4. Would you accept kidney donation from a 71-year-old male with excellent kidney function and normal cardiac investigations to his 16-year-old son, 110 mismatch with no DSA?
cadaveric grafts have higher complications including delayed graft function, acute and chronic rejections, the need for more intensive immunosuppression, …. etc.
However, the graft survival is better than that of marginal kidneys.
some other related factors are needed to evaluate the risk/benefit ratio of transplanting cadaveric grafts rather than marginal grafts.
Living donor transplantation is generally superior to cavaderic kidney transplantation due to less rejection rate, less delayed graft function and therefore better graft and patient outcomes, as well as other factors like cost saving.
Cadaver versus living donor kidneys: Impact of donor factors on antigen induction before transplantationAuthor links open overlay panel
CADAVERIC VERSUS LIVING DONOR KIDNEY TRANSPLANTATIONA Medicare Payment Analysis 1Smith, Craig R.2; Woodward, Robert S.3; Cohen, David S.3; Singer, Gary G.4; Brennan, Daniel C.4; Lowell, Jeffrey A.2; Howard, Todd K.2; Schnitzler, Mark A.35 Author Information
Transplantation: January 27, 2000 – Volume 69 – Issue 2 – p 31
Yes, Dr Ben,
LRD, if safe for a prospective donor, is always better than cadaveric transplant. But the main and the sole determinant is the principle of primum non nocere (‘do no harm’).
as most of us know that Living donor transplantation is generally superior to cavaderic kidney transplantation due to less rejection rate, less delayed graft function and therefore better graft and patient outcomes, even if the donor age is old ( no significant change between50-60 age group and 60-70 age group )
but i found an interesting study for long term graft survival follow up ( almost 25 years after transplant which can’t be apply on old age donors and it is a single centre study ) it says :
Kidney function was found to be better in recipients having received a transplant from a cadaveric donor at 10, 15, and 20 years after kidney transplantation.
The mean age of cadaveric donors (23.84 years) was found to be lower that of the living ones (52.75 years).
No statistically important difference was found in relation to any other investigated factor.
Cadaveric grafts have higher complications including delayed graft function, acute and chronic rejections, the need for more intensive immunosuppression,
According to BTS/RA Living Donor Kidney Transplantation Guidelines 2018 Most US transplant programs currently do not have an upper age limit for accepting donors and are more flexible in applying exclusion criteria for renal risk factors in older donors (20). UK practice also tends to this conclusion.
it can be a comparable option if there no other available living donor & provided that not to be on prolonged waiting list considering the fact that transplantation is the best option for ESRD .
overall, the use of older kidney donors appears to be an equivalent or beneficial alternative to awaiting deceased donor kidneys ( Englum BR, Schechter MA, Irish WD, et al. Outcomes in kidney transplant recipients from older living donors. Transplantation 2015; 99: 309-15. )
I think it is better to have this kidney from his old age father in terms of graft outcome and survival, as the cold ischemia time will be less in living donor kidney transplant, there will be less delayed graft function, inspite of increased risk in recipients of old age donor, the concern about the long term reduced GFR and vasculopathy in recepient of older age donors.
[1] Squifflet JP, Pirson Y, van Cangh P, Otte JB, van Ypersele de Strihou C, Alexandre GP. Renal transplantation in children: a comparative study between parental and well-matched cadaveric grafts. Transplantation. 1981 Oct;32(4):278-81. PMID: 7036444. [2] Fritsche L, Hoerstrup J, Budde K, Frei U, Kahl A, Loening S, May G, Neuhaus P, Neumayer HH, Reinke P, Schoenberger B, Schoenemann C. Kidney transplantation at the Charité: long tradition, elderly patients and the duration of hospitalization. Clin Transpl. 2002:171-9. PMID: 12971447. [3] Andrews PA, Burnapp L. British Transplantation Society / Renal Association UK Guidelines for Living Donor Kidney Transplantation 2018: Summary of Updated Guidance. Transplantation. 2018 Jul;102(7):e307. doi: 10.1097/TP.0000000000002253. PMID: 29688993; PMCID: PMC7228639.
