Last week, this article, Kidney Transplants From Extended Criteria Non-Beating Heart Donors Double Risk Of Death In Elderly brought the issue of of the risks of extended criteria organs into focus. It sounds like a bad thing that a higher-risk organ would double the risk of death.
Not necessarily, says a new report from Wake Forest University Baptist Medical Center. Without them, age would be a barrier to getting a transplant at all and it will help alleviate the burgeoning organ shortage among older adults.
“In the recent past, chronological age has been a considered a barrier for both organ donation and transplantation,” said Phillip Moore, M.D., lead author. “Our experience suggests that by transplanting organs that are considered higher-risk into carefully selected elderly patients, waiting times can be reduced and survival is similar, compared to standard-organ transplants.”
The research, which involved 356 kidney transplants over a 59-month period, is reported in the journal Surgery.
Because of the aging population, there is an increasing need for kidney transplants among older adults. While the number of patients younger than 50 added to the waiting list for kidney transplants has remained constant during the last decade, the number of patients who are 65 or older has tripled. More than half of the people on the current active list are over age 50.
“The crisis in organ supply challenges the transplant community to maximize the use of organs from all consenting donors,” said Moore, a surgery resident.
In 2002, the United Network for Organ Sharing instituted a new policy to make better use of higher-risk organs that were once considered unsuitable for transplantation. These organs from “expanded criteria” donors (ECD) include kidneys from deceased donors over age 60 years or those over age 50 with health conditions such as high blood pressure, stroke or elevated levels of a protein called creatinine. Levels of creatinine, which is produced by muscle, are used to determine kidney function.
“Controversy exists regarding the optimal approach to the elderly donor and recipient,” said Moore. “Ethical concerns have been expressed that providing elderly patients who have end-state renal disease with scarce kidneys from deceased donors may not represent a worthwhile investment.”
Some studies have shown that being older is associated with a higher risk of the transplant failing; other studies have shown that survival of the transplanted organ is similar in all age groups. Moore’s study reviewed 356 transplants over almost six years with respect to recipient age.
Almost one-third of patients were over age 60 and more half of them (54 percent) received ECD kidneys. There were 26 recipients over age 70 and the oldest recipient was 81 years old.
Patient and organ survival rates were similar regardless of patient age – and whether they received an ECD or a standard-criteria donor organ. In addition, the mean waiting time for patients over 60 receiving ECD kidneys was 18 months, compared to 25 months for those receiving standard criteria donor kidneys.
With a mean follow-up of 27 months, patient survival was 91 percent among patients older than 60 years and 95 percent among those younger than 60 years. Survival of the transplanted organ was similar for all age groups: 82 percent in patients over age 60, 83 percent in patients between 40 and 59 years old, and 87 percent in patients 19 to 39 years old.
Survival rates were also similar between patients receiving ECD kidneys and those receiving standard kidneys. Patient survival rates were 93 percent and 89 percent respectively, and kidney survival rates were 82 percent and 81 percent. In the subgroup of recipients over age 70, patient and graft survival rates were both 100.
“By directing ECD kidneys to appropriate elderly patients, waiting times can be reduced and survival is similar compared to standard kidneys in the elderly,” said Moore. “At our center, no specific upper age limit is an absolute barrier to kidney transplantation.”
Kidney transplantation is a preferred treatment for end-stage renal failure, which increases disproportionately with older age. Transplantation is associated with an improved life expectancy and better quality of life and is cost-effective for patients and payers.
“Transplantation between older donors and recipients has resulted in a doubling of the annual transplant activity at our center in the past five years,” said Moore.
Co-researchers were Alan Farney, M.D., Ph.D., Erica Hartmann, M.D., Jeffrey Rogers, M.D., William Doares, PharmD, Michael Gautreaux, Ph.D., Samy Iskandar, MBBCh., Ph.D., Gloria Hairston, B.S., Patricia Adams, M.D. and Robert Stratta, M.D.
- Wake Forest