Is “Old” Ever Too Old for Transplant?

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In recent years, the 60- to 80-year-old age group on the kidney transplant waiting list has increased dramatically, decreasing their chances of ever receiving a kidney. Yet studies show that even those older than 70 can decrease their chance of death and increase the length of their life with a kidney transplant.

Evaluating elderly patients for a transplant should be an “exaggeration” of evaluating younger patients, said Gabriel Danovitch, medical director for the Kidney and Pancreas Transplant Program at the University of California, Los Angeles. Physicians should rule out coronary artery disease, other cardiovascular disease, and cancer. Patients should also have good mobility, muscle strength, and nutritional status. He emphasized an assessment that looks at ‘biological age’ of the individual rather than chronological age.

Danovitch spoke about “Transplantation in the Elderly: Is Old Ever Too Old?” at the Renal Week 2010 session, “What to Do with Medically High-Risk Kidney Transplant Candidates” in November.

Even in highly selected patients, “not surprisingly, the older you are, the more likely you are to die,” Danovitch said. But graft survival does not appear to suffer with increased age of recipients. There is also a drop-off in the incidence of acute rejection in older transplant patients, presumably owing to a less aggressive or functional immune system. However, this is balanced out largely by the fact that older donor age is associated with acute rejection and older recipients tend to get older kidneys.

“It’s important for elderly patients waiting for deceased donor kidneys to remember that they will get kidneys of lower quality,” said Danovitch.

The dilemma for nephrologists, then, is whether or not to encourage living donation as a solution, when those living donors are likely to be the patient’s children or even grandchildren. “We must think about, ‘What are the ethical issues in transplanting younger donors into older patients who probably won’t live much longer?’ ”

“Many elderly patients don’t want to turn to their children,” Danovitch said. “But they also don’t want to wait eight to 10 years for a poor quality deceased donor kidney.” Currently, 10 percent of living donor kidneys go to people more than 65 years old, and that percentage appears to be increasing.

Among the increased risks for elderly transplant patients are infections, surgery complications, pharmacokinetic vulnerability, and lymphomas due to immunosuppression.

Danovitch summed up the hard-learned lessons about elderly transplants from his own practice: “Choose your patients carefully, make sure they know what they are getting into, do not take their immune systems for granted, and watch out for covert infections.” He also noted that better research protocols targeted to the elderly population were needed as the numbers of these patients are likely to continue to increase.