Not all cadaveric kidneys are the same. Standard criteria donor (SCD), expanded criteria donor (ECD) or donation from non heart beating donor. In study using the UNOS data from 1994 to 2012, 250,827 kidney transplant recipients were categorised by donor status: standard criteria donor (SCD), expanded criteria donor (ECD), or living donor (LD); and by donor age: <60, 60-64, 65-69, ≥70 years. 92,646 of the transplants studied from living donors, with 4.5% of the recipients (4,186) transplanted with older LD kidneys. Transplant recipients with older LD kidneys had significantly lower graft and patient survival compared to younger LD recipients. Compared to SCD recipients, graft survival was decreased in recipients with living donors 70 years or older, but patient survival was similar. Older LD kidney recipients had better graft and patient survival than ECD recipients. So, the short answer SCD could be better than this elderly donor in terms of graft survival but same patient survival
Englum BR, Schechter MA, Irish WD, et al. Outcomes in kidney transplant
recipients from older living donors. Transplantation 2015; 99: 309-15
I understand your argument, Dr Mohamed. My focus is on prospective donor and nothing else! If the donor is fit then this is better for the cadaveric kidney could be used for someone else (refer to utilitarian approach).
Potential benefits and risks of living kidney donation.
Improved graft and patient survival, primarily due to superior organ quality, better HLA matching, shorter cold ischemia time, negation of negative donor-related factors (e.g. brain death, cardiovascular instability, use of vasopressins), short waiting time on dialysis, and feasibility of pre-emptive transplantation
Facilitation of pre-emptive transplantation, which allows avoidance of dialysis-related complications, provides optimal medical and psychological condition of the recipient at the time of surgery, reduces risk of acute rejection, and improves graft and patient survival
Donors above 60 years of age have :
** increased risk of peri-operative complications
** existing comorbidities and residual function post-donation
** the long-term transplant outcome in the recipient associated with reduced donor GFR and potential donor vasculopathy.
So in this case the father is not absolute contraindication but if there is another donor as pair kidney donor or cadaveric
Kidney I will proceed with it
A cadaveric donor is a kidney that is donated by someone who has just died Cadaveric organ donors are previously healthy patients who have suffered irreversible catastrophic brain injury of known etiology.
The brain dead donor should have effective cardiovascular function.
No ,,because a living kidney organ has a much higher 5-year survival than a cadaveric kidney (>80 vs. >70% 3-year graft survival).
A living donor-recipient pair who cannot donate directly may decide to opt for exchange to minimize waiting time because of the low likelihood of a paired exchange between two living donor-recipient pairs.
Ross LF, Rubin DT, Siegler M, Josephson MA, Thistlethwaite JR, Woodle ES. Ethics of a paired-kidney-exchange program. N Engl J Med 1997; 36: 1752.
Yes, for the reasons that we discussed earlier in the week, it may be worthwhile discussing in paired exchange scheme but I know most clinicians might raise eye brows on this suggestion that, in my opinion, might help this patient getting a younger kidney and other recipient who can not have the donor due to immunological reasons.
Old age not contraindication to donation especially those with no co morbids but needs intensive evaluation with full explanation to the donor and recipient all the risk
Proceeding in kidney transplantation is preferable than being in waiting list several years
Also receiving kidney donation from live donor is much better than deceased donors.
Effect on donor :
Has high risk of peri operative complications.
In spite they have low GFR but decline if GFR after donation is same as general population
Effect on recipient:
There is increased risk of acute rejection delayed graft function and graft failure from old aged donor compared to thoses received from young donors.
I will accept this donor if no other options also after full discussion with donor and recipient regarding all the risk
The overall survival of patient receiving a kidney from an elderly living donor is lower than that from a younger living donor. But the results are similar to or better than receiving a younger deceased donor, be it a standard criteria donor or an extended criteria donor (1).
Although the risks for delayed graft function, acute rejection and graft failure from a living donor aged more than 65 years is higher as compared to a younger live donor, the results are comparable to a deceased donor graft outcome (2).
