Older candidates for kidney transplantation: Who to refer and what to expect?

Age Disparities in Access to First and Repeat Kidney Transplantation

BACKGROUND

Evidence suggests that older patients are less frequently placed on the waiting list for kidney transplantation (KT) than their younger counterparts. The trends and magnitude of this age disparity in access to first KT and repeat KT (re-KT) remain unclear.

METHODS

Using the US Renal Data System, we identified 2 496 743 adult transplant-naive dialysis patients and 110 338 adult recipients with graft failure between 1995 and 2018. We characterized the secular trends of age disparities and used Cox proportional hazard models to compare the chances of listing and receiving first KT versus re-KT by age (18-64 y versus ≥65 y).

RESULTS

Older transplant-naive dialysis patients were less likely to be listed (adjusted hazard ratio [aHR] = 0.18; 95% confidence interval [CI], 0.17-0.18) and receive first KT (aHR = 0.88; 95% CI, 0.87-0.89) compared with their younger counterparts. Additionally, older patients with graft failure had a lower chance of being listed (aHR = 0.40; 95% CI, 0.38-0.41) and receiving re-KT (aHR = 0.76; 95% CI, 0.72-0.81). The magnitude of the age disparity in being listed for first KT was greater than that for re-KT ( Pinteraction  < 0.001), and there were no differences in the age disparities in receiving first KT or re-KT ( Pinteraction  = 0.13). Between 1995 and 2018, the age disparity in listing for first KT reduced significantly ( P  < 0.001), but the age disparities in re-KT remained the same ( P  = 0.16).

CONCLUSIONS

Age disparities exist in access to both first KT and re-KT; however, some of this disparity is attenuated among older adults with graft failure. As the proportion of older patients with graft failure rises, a better understanding of factors that preclude their candidacy and identification of appropriate older patients are needed.

Disparities in Kidney Transplant Waitlisting Among Young Patients Without Medical Comorbidities

Importance

Disparities in kidney transplant referral and waitlisting contribute to disparities in kidney disease outcomes. Whether these differences are rooted in population differences in comorbidity burden is unclear.

Objective

To examine whether disparities in kidney transplant waitlisting were present among a young, relatively healthy cohort of patients unlikely to have medical contraindications to kidney transplant.

Design, Setting, and Participants

This retrospective cohort study used the US Renal Data System Registry to identify patients with end-stage kidney disease who initiated dialysis between January 1, 2005, and December 31, 2019. Patients who were older than 40 years, received a preemptive transplant, were preemptively waitlisted, or had documented medical comorbidities other than hypertension or smoking were excluded, yielding an analytic cohort of 52 902 patients. Data were analyzed between March 1, 2022, and February 1, 2023.

Main Outcome(s) and Measure(s)

Kidney transplant waitlisting after dialysis initiation.

Results

Of 52 902 patients (mean [SD] age, 31 [5] years; 31 132 [59%] male; 3547 [7%] Asian/Pacific Islander, 20 782 [39%] Black/African American, and 28 006 [53%] White) included in the analysis, 15 840 (30%) were waitlisted for a kidney transplant within 1 year of dialysis initiation, 11 122 (21%) were waitlisted between 1 and 5 years after dialysis initiation, and 25 940 (49%) were not waitlisted by 5 years. Patients waitlisted within 1 year of dialysis initiation were more likely to be male, to be White, to be employed full time, and to have had predialysis nephrology care. There were large state-level differences in the proportion of patients waitlisted within 1 year (median, 33%; range, 15%-58%). In competing risk regression, female sex (adjusted subhazard ratio [SHR], 0.92; 95% CI, 0.90-0.94), Hispanic ethnicity (SHR, 0.77; 95% CI, 0.75-0.80), and Black race (SHR, 0.66; 95% CI, 0.64-0.68) were all associated with lower waitlisting after dialysis initiation. Unemployment (SHR, 0.47; 95% CI, 0.45-0.48) and part-time employment (SHR, 0.74; 95% CI, 0.70-0.77) were associated with lower waitlisting compared with full-time employment, and more than 1 year of predialysis nephrology care, compared with none, was associated with greater waitlisting (SHR, 1.51; 95% CI, 1.46-1.56).

