Elderly Kidney Transplantation Candidates Passed Over

NATIONAL HARBOR, MD – The prognosis for older adult kidney transplant recipients has improved dramatically in recent years, and these individuals deserve to be referred for transplantation more often than they currently are, according to transplant surgeon, Dr. Dorry Segev.

Dr. Segev pointed to data from his own and other studies, showing that not only have survival rates among older adult kidney recipients improved, but the use of donor kidneys from older adults can in some cases be considered acceptable for younger recipients.

"What we knew about transplantation 20 years ago is completely different now. Immunosuppression agents are better, clinical protocols are better. ...Those aged 65 and older can have pretty good outcomes with transplantation," said Dr. Segev of the department of surgery at Johns Hopkins University, Baltimore.

Today, 2-year survival following kidney transplantation among those aged 65 and older is approximately 90%, based on data from 7,823 patients who were transplanted in 2009-2011, in contrast to about 80% among 1,153 who were transplanted in 1991-1993. And, older adults who do receive kidney transplants have almost double the survival benefit, compared with those who remain on the waiting list. "We’re transplanting more older adults, and they’re doing better," Dr. Segev said

Nevertheless, about 300,000 adults aged 65 years and older are currently on the waiting list for donor kidneys, and there is evidence that these individuals are referred for transplantation less often than younger individuals with chronic kidney disease. In another study from Dr. Segev’s group, national registry data on 6,988 Medicare recipients (aged 65 and older) of a first kidney transplant in 1999-2006 were compared with those of 128,850 older adults with end-stage renal disease in those same years who did not have absolute or relative contraindications to transplantation (J. Am. Geriatr. Soc. 2012;60:1-7).

Of the 11,756 who would be considered "excellent" candidates for transplantation (defined as greater than 87% predicted 3-year posttransplantation survival, corresponding to the top 20% of transplanted older adults), just 24% had access to transplantation and 13% actually received a kidney transplant. It was estimated that 11% of these candidates would have identified a suitable live donor had they been referred for kidney transplantation. "Those who should be transplanted are getting referred at an extremely low rate," Dr. Segev commented.

One way to counter the belief that donor kidneys are "wasted" on adults with lower remaining life expectancy is to consider kidney options that may not be appropriate for younger recipients, including "expanded criteria" donor kidneys, older living donors, and a special category designated by the Centers for Disease Control and Prevention as "infectious disease risk" donors.

"Expanded criteria" donors (ECDs) include those who are aged 60 years and older, or age 50-59 with two of the following three criteria: hypertension, stroke as the cause of death, or terminal creatinine greater than 1.5 mg/dL. There is a separate recipient waiting list for ECDs, of which "many are great kidneys," Dr. Segev said.

In a review of 142,907 first-time deceased-donor kidney registrants who were reported to UNOS (United Network for Organ Sharing) between 2003 and 2008, Dr. Segev and his associates found that just 67% of adults older than 65 years who were predicted to benefit from ECDs were listed for them, with huge variation (0% to 100%) by center (Am. J. Transplant. 2010;10:802-9).

Older living donors are another potential – but underutilized – source of donor kidneys for their peers. Among 219 healthy adults aged 70 and older who have donated kidneys at 80 U.S. transplantation centers, graft loss in the recipients was significantly higher than were matched 50- to 59-year-old, live-donor allografts, but were similar to matched, nonextended-criteria, 50- to 59-year-old, deceased-donor allografts. Mortality among the older living kidney donors was no higher than that among healthy matched controls, and in fact they lived longer (Clin. J. Am. Soc. Nephrol. 2011;6:2887-93).

"The study showed that donors do well and recipients do well, particularly older recipients. ... Many older adults have a social network of other older adults who would be willing to donate if they knew it was possible," Dr. Segev said.

Another source of alternative donor organs that might be appropriate for selected elderly patients are those from the Centers for Disease Control and Prevention’s "Infectious Risk Donors." These include men who have sex with men (MSM), injection drug users, hemophiliacs, prostitutes, those exposed to HIV, those who have had sex with anyone in the previous categories, and incarcerated individuals. Such donors account for nearly 10% of the donor pool, and their organs are discarded more often than other donor organs.