Recent Studies demonstrate that within only one decade the 5-year death censored graft survival rates of kidneys from deceased donors aged ≥70 years improved to a level that was comparable to the graft survival of kidneys from donors aged 60–69 years in the previous decade.Remarkably, the proportion of deceased donors aged≥70 years more than doubled from 6.7 to 15.4%.
Nonetheless, we were able to show that the graft survival of kidneys from deceased donors aged ≥70 years improved, in the short time interval of one decade, to the level previously seen for kidneys from donors aged 60–69 years.At the same time, the graft survival of kidneys from 60 to 69-year-old donors improved to the level of 50–59-year old donors from the previous decade.
These results may help to further expand the kidney donor pool especially for recipients aged ≥45 years.
Reference ;
by F Echterdiek · 2019 · Cited by 18 — Therefore, if kidneys from older donors (age ≥60 years) are transplanted into younger recipients (<65 years), they should be chosen primarily .
Living donation is better than deceased donation as deceased donation is associated with prolonged ischemia time, higher complications, intense immune suppression and higher rate of rejections. But the principle of Do No harm should be adhered to.
I will prefer accepting a kidney from his old age father rather than keeping him on the waitlist for many years and exposing him to the risk of staying on dialysis and increasing the risk of CV mortality and infections.
Living donor transplantation is generally superior to cavaderic kidney transplantation due to less rejection rate, less delayed graft function and therefore better graft and patient outcomes, as well as other factors like cost saving.
However, the graft survival is better than that of marginal kidneys. some other related factors are needed to evaluate the risk/benefit ratio of transplanting cadaveric grafts rather than marginal grafts.
I think if the GFR of this elderly healthy male is good enough for donation, then I would prefer him over cadaveric donation.
This is due to:
Older kidney donors appear to have an equivalent or beneficial alternative outcome to awaiting deceased donor kidneys.
Donor GFR rather than age has been demonstrated to be an important determinant of transplanted kidney function.
Ref:
Englum BR, Schechter MA, Irish WD, et al. Outcomes in kidney transplant recipients from older living donors. Transplantation 2015; 99: 309-15.
Hawley CM, Kearsley J, Campbell SB, et al. Estimated donor glomerular filtration rate is the most important donor characteristic predicting graft function in recipients of kidneys from live donors. Transpl Int 2007; 20: 64-72.
living kidney donation is surpassing the cadaveric kidney donation even in the setting of marginal donor for several reasons:
1} shorter waiting time.
2} pre-emptive transplantation.
3} Precluding the drawbacks of cold ischemia time integral to cadaveric kidney donation.
4} Avoiding the detrimental consequences of hemodialysis therapy.
5} Despite the fact that Marginal donor kidney is inferior in survival than standard donor kidney, its still preferable to cadaveric kidney due to the advantageous survival.
6} Emotional background of the donor is playing a pivotal role in successful transplantation.
references:
British transplant guideline : bts.org.uk
I agree with Dr Wael Jebur contribution. However, I want to add that the paired kidney donation program can be of great value in such a case scenario as it may help to provide a more suitable kidney from a living donor to the recipient.
There is no study compare the outcome of graft between cadaveric and elderly donors. But one study concluded that LRD allograft have superior outcome compared to cadaveric allograft.
According to BTS 2018, old age donor has less long-term graft survival and function. I think the net result could be equal for both.
We need a comparison study between both groups for a long time
Living renal donation is by far better than deceased donation in many aspects,
First regarding the timing, it could be preemptive renal transplantation for better life quality of the recipient or even interventional during the dialytic support for the recipient, provided that in cases of desensitization this becomes more flexible compared to deceased renal donation.
The other advantage of living donation over the deceased donation ,is avoiding much worse effects of delayed graft function, longer ischemia time ,marginal kidneys or other events that might affect graft survival or even patient’s survival and quality of life expected.
According toKDIGO and British Transplantation Society guidelines
a cadaveric kidney transplant has high risk for DGF and rejection but living donor less DGF and less rejection but if the kidney is marginal the benefit need to be weight versus the disadvantage
no because the studies report that older living ( older than 70 y) has better or at least equal outcome when compared to deceased donor.
