Kidney Transplantation Offers Better Survival Odds Than Dialysis in the Elderly

Medscape Conference Coverage, based on selected sessions at the:
World Congress of Nephrology 2009: A Joint Meeting of the European Renal Association–European Dialysis and Transplant Association (ERA-EDTA) and the International Society of Nephrology (ISN)

This coverage is not sanctioned by, nor a part of, the European Renal Association–European Dialysis and Transplant Association or the International Society of Nephrology. Conference news does not receive grant support and is produced independently.

From Medscape Medical News
WCN 2009: Kidney Transplantation Offers Better Survival Odds Than Dialysis in the Elderly
Caroline Helwick

May 27, 2009 (Milan, Italy) — Patients 65 years and older experience more complications from kidney transplantation than younger organ recipients, but studies presented here at the World Congress of Nephrology, a Joint Meeting of the European Renal Association–European Dialysis and Transplant Association and the International Society of Nephrology suggest that benefits, including prolonged survival, can outweigh the risks of remaining on dialysis.

Ulrich Frei, MD, professor of medicine at Charité University Hospital in Berlin, Germany, an expert in the field who was not involved in the study, discussed transplantation in the elderly, and maintained that "it is worthwhile to transplant to elderly recipients, as you can improve life expectancy over dialysis."

The average additional years gained through transplant is 3.7 in patients 65 years and older, and 8.7 in younger patients, he said.

"In a population with a well-matched graft," he noted, "there is little to no influence of the recipient's age on outcome. In fact, the influence of the recipient's age is rather low, whereas the influence of older donor age is overwhelming."

Rejection risk is fairly high when older recipients receive organs from older donors, but is similar between the other 2 groups — older donors giving to younger recipients and younger recipients giving to older donors — he pointed out.

Elderly Lived Longer With Transplant in Scandinavian Study

In a Scandinavian study comparing dialysis and transplantation in the elderly, risk for death was initially increased with transplantation, but at longer follow-up, more transplant patients were alive. Although population-based studies have shown that kidney transplantation offers survival benefits over dialysis, there have been few data comparing the treatment modes

Kristian Heldal, MD, from the University of Oslo in Norway, reported the results of a study of 286 patients 70 years and older who started dialysis between 1990 and 2005 and who were wait-listed for kidney transplantation. Patients were included at the time of wait-listing or the start of dialysis and were followed until death or the end of the study (May 2008). Outcomes for the patients who remained on dialysis were compared with those who received an organ transplant.

The groups were similar in terms of time spent on dialysis before wait-listing (approximately 6 months), age at wait-listing (approximately 74 years), and percentage of hemodialysis and peritoneal dialysis (approximately 80% hemodialysis). The only difference was a higher percentage of female patients in the transplantation group (32% vs 19%; P = .05).

During the study period, 81% of the elderly patients received a kidney transplant, with 16% of organs obtained from living donors. The median time from wait-listing to transplantation was 0.8 years.

Although the transplant group had a 2- to 3-fold higher risk for death in the first year posttransplant, risk declined thereafter, and a survival benefit was observed beginning 2.5 years after the time of wait-listing, Dr. Heldal reported.

Survival at 5 years was 31% in the wait-list group and 49% in the transplant group. Median survival was 3.4 years (range, 3.0 to 3.

in the wait-list group and 4.8 years (range, 3.8 to 5.9) in the transplant group. In the time-dependent Cox model, adjusted for age, sex, and dialysis modality, wait-list patients had a 35% increased risk for death, but this was not statistically significant (P = .14).

"Based on these data, it is our opinion that there is no reason to establish an absolute upper age limit for kidney transplantation, assuming the organ supply is sufficient and the patient and physician are willing to accept the initially higher risk with transplant," Dr. Heldal maintained.

Dr. Frei, in delivering a talk on transplantation in the elderly, emphasized that although there is no fixed age limit, transplantation in people older than 70 years is still rare in most centers. The special risk profile in older patients must be considered, he said. This includes increased risk for infectious complications and resulting mortality (which has declined in younger patients in recent years), increased risks for rejection and diabetes, and reduced graft survival.

Some of these complications were not found, however, in an Italian study presented at the meeting, although mortality was higher in the older patients. The study compared outcomes between transplant recipients 65 years and older (n = 151) and those younger than 65 (n = 302).

Mortality was 23% in the older group and 9% in the younger (P < .05), with graft loss being responsible for death in 18% and 1%, respectively (P < .05) after a median follow-up of approximately 3 years (up to 17 years).

The chief causes of death were similar between the 2 age groups — cardiovascular disease, sepsis, and cancer — although the older group experienced more complications, including delayed graft function, urinary tract infections, urologic complications, cardiovascular events, and cancer. Episodes of new-onset diabetes, pneumonia, and acute rejection, however, were similar.

Lead author Maria Messina, MD, from the Renal Transplant Unit, San Giovanni Battista Hospital, University of Turin in Italy, said that "a higher mortality in this population is undeniable," but one can maximize benefits and minimize complications through careful pretransplant screening, early diagnosis and treatment of complications, and a tailored immunosuppressive protocol.

Dr. Frei added that since the elderly will not live as long as younger recipients, "there is a special need to keep waiting time in the older kidney-transplant candidates short."

World Congress of Nephrology 2009: A Joint Meeting of the European Renal Association–European Dialysis and Transplant Association (ERA-EDTA) and the International Society of Nephrology (ISN): Abstracts Sa719 and SU702. Presented May 24 and 25, 2009.

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Caroline Helwick

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