1 Division of Nephrology, Department of Medicine and 2 Clinic of Visceral and Transplantation Surgery, University Hospital, Geneva, Switzerland
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Abstract |
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Methods. From October 1983 to March 1999, 310 renal transplantations were performed at Geneva University Hospital in 283 patients, of which 49 were done in 48 patients older than 60 years (mean age 65.6±4.1 years). The following data were analysed at 1, 5, and 10 years, and compared between the patients >60 years and <60 years old: actuarial patient and graft survival, serum creatinine, causes of graft loss, and patient death.
Results. Patient survival at 10 years was 81% for patients <60 years and 44% for patients >60 years. Graft survival at 10 years was 59% for patients <60 years and 32% for patients >60 years. Graft survival at 10 years censored for death with functioning graft was 65% for patients <60 years and 81% for patients >60 years. Main causes of mortality in the older patients were related to cardiovascular events (47%), neoplasia (41%), and sepsis (18%). Overall, recipient and donor age were not predictive factors for graft survival, as shown by multiple logistic regression.
Conclusions. Renal transplantation should be considered in patients older than 60 years, since graft survival is excellent in this population. Although these patients have a shorter life expectancy, they benefit from renal transplantation similarly to younger kidney transplant recipients.
Keywords: elderly; end-stage renal disease; haemodialysis; kidney graft failure; renal transplantation; retrospective study; survival
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Introduction |
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However, transplantation is the best treatment demonstrated for end-stage renal disease patients [5] and in the cyclosporin era, renal transplantation became an alternative to dialysis for these patients [6] and some centres have reported good 5-year graft and patient survivals [79]. Among elderly patients with end-stage renal failure, patient survival is increased in transplanted patients in comparison with haemodialysed patients awaiting transplantation. Between 1991 and 1997, in the United States, renal transplantation in patients older than 60 years was associated with a 61% decrease in long-term risk of death and with an additional 4-year life expectancy, as compared to haemodialysis [5]. However, few data on long-term follow-up in elderly transplant recipients are available. Moreover, due to scarcity of organs and shorter life expectancy in this population, allocating cadaveric kidneys to these patients is still controversial.
In this retrospective study, we report a single-centre, long-term follow-up of kidney transplantation in patients older than 60 years. The aims of this study were to determine whether 10-year patient and graft survival could support a policy of cadaveric kidney transplantation for patients older than 60 years in our centre, and which factors played a role in long-term graft and patient survivals.
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Subjects and methods |
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Pre-transplantation screening included cardiac ultrasound, stress thallium testing, and cerebrovascular and inferior limb Doppler studies. Patients were then admitted to the waiting list after correction of any significant vascular and coronary lesions. The main exclusion criteria were: positive cross-match for T-cell lymphocytes, evidence of active infection, clinically significant cardiac abnormality, malignancy within the previous 5 years, and severe psychiatric disorders.
The standard immunosuppressive regimen consisted in a cyclosporin, steroids, and azathioprine triple therapy. The Neoral formulation (Novartis, Basel, Switzerland) was used as of 1994. Mycophenolate mofetil (Cell-cept, Roche, Basel, Switzerland) replaced azathioprine as of 1996. Thymoglobulins (ATG, Merieux-Pasteur, Marcy l'Etoile, France) and tacrolimus (Prograf, Fusjisawa, Killorglin, Ireland) were used as a rescue therapy.
The following data were analysed at 1, 5, and 10 years and compared between the patients >60 years and <60 years of age: actuarial patient and graft survival, serum creatinine, causes of graft loss, and patient death.
Graft survival for the overall population was also analysed according to donor age, with a cut-off value arbitrarily set at 50 years. Selected parameters were assessed as independent factors for graft outcome by multiple regression analysis.
A complete follow-up was obtained for 301 transplantation procedures (97%). Median follow-up was 6.6 years (range 0.216 years).
