Living Donor Kidney Transplantation From the Elderly Donor

Impact of donor and recipient age difference on long-term allograft survival after living donor renal transplantation: analysis of 478 cases

INTRODUCTION

Either deceased or living-related renal transplantation constitutes the best therapeutic option for patients with end-stage renal disease. In this retrospective study, an attempt to identify parameters that affect allograft survival in living donor renal transplantation was made.

METHODS

Between January 2000 and July 2012, 478 adult patients received a renal transplant from a living-related donor in our center and their records were retrospectively reviewed in November 2012. Data concerning donor age, recipient age, donor/recipient age difference, donor/recipient gender, and ABO compatibility/incompatibility were recorded and associated with renal allograft survival rate.

RESULTS

Renal allograft survival rate was 96%, 89.5%, and 77.7% in the first, fifth, and 10th yr after transplantation, respectively. Only the difference between donor and recipient age was statistically significant in relation to graft survival. In cases with age difference >13 yr, graft survival rate was lower from the third yr onward.

CONCLUSIONS

Only the age difference between donor and recipient exerts an adverse impact on graft outcome after living donor renal transplantation, whereas donor age, recipient age, donor/recipient gender, and ABO incompatibility do not significantly influence renal allograft survival.

Controversies related to living kidney donors

Background

Increasing the living-donor pool by accepting donors with an isolated medical abnormality (IMA) can significantly decrease the huge gap between limited supply and rising demand for organs. There is a wide range of variation among different centres in dealing with these categories of donors. We reviewed studies discussing living kidney donors with IMA, including greater age, obesity, hypertension, microscopic haematuria and nephrolithiasis, to highlight the effect of these abnormalities on both donor and recipient sides from medical and surgical perspectives.

Methods

We systematically searched MEDLINE, ISI Science Citation Index expanded, and Google scholar, from the inception of each source to January 2011, using the terms ‘kidney transplant’, ‘renal’, ‘graft’, ‘living donor’, ‘old’, ‘obesity’, ‘nephrolithiasis’, ‘haematuria’ and ‘hypertension’. In all, 58 studies were found to be relevant and were reviewed comprehensively.

Results

Most of the reviewed studies confirmed the safety of using elderly, moderately obese and well-controlled hypertensive donors. Also, under specific circumstances, donors with nephrolithiasis can be accepted. However, persistent microscopic haematuria should be considered seriously and renal biopsy is indicated to exclude underlying renal disease.

Conclusion

Extensive examination and cautious selection with tailored immunosuppressive protocols for these groups can provide a satisfactory short- and medium-term outcome. Highly motivated elderly, obese, controlled hypertensive and the donor with a unilateral small stone (<1.5 cm, with normal metabolic evaluation) could be accepted. Donors with dysmorphic and persistent haematuria should not be accepted. A close follow-up after donation is crucial, especially for obese donors who developed microalbuminuria.

Recipient outcomes for expanded criteria living kidney donors: the disconnect between current evidence and practice

Older individuals or those with medical complexities are undergoing living donor nephrectomy more than ever before. Transplant outcomes for recipients of kidneys from these living expanded criteria donors are largely uncertain. We systematically reviewed studies from 1980 to June 2008 that described transplant outcomes for recipients of kidneys from expanded criteria living donors. Results were organized by the following criteria: older age, obesity, hypertension, reduced glomerular filtration rate (GFR), proteinuria and hematuria. Pairs of reviewers independently evaluated each citation and abstracted data on study and donor characteristics, recipient survival, graft survival, serum creatinine and GFR. Transplant outcomes for recipients of kidneys from older donors (> or =60 years) were described in 31 studies. Recipients of kidneys from older donors had poorer 5-year patient and graft survival than recipients of kidneys from younger donors [meta-analysis of 12 studies, 72% vs. 80%, unadjusted relative risk (RR) of survival 0.89, 95% confidence interval (CI) 0.83-0.95]. In meta-regression, this association diminished over time (1980s RR 0.79, 95% CI 0.65-0.96 vs. 1990s RR 0.91, 95% CI 0.85-0.99). Few transplant outcomes were described for other expanded criteria. This disconnect between donor selection and a lack of knowledge of recipient outcomes should give transplant decision-makers pause and sets an agenda for future research.

Outcomes of kidney transplantation from older living donors to older recipients

BACKGROUND

More than half the newly wait-listed patients for kidney transplantation in 2005 were older than 50 years, and 13% were older than 65 years. As waiting times for a deceased donor kidney increase, these older candidates are disadvantaged by rapidly deteriorating health, often resulting in death or removal from the wait list before transplantation.

STUDY DESIGN

An observational cohort study was conducted using data from the Organ Procurement Transplant Network/United Network for Organ Sharing.

SETTING & PARTICIPANTS

All adult kidney-only transplantations performed in recipients 60 years and older from 1996 to 2005 were included.

PREDICTOR

The recipient cohort was stratified into 4 groups based on donor source: older living donor (OLD: living donor age > 55 years), younger living donor (YLD: living donor age </= 55 years), standard criteria deceased donor (SCD), and expanded criteria deceased donor (ECD).

OUTCOMES & MEASUREMENTS

Early posttransplantation outcomes, graft survival, patient survival, renal function 1 year posttransplantation, and relative risk of graft loss and patient death were compared.

RESULTS

Of 23,754 kidney transplantations performed in recipients 60 years and older, 7,006 were living donor transplantations (1,133 were > 55 years [OLD] and 5,873 were <or= 55 years [YLD]), 12,197 from SCDs, and 4,551 from ECDs. Early posttransplantation outcomes were best in YLD transplantations, followed by SCD and OLD transplantations. OLD transplantations were associated with inferior 3-year graft survival rates (85.7%), but similar 3-year patient survival rates (88.4%) compared with YLD (3-year graft survival, 83.4%; patient survival, 87.4%) and had superior graft survival compared with all deceased donor options. Compared with OLD transplantations, ECD transplantations were associated with a greater risk of graft loss (hazard ratio, 2.36; 95% confidence interval, 1.18 to 4.74).

LIMITATIONS

Observational retrospective studies using registry data are subject to inherent limitations, including the possibility of selection bias.

CONCLUSIONS

With superior graft and patient survival in recipients of transplants from OLDs compared with SCDs and ECDs, OLDs may be an important option for elderly transplantation candidates and should be considered for older patients with a willing and suitable older donor.