Conclusions and Relevance

This retrospective cohort study found that fewer than one-third of patients without major medical comorbidities were waitlisted for a kidney transplant within 1 year of dialysis initiation, with sociodemographic disparities in waitlisting even in this cohort of young, relatively healthy patients unlikely to have a medical contraindication to transplantation. Transplant policy changes are needed to increase transparency and address structural barriers to waitlist access.

Predicting older-donor kidneys' post-transplant renal function using pre-transplant data

This paper provides a methodology for predicting post-transplant kidney function, that is, the 1-year post-transplant estimated Glomerular Filtration Rate (eGFR-1) for each donor-candidate pair. We apply customized machine-learning algorithms to pre-transplant donor and recipient data to determine the probability of achieving an eGFR-1 of at least 30 ml/min. This threshold was chosen because there is insufficient survival benefit if the kidney fails to generate an eGFR-1 ≥ 30 ml/min. For some donor-candidate pairs, the developed algorithm provides highly accurate predictions. For others, limitations of previous transplants' data results in noisier predictions. However, because the same kidney is offered to many candidates, we identify those pairs for whom the predictions are highly accurate. Out of 6977 discarded older-donor kidneys that were a match with at least one transplanted kidney, 5282 had one or more identified candidate, who were offered that kidney, did not accept any other offer, and would have had ≥80% chance of achieving eGFR-1 ≥ 30 ml/min, had the kidney been transplanted. We also show that transplants with ≥80% chance of achieving eGFR-1 ≥ 30 ml/min and that survive 1 year have higher 10-year death-censored graft survival probabilities than all older-donor transplants that survive 1 year (73.61% vs. 70.48%, respectively).

Social support mediates the relationship between illness perception and psychosocial adaptation among young and middle-aged kidney transplant recipients in China

Background

No research has yet been done on social support's influence on the association between illness perception and psychosocial adaptation among young and middle-aged kidney transplant recipients in China. Accordingly, it remains unclear how medical personnel can assist patients in successfully adjusting to the early postoperative period and improving their health.

Objective

This study sought to explore the influence of illness perception and social support on the psychosocial adaptation of young and middle-aged recipients of kidney transplants in China during the early postoperative period.

Methods

This study adopted a cross-sectional design. The study included 236 young and middle-aged kidney transplant recipients from a tertiary hospital in China. Demographic and disease-related data were collected. Additionally, the Psychosocial Adjustment to Illness Scale-Self-Report, the Brief Illness Perception Questionnaire, and the Multidimensional Scale of Perceived Social Support were used to assess participants' psychosocial adaptation, illness perception, and social support, respectively. The model was examined using descriptive analysis, Pearson's correlation analysis, hierarchical multiple regression analysis, and the PROCESS Macro in SPSS 26.0.

Results

A total of 176 (74.56%) participants reported an average psychosocial adaptation score >50, which is relatively negative. Marital status, education level, residence, per capita monthly income (in Chinese yuan), medical insurance, work status, post-transplant time, body mass index, creatinine status, and complications were all related to psychosocial adaptation (p < 0.05). The more negative their illness perception and the worse their social support, the worse the psychosocial adaptation of young and middle-aged kidney transplant recipients. Further, the effect of illness perception on psychosocial adaptation was partially mediated by social support (36.56%).

Conclusion

In general, the psychosocial adaption level of young and middle-aged kidney transplant recipients was negative during the early postoperative period. Healthcare teams should assist patients in building a positive illness perception shortly following kidney transplantation, while also providing psychological care and support to help them cope with the onset of psychosocial issues.

Analysis of Complications and Recipients' and Graft Survival in Patients 60 Years of Age and Older in the Long-Term Follow-up Period After Kidney Transplant: A Single-Center, Paired Kidney Analysis

BACKGROUND

Long-term results of kidney transplant (KTx) in older patients may differ from younger recipients owing to increased cardiovascular comorbidities. The study aimed to analyze surgical and nonsurgical complications that develop in the long-term follow-up period after KTx, and factors that influence results of KTx in recipients aged 60 years and older (≥60) compared with younger recipients (<60).