Studies from UNOS data report that decreased graft and overall survival for recipients of older living donor kidneys; but still the older living donor kidneys perform equall or better than than deceased donor kidneys.
Berger et al found that living donors of 70 years or older has no significant differences in short-term graft failure or recipient survival when compared to recipients of 50- to 59- year-old deceased donors.
When compared to SCD and ECD kidneys, these older living donor kidneys has better outcome.
references:
1- Gill JS, Gill J, Rose C, Zalunardo N, Landsberg D. The older living kidney
donor: Part of the solution to the organ shortage. Transplantation.
2006;82:1662–1666.
2- Berger JC, Muzaale AD, James N, et al. Living kidney donors ages 70
and older: recipient and donor outcomes. Clin J Am Soc Nephrol.
2011;6:2887–2893.
CARLOS TADEU LEONIDIO
2 years ago
Please substantiate your answer
Yes, I would. We have a low missmatch .
Despite being healthy, the expectation of viability of this kidney is a few years, due to normal aging itself. However, the recipient is very young and will inevitably need another transplant later on.
With regard to the donor, despite his advanced age, he is quite healthy and unilateral nephrectomy will have little impact on his life expectancy.
Rehab Fahmy
2 years ago
can be accepted if there is no other comorbiditie,and if he is the only donor
Naglaa Abdalla
2 years ago
BTS recommendations:
Old age alone is not an absolute contraindication to donation but the
medical work-up of older donors must be particularly rigorous to
ensure they are suitable. (A1)
ahmed saleeh
2 years ago
71 year old donor with normal kidney function , normal cardiac investigations, is still a relative contraindication for Tx due to his age
Regarding graft survival : old age graft has high incidence of glomerulosclerosis as well as delayed graft function
Regarding receipt: relatively poor outcome yet better than deceased-donor
Regarding donor : the main risk is due to perioperative complications and risk of surgery .. after Exclusion of the donor’s original risk factors .
Mohamed Ghanem
2 years ago
Although advanced age alone does not always rule out donation, older donors must undergo more intensive medical screening to ensure they are acceptable
Donors over the age of 60 should be carefully considered due to the increased risk of peri-operative complications, pre-existing comorbidities, residual function following donation, as well as the long-term transplant outcome in the recipient due to decreased donor GFR and potential donor vasculopathy Pre donation assessment
Pre-donation In elderly donors, cardio-respiratory function needs to be carefully evaluated. If necessary, the majority of facilities do a stress echocardiography and/or a cardiac perfusion scan
It may be necessary to do respiratory function testing for smokers and those who have airway illness
The potential of cardiopulmonary exercise testing to predict postoperative problems
Screening of serum PSA is mandatory in males above 55 years Graft Outcome Renal function declines progressively with age and kidneys from older living donors have reduced function
After a living donor transplant, the 5-year graft survival rate was 76% for kidneys from donors older than 60 (n=241) and 79% for kidneys from donors younger than 60 (n=518). However, serum creatinine levels in recipients of kidneys from younger donors remained much lower, and graft survival was significantly greater after 5 years following transplantation
Ref :
BTS guidelines for living kidney donation
Theepa Mariamutu
2 years ago
Benefit of getting ECD kidneys
KTR will have Improved graft and patient survival than remaining dialysis
Living donor, although is ECD, the kidney – less CIT, better HLA matching, no AKI or sepsis when it is compared to deceased donor
Better controlled environment for surgery- LD better than deceased donor in the sense of surgical preparation
Since there is available donor- KTR will receive KT prior to dialysis or short dialysis vintage
Transplant allows utilization of cadaveric kidneys to other recipient who remaining on dialysis
Complications / risk
The age difference between the donor and recipient is more than 15 years- some studies showed the age difference is one of the risk factors for reduced graft survival
Older donor has higher risk of pre and perioperative complications
The recipient might need second transplant in future
Deceased donor transplant might offer younger kidneys later
Having analysed the situation, I would like to proceed with the transplantation if there is no other suitable donor available to reduce the dialysis vintage or better if could be done pre-emptively.
