kidney transplants from similarly aged deceased persons between 2002 and 2015 were analyzed. One- and five-year patient survival was 82.1% and 60.1%, respectively, whereas the corresponding rates for death-censored graft survival were 95.6% and 93.1%, respectively.
“This study showed that elderly patients do indeed benefit from kidney transplantation, even when the donor organ is also old. Graft survival was found to be excellent, with nearly all patients remaining dialysis-free for the rest of their lives. In that light, we may have to reconsider our recommendation. We always thought that transplantation should generally not be offered to the very elderly (>75 years) because of the perioperative risks. The present study suggests otherwise. Larger studies that also take quality of life, number of hospital admissions and duration of hospital stays into account are also needed, however”, concludes Professor Gansevoort.
[1] Jimena Cabrera, Mario Fernández-Ruiz, Hernando Trujillo et al. Kidney transplantation in the extremely elderly from extremely aged deceased donors: a kidney for each age. Nephrology Dialysis Transplantation, 12 Feb 2020 [epub ahead of print]. https://doi.org/10.1093/ndt/gfz293
[2] ERA-EDTA Registry: ERA-EDTA Registry Annual Report 2017. Amsterdam UMC, location AMC, Department of Medical Informatics, Amsterdam, the Netherlands, 2019. https://era-edta-reg.org/files/annualreports/pdf/AnnRep2017.pdf
With more than 7,000 active members, the ERA-EDTA is one of the biggest nephrology associations worldwide leading European nephrology and one of the most important European Medical Associations. It organizes annual congresses and other educational and scientific activities, it produces guidelines, collects data and performs epidemiological studies through its Registry. It supports fellowships and educational/research projects through its committees and working groups. Its publications are NDT and CKJ (this last journal is Open Access). The ERA-EDTA also has an online journal: NDT-Educational. The 2020 Congress will be held on 6-9 June in Milan, Italy.