METHODS

One hundred seventy-five patients aged ≥60 years and 175 patients aged <60 years who received a kidney graft from the same deceased donor were enrolled in the study. In the long-term follow-up period (3 months to 5 years after KTx) the incidence of surgical and nonsurgical complications, as well as patient and kidney graft survival, were compared. Additionally, the influence of early complications on patients and kidney graft survival was assessed.

RESULTS

There were no differences between recipients aged ≥60 years compared with recipients aged <60 years in occurrence of surgical complications (graft artery stenosis: 0.6% vs 2.3%; ureter stenosis: 3.4% vs 1.1%; lymphocele: 6.9% vs 3.4%) and nonsurgical complications (urinary tract infection: 19.4% vs 23.4%; pneumonia: 8.6% vs 8.6%; cytomegalovirus infection: 6.3% vs 8%; new-onset diabetes after transplant: 16.6% vs 17.1%; cancer incidence: 5.7% vs 4.6%; acute rejection episode: 13.1% vs 17.1%). Five-year recipient survival was lower in a group of patients aged ≥60 years (death, 15.4% vs 8%; death with functioning graft, 12% vs 5.1%).

CONCLUSIONS

The incidence of surgical and nonsurgical complications, as well as kidney-graft survival, in recipients aged ≥60 years in a 5-year follow-up period is comparable to younger recipients aged <60 years.

Impact of kidney transplantation on functional status

BACKGROUND AND AIMS

Functional capacity (FC) is known to affect morbidity and mortality in kidney transplantation. Despite this important role, little is known about the variables influencing post-transplant FC. Our study aims at identifying these crucial associations.

METHOD

Our study included 16,684 renal transplant recipients (RTR). Patients had transplant between 1 September 2018 and 1 September 2019. Mild functional impairment was defined as those with a KPSS score > or = 80; moderate functional impairment was defined as those with a KPSS score between 50 and 70 and severe functional impairment was defined as those with a KPSS score < or =40. The outcome measured was FC at follow-up one-year post-transplant. Abnormal FC at follow-up was defined as those with KPSS score less than 80%. Normal FC at follow-up was defined as those with KPSS score equal or above 80%. Multivariate logistic regression was used to assess with the relationship between patient characteristics and abnormal functional status post-transplant.

RESULTS

Three groups were identified; those with none-to-mild functional impairment at time of transplant (Group A; n = 8388), those who had moderate impairment at time of transplant (Group B; n = 7694) and those who had severe impairment at time of transplant (Group C; n = 602). Abnormal FC at one-year post transplant was present in 7.69%, 28.89%, 49.49% of patients in group A, B and C, respectively. Glucocorticoid withdrawal was associated with lower risk of developing abnormal FC post-transplant (OR = 0.75, p value = .02, 95% confidence intervals: 0.64 to 0.97), while recipient diabetes was associated with higher risk of abnormal FC (OR = 1.44, p value <.01, 95% confidence intervals: 1.20 to 1.74) in adjusted model.

CONCLUSION

Kidney transplantation is associated with substantial improvement in all stages of FC in KTRs. Glucocorticoid withdrawal and diabetes mellitus are potentially modifiable factors of FC and merit further considerations during pre-transplant workup and post-transplant immunosuppressive therapeutic planning.Key messagesKidney transplantation is associated with substantial improvement in all stages of FC in KTRs.Glucocorticoid withdrawal and diabetes mellitus are potentially modifiable factors of FC and merit further considerations during pre-transplant workup and post-transplant immunosuppressive therapeutic planning.