All statistics were performed using the Statistica software package (Statsoft, Tulsa, Oklahoma). Patient and graft survivals were calculated with the KaplanMeier method. Survival curves were compared with the Mantel-Cox log-rank test. Cox's proportional hazard method was used for multiple regression analysis. Comparison of parametric data was done with Student's t-test for continuous variables, and with 2 test with Yates correction or Fisher's exact test, wherever appropriate, for categorical variables. Values of P<0.05 were considered significant.
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Results |
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Discussion |
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Patient and graft survivals after a 5-year follow-up in this transplanted elderly population (78 and 65% respectively) compare favourably with what was previously reported in the literature. American centres reported 5-year patient and graft survivals in recipients over 60 ranging from 64 to 68% and from 55 to 62% respectively [7,8]. These studies included 1830% of patients transplanted with living donors kidneys. In Europe, an 80% patient and graft survival at 5 years was reported for elderly recipients of cadaveric kidneys by Cantarovich et al. [9]. Recently published data from The UK National Data Base showed slightly more than 50% cadaveric kidney graft survival at 5 years for patients older than 60 years [10]. The difference in graft survival between these two studies may be partially related to the pre-transplant cardiovascular co-morbidities of the recipients.
Studies with long-term analysis of patient and graft survival are lacking. With a median follow-up of 6.6 years, we report 44% patient survival, and 81% graft survival censored for death with function in actuarial terms. Measured serum creatinine at 5 years in patients with functioning grafts indicates good renal function. This result is probably explained by a lower rejection rate in this population, as previously reported [8]. Accordingly in our study, there is less immune-induced graft loss in the older group.
Many centres, including ours, still hesitate to accept older patients for renal transplantation list on account of their shorter life expectancy. However, our results as well as those from other studies [710] might convince more centres that age per se is not a contraindication to renal transplantation. Prior to analysing our results, less than 20% of the dialysed patients over 60 years were considered potential transplant candidates. We should be able to increase this percentage by considering every patient over 60 years as a potential recipient. Their survival can be improved by a careful selection and thoroughly assessing cardiac and infectious risk as well as a tailored immunosuppression [11].
A controversial point in kidney transplantation in the elderly is donor age. It is well known that kidney graft failure increases with donor age [10,12,13]. The use of older kidneys is nonetheless considered as acceptable, because of the scarcity of cadaveric kidney donors. Moreover, some authors have also shown a good graft survival when kidneys from older donors are transplanted into older recipients, and advocated a donorrecipient age matching [14]. In contrast, a recent publication reported a 14% decrease in 5-year graft survival for patients over 60 years who are transplanted with kidneys from donors over 60 years of age compared to kidneys from donors under the age of 60 years [15].
Our recipient and donor populations are too small to allow us to match the age of donors and recipients. However, donor age was not a predictive factor of graft survival in a multiple regression analysis. Additionally, no significant difference in actuarial graft survival was found when comparing recipients of kidneys from donors over and under 50 years of age. This might be explained by the fact that a majority of older donors were under 60 (mean 55.3±4.8 years).
Our results are in conflict with what has been previously published in the literature where graft failure increases progressively with advancing donor age [12,13]. However, recently published Japanese data on living donor kidney transplantation report that graft survival at 10 years remains at around 70% with donors from 50 to 59 years of age, but declined dramatically to 45% with donors over 60 [16].
Therefore we consider that allocating kidneys from donors between 50 and 60 years of age to elderly end-stage renal failure patients does not harm their long-term renal function. There is a consensus in the literature that cadaveric kidneys from donors up to 60 years of age should be transplanted. Kidneys from donors older than 60 years can also be transplanted, provided biopsy-proven sufficient renal integrity has been demonstrated preoperatively [17].
In summary, regarding the poor survival and quality of life of elderly patients on haemodialysis, we believe that renal transplantation should be offered to patients older than 60, after proper screening for cardiovascular and infectious disease. However, on account of the shorter life expectancy of older recipients, and the good survival of kidney grafts from donors over 50 at 5 and 10 years, it seems logical and ethically fair to preferentially allocate kidneys from donors over 50 to these patients.
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Notes |
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References |
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