"It seems wasteful to discard these. There should be someone on the list who would benefit from them, even with higher infectious risk. The real diseases we worry about – HIV and HCV [hepatitis C virus] – take years for sequelae to develop," Dr. Segev said.

In two separate studies, the risk of infection from such an organ per 10,000 donors during the "window period" prior to positive test results for injection drug users was 4.9 for HIV and 32.4 for HCV. For MSM, those risks were 4.2 and 3.5, respectively, and for commercial sex workers, 2.7 and 12.3, respectively. The others incurred lower risks (Am. J. Transplant. 2011;1176-87; 11:1188-200).

New data from Dr. Segev’s group suggest that the risk of a poor outcome (defined as 33% or more of the year after the kidney transplantation that was spent hospitalized or dying) among older transplant recipients increases by an adjusted odds ratio of 1.42 per 10 years. Years on pretransplantation dialysis also was a significant predictor (1.11), whereas the receipt of a live donor organ was protective (0.59).

In all, the risks of kidney transplantation for older adults include the upfront risks of surgery, particularly among those with comorbidities; the risk of immunosuppression; and the ongoing need for medical follow-up. But the benefits can include longer survival and improved quality of life, Dr. Segev said.

Dr. Segev disclosed that he is a consultant, scientific advisor, and speaker for Sanofi.

NATIONAL HARBOR, MD – The prognosis for older adult kidney transplant recipients has improved dramatically in recent years, and these individuals deserve to be referred for transplantation more often than they currently are, according to transplant surgeon, Dr. Dorry Segev.

Dr. Segev pointed to data from his own and other studies, showing that not only have survival rates among older adult kidney recipients improved, but the use of donor kidneys from older adults can in some cases be considered acceptable for younger recipients.

"What we knew about transplantation 20 years ago is completely different now. Immunosuppression agents are better, clinical protocols are better. ...Those aged 65 and older can have pretty good outcomes with transplantation," said Dr. Segev of the department of surgery at Johns Hopkins University, Baltimore.

Today, 2-year survival following kidney transplantation among those aged 65 and older is approximately 90%, based on data from 7,823 patients who were transplanted in 2009-2011, in contrast to about 80% among 1,153 who were transplanted in 1991-1993. And, older adults who do receive kidney transplants have almost double the survival benefit, compared with those who remain on the waiting list. "We’re transplanting more older adults, and they’re doing better," Dr. Segev said

Nevertheless, about 300,000 adults aged 65 years and older are currently on the waiting list for donor kidneys, and there is evidence that these individuals are referred for transplantation less often than younger individuals with chronic kidney disease. In another study from Dr. Segev’s group, national registry data on 6,988 Medicare recipients (aged 65 and older) of a first kidney transplant in 1999-2006 were compared with those of 128,850 older adults with end-stage renal disease in those same years who did not have absolute or relative contraindications to transplantation (J. Am. Geriatr. Soc. 2012;60:1-7).

Of the 11,756 who would be considered "excellent" candidates for transplantation (defined as greater than 87% predicted 3-year posttransplantation survival, corresponding to the top 20% of transplanted older adults), just 24% had access to transplantation and 13% actually received a kidney transplant. It was estimated that 11% of these candidates would have identified a suitable live donor had they been referred for kidney transplantation. "Those who should be transplanted are getting referred at an extremely low rate," Dr. Segev commented.

One way to counter the belief that donor kidneys are "wasted" on adults with lower remaining life expectancy is to consider kidney options that may not be appropriate for younger recipients, including "expanded criteria" donor kidneys, older living donors, and a special category designated by the Centers for Disease Control and Prevention as "infectious disease risk" donors.

"Expanded criteria" donors (ECDs) include those who are aged 60 years and older, or age 50-59 with two of the following three criteria: hypertension, stroke as the cause of death, or terminal creatinine greater than 1.5 mg/dL. There is a separate recipient waiting list for ECDs, of which "many are great kidneys," Dr. Segev said.