Comparison of kidney allograft survival in the Eurotransplant senior program after changing the allocation criteria in 2010-A single center experience

Aims

The European Senior Program (ESP) aims to avoid waiting list competition between younger and elderly patients applying for renal transplantation. By listing patients ≥65 years on a separate waiting list and locally allocating of grafts ≥65 years exclusively to this cohort, waiting and cold ischemia times are predicted to be shortened, potentially resulting in improved kidney transplantation outcomes. This study compared a historic cohort of renal transplant recipients being simultaneously listed on the general and the ESP waiting lists with a collective exclusively listed on the ESP list in terms of surrogates of the transplantation outcome.

Methods

Total 151 eligible patients ≥ 65 years from Münster transplant Center, Germany, between 1999 and 2014 were included. Graft function, graft and patient survival were compared using surrogate markers of short- and long-term graft function. Patients were grouped according to their time of transplantation.

Results

Recipients and donors in the newESP (nESP) cohort were significantly older (69.6 ± 3.5 years vs 67.1 ± 2 years, p<0.05; 72.0 ± 5.0 years vs 70.3 ± 5.0 years, p = 0.039), had significantly shorter dialysis vintage (19.6 ± 21.7 months vs 60.2 ± 28.1 months, p<0.001) and suffered from significantly more comorbidities (2.2 ± 0.9 vs 1.8 ± 0.8, p = 0.009) than the historic cohort (HC). Five-year death-censored graft survival was better than in the HC, but 5-year graft and patient survival were better in the ESP cohort. After 2005, cold ischemia time between groups was comparable. nESP grafts showed more primary function and significantly better long-term graft function 18 months after transplantation and onwards.

Conclusion

nESP recipients received significantly older grafts, but experienced significantly shorter time on dialysis. Cold ischemia times were comparable, but graft function in the nESP cohort was significantly better in the long term.

Standard work-up of the low-risk kidney transplant candidate: a European expert survey of the ERA-EDTA Developing Education Science and Care for Renal Transplantation in European States Working Group

BACKGROUND

Existing guidelines on the evaluation and preparation of recipients for kidney transplantation target the entire spectrum of patients with end-stage renal disease. Within the ERA-EDTA Developing Education Science and Care for Renal Transplantation in European States (DESCARTES) Working Group, it was proposed that in a subset of relatively young patients (<40 years) without significant comorbidities (such as diabetes or cardiovascular disease), the work-up for transplantation could be restricted to a small set of tests.

METHODS

Aiming for agreement between transplant centres across Europe, we surveyed the opinion of 80 transplant professionals from 11 European states on the composition of a minimal work-up.

RESULTS

We show that there is a wide agreement among European experts that the work-up for kidney transplantation of the low-risk candidate, as opposed to the standard risk candidate, could include a limited number of investigations. However, there is some disagreement regarding the small number of diagnostic procedures, which is related to geographical location within Europe and the professional background of respondents.

CONCLUSIONS

Based on the results of the survey, published guidelines and expert meetings by the DESCARTES Working Group, we have formulated a proposal for the work-up of low-risk kidney transplant candidates.

Role of Physical Performance Assessments and Need for a Standardized Protocol for Selection of Older Kidney Transplant Candidates

The older adult population (65 years or older) with advanced or end-stage kidney disease is steadily growing, but rates of transplantation within this cohort have not increased in a similar fashion. Physical deconditioning, resulting in poor post-transplantation outcomes, is a primary concern among older renal patients. The assessment of physical function often holds more weight in the selection process for older candidates, despite evidence showing benefits of transplantation to this vulnerable population. Although several frailty assessment tools are being used increasingly to assess functional status, there is no standardized selection process for older candidates based on these assessment results. Also, it is unknown if timely targeted physical therapy interventions in older patients result in significant improvement of functioning capacity, translating to higher listing and transplantation rates, and improved post-transplantation outcomes. It is therefore of upmost importance not only to incorporate an effective objective functional status assessment process into selection and waitlist evaluation protocols, but also to have targeted interventions in place to maintain and improve physical conditioning among older renal patients. This paper reviews the commonly utilized assessment tools, and their applicability to older patients with renal disease. We also propose the need for definitive selection and waitlist management guidelines to formulate a streamlined assessment of functional capacity and transplant eligibility, as well as a process to maintain functional status, thereby increasing the access of older patients to renal transplantation.