Plage H, Pielka P, Liefeldt L, Budde K, Ebbing J, Sugünes N, Miller K, Cash H, Bichmann A, Sattler A, Kotsch K, Friedersdorff F. Extended Criteria Donors in Living Kidney Transplantation Including Donor Age, Smoking, Hypertension and BMI. Ther Clin Risk Manag. 2020 Aug 24;16:787-793. doi: 10.2147/TCRM.S256962. PMID: 32922016; PMCID: PMC7455534.
Rahul Yadav rahulyadavdr@gmail.com
2 years ago
Due to his healthy kidney for age, this donor is accepted for donation (1).
In this case, a cadaveric donor is another option. Living donor kidneys is more suitable than cadaveric because they it is genetically related with a 4/6 match, shorter cold ischemia time, and shorter waiting time.
At the same time, age related graft function decline due to elderly donor and slightly increased chance of graft dysfunction due to any insult intra or post-operatively compared to relatively young donors must be explained.
Reference:
British Transplantation Society. Renal Association Guidelines for Living Donor Kidney Transplantation, 4th ed.; British Transplantation Society: Macclesfield, UK, 2018; Available online: https//bts.org.uk/wp-ontent/uploads/2018/07/FINAL_LDKT-guidelines_June-2018.pdf (accessed on 18 September 2022)
Alyaa Ali
2 years ago
According to BTS guidelines 2018
Old age alone is not an absolute contraindication to donation, but the medical work-up of older donors must be extremely meticulous to ensure they are suitable.
Both donor and recipient must be made aware that the older donor may be at greater risk of peri-operative complications and that the function and long term survival of the graft may be compromised especially if the age more than 60 years.
Workup of the older donor
Pre-donation cardiopulmonary function through
Stress echocardiogram and/or myocardial perfusion scan if indicated.
Respiratory function tests are indicated in smokers and in those with airway diseases
Cardiopulmonary exercise testing especially the definition of anaerobic threshold.
Screening of serum PSA is mandatory in males above 55 years.
Review of bowel function and doing tests for faecal occult blood.
Estimation of renal function.
If the older donor is judged fit, after meticulous medical evaluation, and if the renal function is normal after correction for age and gender,the donor can be considered for donation.
In this case , the old father has excellent renal function and normal cardiac function can be considered for donation. Both donor and recipient must be made aware that the older donor may be at greater risk of peri-operative complications and that the function and long term survival of the graft may be compromised especially if the age more than 60 years.
.
Transplant recipients with older LD kidney had significantly lower graft and patient survival compared to younger LD recipients,
Compared to standard criteria donor recipients , graft survival was decreased in recipients with living donors 70 years or olders,but patient survival was similar.
Older LD kidney recipients had better graft and patient survival than ECD recipients.
The use of older donors appears to beneficial alternative to awaiting deceased donor kidneys.
Hinda Hassan
2 years ago
As the organ shortage increases, inherently the demand for donor kidneys continues to rise. Thus, live kidney donation is essential for increasing the donor pool. In order to create successful expansion, extended criteria live kidney donors should be considered. Based on the literature search, live kidney donation in older donors (up to 70 years of age) seems to be safe as outcome is comparable to younger donors. (1) Studies have estimated the average risk of post donation ESRD for living kidney donors in the United States, but personalized estimation on the basis of donor characteristics remains unavailable. 