In a review of 142,907 first-time deceased-donor kidney registrants who were reported to UNOS (United Network for Organ Sharing) between 2003 and 2008, Dr. Segev and his associates found that just 67% of adults older than 65 years who were predicted to benefit from ECDs were listed for them, with huge variation (0% to 100%) by center (Am. J. Transplant. 2010;10:802-9).

Older living donors are another potential – but underutilized – source of donor kidneys for their peers. Among 219 healthy adults aged 70 and older who have donated kidneys at 80 U.S. transplantation centers, graft loss in the recipients was significantly higher than were matched 50- to 59-year-old, live-donor allografts, but were similar to matched, nonextended-criteria, 50- to 59-year-old, deceased-donor allografts. Mortality among the older living kidney donors was no higher than that among healthy matched controls, and in fact they lived longer (Clin. J. Am. Soc. Nephrol. 2011;6:2887-93).

"The study showed that donors do well and recipients do well, particularly older recipients. ... Many older adults have a social network of other older adults who would be willing to donate if they knew it was possible," Dr. Segev said.

Another source of alternative donor organs that might be appropriate for selected elderly patients are those from the Centers for Disease Control and Prevention’s "Infectious Risk Donors." These include men who have sex with men (MSM), injection drug users, hemophiliacs, prostitutes, those exposed to HIV, those who have had sex with anyone in the previous categories, and incarcerated individuals. Such donors account for nearly 10% of the donor pool, and their organs are discarded more often than other donor organs.

"It seems wasteful to discard these. There should be someone on the list who would benefit from them, even with higher infectious risk. The real diseases we worry about – HIV and HCV [hepatitis C virus] – take years for sequelae to develop," Dr. Segev said.

In two separate studies, the risk of infection from such an organ per 10,000 donors during the "window period" prior to positive test results for injection drug users was 4.9 for HIV and 32.4 for HCV. For MSM, those risks were 4.2 and 3.5, respectively, and for commercial sex workers, 2.7 and 12.3, respectively. The others incurred lower risks (Am. J. Transplant. 2011;1176-87; 11:1188-200).

New data from Dr. Segev’s group suggest that the risk of a poor outcome (defined as 33% or more of the year after the kidney transplantation that was spent hospitalized or dying) among older transplant recipients increases by an adjusted odds ratio of 1.42 per 10 years. Years on pretransplantation dialysis also was a significant predictor (1.11), whereas the receipt of a live donor organ was protective (0.59).

In all, the risks of kidney transplantation for older adults include the upfront risks of surgery, particularly among those with comorbidities; the risk of immunosuppression; and the ongoing need for medical follow-up. But the benefits can include longer survival and improved quality of life, Dr. Segev said.

Dr. Segev disclosed that he is a consultant, scientific advisor, and speaker for Sanofi.

NATIONAL HARBOR, MD – The prognosis for older adult kidney transplant recipients has improved dramatically in recent years, and these individuals deserve to be referred for transplantation more often than they currently are, according to transplant surgeon, Dr. Dorry Segev.

Dr. Segev pointed to data from his own and other studies, showing that not only have survival rates among older adult kidney recipients improved, but the use of donor kidneys from older adults can in some cases be considered acceptable for younger recipients.

"What we knew about transplantation 20 years ago is completely different now. Immunosuppression agents are better, clinical protocols are better. ...Those aged 65 and older can have pretty good outcomes with transplantation," said Dr. Segev of the department of surgery at Johns Hopkins University, Baltimore.

Today, 2-year survival following kidney transplantation among those aged 65 and older is approximately 90%, based on data from 7,823 patients who were transplanted in 2009-2011, in contrast to about 80% among 1,153 who were transplanted in 1991-1993. And, older adults who do receive kidney transplants have almost double the survival benefit, compared with those who remain on the waiting list. "We’re transplanting more older adults, and they’re doing better," Dr. Segev said

Nevertheless, about 300,000 adults aged 65 years and older are currently on the waiting list for donor kidneys, and there is evidence that these individuals are referred for transplantation less often than younger individuals with chronic kidney disease. In another study from Dr. Segev’s group, national registry data on 6,988 Medicare recipients (aged 65 and older) of a first kidney transplant in 1999-2006 were compared with those of 128,850 older adults with end-stage renal disease in those same years who did not have absolute or relative contraindications to transplantation (J. Am. Geriatr. Soc. 2012;60:1-7).