The Relationship Between Frailty and Decreased Physical Performance With Death on the Kidney Transplant Waiting List

INTRODUCTION

Frailty and decreased physical performance are associated with poor outcomes after kidney transplant. Less is known about their relationship with pretransplant outcomes. The aim of this study was to characterize associations between frailty and physical performance with death on the kidney transplant waiting list.

DESIGN

Since December 2014, high-risk kidney transplant candidates at our center (age > 59, diabetic and/or history of >3 years dialysis) have undergone frailty and physical performance testing using Fried Criteria and the Short Physical Performance Battery.

RESULTS

Between December 2014 and November 2016, 272 high-risk candidates underwent testing and were approved for transplant. Both frailty and physical performance score were significantly associated with death on the waiting list (hazard ratio [HR]: 6.7, confidence interval [CI]: 1.5-30.1; P = .01; HR: 0.8 per 1-point increase, CI: 0.7-1.0; P = .02, respectively). The relationship between frailty, physical performance score, and death on the waiting list appeared to be independent of age, diabetes, or duration of dialysis.

DISCUSSION

Frailty and decreased physical performance appear to be independently associated with increased mortality on the kidney transplant waiting list. Further studies are needed to determine whether improving frailty and physical performance prior to transplant can decrease waiting list mortality.

Cost of Dialysis Therapy by Modality in Manitoba

BACKGROUND AND OBJECTIVES

The prevalence of ESKD is increasing worldwide. Treating ESKD is disproportionately costly in comparison with its prevalence, mostly due to the direct cost of dialysis therapy. Here, we aim to provide a contemporary cost description of dialysis modalities, including facility-based hemodialysis, peritoneal dialysis, and home hemodialysis, provided with conventional dialysis machines and the NxStage System One.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We constructed a cost-minimization model from the perspective of the Canadian single-payer health care system including all costs related to dialysis care. The labor component of costs consisted of a breakdown of activity-based per patient direct labor requirements. Other costs were taken from statements of operations for the kidney program at Seven Oaks General Hospital (Winnipeg, Canada). All costs are reported in Canadian dollars.

RESULTS

Annual maintenance expenses were estimated as $64,214 for in-center facility hemodialysis, $43,816 for home hemodialysis with the NxStage System One, $39,236 for home hemodialysis with conventional dialysis machines, and $38,658 for peritoneal dialysis. Training costs for in-center facility hemodialysis, home hemodialysis with the NxStage System One, home hemodialysis with conventional dialysis machines, and peritoneal dialysis are estimated as $0, $16,143, $24,379, and $7157, respectively. The threshold point to achieve cost neutrality was determined to be 9.7 months from in-center hemodialysis to home hemodialysis with the NxStage System One, 12.6 months from in-center hemodialysis to home hemodialysis with conventional dialysis machines, and 3.2 months from in-center hemodialysis to peritoneal dialysis.

CONCLUSIONS

Home modalities have lower maintenance costs, and beyond a short time horizon, they are most cost efficient when considering their incremental training expenses.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2018_07_18_CJASNPodcast_18_8_F.mp3.

[Therapy escalation for the potential organ donor : Are all intensive care measures also ethically justifiable?]

The gap between the number of organs needed and the number available has dramatically increased in Germany in the last decade-for intensivists and transplantation specialists, it is challenging to cover the demand responsibly. It is therefore increasingly important to identify potential organ donors in order to realize organ donation. An escalation of intensive care measures is often required, which raises critical ethical questions. In Germany, organ donation is only allowed after brain death with prior informed consent from the deceased or his/her relatives. Determining the willingness of the potential organ donor and adapting the subsequent intensive care to it requires experience and empathy. Therapy escalation for the realization of organ donation is not opposed to the basic ethical principles of medicine, but remains an individual decision. A time limitation of this last intensive therapy phase to achieve optimal conditions for transplantation should be discussed with the relatives and adapted to the medical requirements. This article would like to highlight ethical questions that are relevant in the context of therapy escalation of potential organ donors and, thus, support the decision-making process.