133,824 living kidney donors were studied from 1987 to 2015, as reported to the Organ Procurement and Transplantation Network, with ESRD ascertainment via Centers for Medicare and Medicaid Services linkage, using Cox regression with late entries. Black race (hazard ratio [HR], 2.96; 95% confidence interval [95% CI], 2.25 to 3.89; P<0.001) and male sex (HR, 1.88; 95% CI, 1.50 to 2.35; P<0.001) was associated with higher risk of ESRD in donors. Among nonblack donors, older age was associated with greater risk (HR per 10 years, 1.40; 95% CI, 1.23 to 1.59; P<0.001). Among black donors, older age was not significantly associated with risk (HR, 0.88; 95% CI, 0.72 to 1.09; P=0.3). Greater permissiveness may be warranted in older black candidate donors; young black candidates should be evaluated carefully.(5) End-Stage Renal Disease (ESRD) risk was studied in living kidney donors (LKDs) who donated in the United States between 1994 and 2016 (n = 123 526).Two hundred eighteen LKDs developed ESRD, with a median of 11.1 years between donation and ESRD. Absolute 20-year risk was low but not uniform, with risk associated with race, age, and sex and increasing exponentially over time. LKDs had increased risk of ESRD if they were male , had higher BMI or lower estimated GFR , were first-degree relatives of the recipient ; full sibling ; identical twin , or lived in lower socioeconomic status neighborhoods at donation . there was a significant interaction between donation age and race, with higher risk at older ages for white LKDs , but higher risk at younger ages for black LKDs(2)
Factors associated with transplantation from older living donors and the association of living donor age with allograft function and survival were studied in 73,073 donors.it revealed that the outcomes are excellent with living donors <65 years. Expanded use of older living donors may help meet the demand for transplantation.(3)
Individuals with isolated medical abnormalities (IMAs) are undergoing living donor nephrectomy more frequently. Knowledge of health risks for these living donors is important for donor selection, informed consent and follow-up. A systematic review studies living kidney donors with preexisting IMAs, including older age, obesity, hypertension, reduced glomerular filtration rate (GFR), proteinuria, microscopic hematuria and nephrolithiasis. 22 studies were on older donors (n = 987), 10 on obese donors (n = 484), 6 on hypertensive donors (n = 125), 4 on donors with nephrolithiasis (n = 32), 2 on donors with microscopic hematuria and one study each on donors with proteinuria or reduced GFR. Perioperative outcomes for donors with and without IMAs were similar. Few studies reported longer term (≥1 year) rates of hypertension, proteinuria or renal function. Studies were frequently retrospective and without a comparison group. Given the variability among studies and their methodological limitations, uncertainties remain regarding long-term medical outcomes for IMA donors. As transplant centers continue to cautiously screen and counsel potential IMA donors, rigorously conducted, longer term prospective cohort studies are needed.(4)
In the United States, 219 healthy adults aged ≥70 have donated kidneys at 80 of 279 transplant centers. Competing risks models with matched controls were used to study the independent association between older donor age and allograft survival, accounting for the competing risk of recipient mortality as well as other transplant factors. Among recipients of older live donor allografts, graft loss was significantly higher than matched 50-to 59-year-old live donor allografts (subhazard ratio [SHR] 1.62, 95% confidence interval [CI] 1.16 to 2.28, P = 0.005) but similar to matched nonextended criteria 50-to 59-year-old deceased donor allografts (SHR 1.19, 95% CI 0.87 to 1.63, P = 0.3). Mortality among living kidney donors aged ≥70 was no higher than healthy matched controls drawn from the NHANES-III cohort; in fact, mortality was lower, probably reflecting higher selectivity among older live donors than could be captured in National Health and Nutrition Examination Survey III (NHANES-III; HR 0.37, 95% CI 0.21 to 0.65, P < 0.001).(6) So these findings support living donation among older adults but highlight the advantages of finding a younger donor, particularly for younger recipients.