Of the 11,756 who would be considered "excellent" candidates for transplantation (defined as greater than 87% predicted 3-year posttransplantation survival, corresponding to the top 20% of transplanted older adults), just 24% had access to transplantation and 13% actually received a kidney transplant. It was estimated that 11% of these candidates would have identified a suitable live donor had they been referred for kidney transplantation. "Those who should be transplanted are getting referred at an extremely low rate," Dr. Segev commented.

One way to counter the belief that donor kidneys are "wasted" on adults with lower remaining life expectancy is to consider kidney options that may not be appropriate for younger recipients, including "expanded criteria" donor kidneys, older living donors, and a special category designated by the Centers for Disease Control and Prevention as "infectious disease risk" donors.

"Expanded criteria" donors (ECDs) include those who are aged 60 years and older, or age 50-59 with two of the following three criteria: hypertension, stroke as the cause of death, or terminal creatinine greater than 1.5 mg/dL. There is a separate recipient waiting list for ECDs, of which "many are great kidneys," Dr. Segev said.

In a review of 142,907 first-time deceased-donor kidney registrants who were reported to UNOS (United Network for Organ Sharing) between 2003 and 2008, Dr. Segev and his associates found that just 67% of adults older than 65 years who were predicted to benefit from ECDs were listed for them, with huge variation (0% to 100%) by center (Am. J. Transplant. 2010;10:802-9).

Older living donors are another potential – but underutilized – source of donor kidneys for their peers. Among 219 healthy adults aged 70 and older who have donated kidneys at 80 U.S. transplantation centers, graft loss in the recipients was significantly higher than were matched 50- to 59-year-old, live-donor allografts, but were similar to matched, nonextended-criteria, 50- to 59-year-old, deceased-donor allografts. Mortality among the older living kidney donors was no higher than that among healthy matched controls, and in fact they lived longer (Clin. J. Am. Soc. Nephrol. 2011;6:2887-93).

"The study showed that donors do well and recipients do well, particularly older recipients. ... Many older adults have a social network of other older adults who would be willing to donate if they knew it was possible," Dr. Segev said.

Another source of alternative donor organs that might be appropriate for selected elderly patients are those from the Centers for Disease Control and Prevention’s "Infectious Risk Donors." These include men who have sex with men (MSM), injection drug users, hemophiliacs, prostitutes, those exposed to HIV, those who have had sex with anyone in the previous categories, and incarcerated individuals. Such donors account for nearly 10% of the donor pool, and their organs are discarded more often than other donor organs.

"It seems wasteful to discard these. There should be someone on the list who would benefit from them, even with higher infectious risk. The real diseases we worry about – HIV and HCV [hepatitis C virus] – take years for sequelae to develop," Dr. Segev said.

In two separate studies, the risk of infection from such an organ per 10,000 donors during the "window period" prior to positive test results for injection drug users was 4.9 for HIV and 32.4 for HCV. For MSM, those risks were 4.2 and 3.5, respectively, and for commercial sex workers, 2.7 and 12.3, respectively. The others incurred lower risks (Am. J. Transplant. 2011;1176-87; 11:1188-200).

New data from Dr. Segev’s group suggest that the risk of a poor outcome (defined as 33% or more of the year after the kidney transplantation that was spent hospitalized or dying) among older transplant recipients increases by an adjusted odds ratio of 1.42 per 10 years. Years on pretransplantation dialysis also was a significant predictor (1.11), whereas the receipt of a live donor organ was protective (0.59).

In all, the risks of kidney transplantation for older adults include the upfront risks of surgery, particularly among those with comorbidities; the risk of immunosuppression; and the ongoing need for medical follow-up. But the benefits can include longer survival and improved quality of life, Dr. Segev said.

Dr. Segev disclosed that he is a consultant, scientific advisor, and speaker for Sanofi.