Ref:
1-Ali R. Ahmadi, Jeffrey A. Lafranca, Laura A. Claessens, Raoul M.S. Imamdi, Jan N.M. Ijzermans, Michiel G.H. Betjes, Frank J.M.F. Dor,Shifting paradigms in eligibility criteria for live kidney donation: a systematic review,Kidney International,Volume 87, Issue 1,2015,Pages 31-45,
2-Wainright, JL, Robinson, AM, Wilk, AR, Klassen, DK, Cherikh, WS, Stewart, DE. Risk of ESRD in prior living kidney donors. Am J Transplant. 2018; 18: 1129– 1139. https://doi.org/10.1111/ajt.14678 30Gill, John S.; Gill, Jagbir; Rose, Caren; Zalunardo, Nadia; Landsberg, David, The Older Living Kidney Donor: Part of the Solution to the Organ Shortage,Transplantation: December 27, 2006 – Volume 82 – Issue 12 – p 1662-1666 doi: 10.1097/01.tp.0000250715.32241.8a4-Young, A., Storsley, L., Garg, A.X., Treleaven, D., Nguan, C.Y., Cuerden, M.S. and Karpinski, M. (2008), Health Outcomes for Living Kidney Donors with Isolated Medical Abnormalities: A Systematic Review. American Journal of Transplantation, 8: 1878-1890. https://doi.org/10.1111/j.1600-6143.2008.02339.x
5-Allan B. Massie, Abimereki D. Muzaale, Xun Luo, Eric K.H. Chow, Jayme E. Locke, Anh Q. Nguyen, Macey L. Henderson, Jon J. Snyder, Dorry L. Segev, Quantifying Postdonation Risk of ESRD in Living Kidney Donors, JASN Sep 2017, 28 (9) 2749-2755; DOI: 10.1681/ASN.2016101084
6- Living Kidney Donors Ages 70 and Older: Recipient and Donor Outcomes
Jonathan C. Berger, Abimereki D. Muzaale, Nathan James, Mohammed Hoque, Jacqueline M. Garonzik Wang, Robert A. Montgomery, Allan B. Massie, Erin C. Hall, Dorry L. Segev
CJASN Dec 2011, 6 (12) 2887-2893; DOI: 10.2215/CJN.04160511
Ramy Elshahat
2 years ago
71 years old potential donor with normal kidney functions is willing to donate for his son. Physiological age is more relevant than chronological age and donation at such age is not a contraindication but 2 points need to be fulfilled: 1-donor safety: Studies showed older donors are more exposed to perioperative complications so intensive evaluation should be addressed. 2-regarding quality of the organ: advanced age-related glomerular sclerosis is expected so, measurement of eGFR by 24h creatinine clearance and renal isotope scan with split kidney functions will afford a better picture of the actual kidney functions. affording grafts with poor quality for potential young recipients associated with short graft survival. Furthermore, a donor-recipient age difference of >30 years increases the risk of graft loss within 12 months post-transplantation. My final decision is not to accept the donor but not for this particular potential recipient and it’s better to provide them with paired kidney exchange to the older recipient.
Please substantiate your answer
according to our center policy, we don’t accept donors aged more than 55 years old.
References: TakahisaHiramitsu,u1ToshihideTomosu.et al.Adult Living-Donor Kidney Transplantation, Donor Age, and Donor–Recipient Age Kidney International ReportsVolume 6, Issue 12, December 2021, Pages 3026-3034
Wadia Elhardallo
2 years ago
Please substantiate your answer
According to British transplantation society Old age alone is not an absolute contraindication to donation but the medical work-up of older donors must be particularly rigorous to ensure they are suitable. (A1) and both donor and recipient must be made aware that the older donor maybe at greater risk of peri-operative complications and that the function and possibly the long-term survival of the graft may be compromised. This is particularly evident with donors >60 years of age. (B1) as in this case. The older donor needs more careful consideration with respect to the increased risk of peri-operativecomplications, existing comorbidities and residual function post-donation, and also the long-term transplant outcome in the recipient associated with reduced donorGFR and potential donor vasculopathy. Graft Outcome from Older Donors: Ø higher incidence of delayed graft function Ø increased risk of graft failure Despite being immunologically good match, both donor and recipient should be counselled of all possible risk regarding age difference. So better option is younger donor if not available, his father can donate if medical evaluation is satisfactory living is superior to deceased and waiting list. Reference: 1. BTS/RA Living Donor Kidney Transplantation Guidelines 2018 2. Foley DP, Patton PR, Meier-Kriesche HU, Li Q, Shenkman B, Fujita S, Reed A, Hemming AW, Kim RD, Howard RJ. Long-term outcomes of kidney transplantation in recipients 60 years of age and older at the University of Florida. Clin Transpl. 2005:101-9. PMID: 17424728. 3. Ferrari P, Lim W, Dent H, McDonald SP. Effect of donor-recipient age difference on graft function and survival in live-donor kidney transplantation. Nephrol Dial Transplant. 2011 Feb;26(2):702-8. doi: 10.1093/ndt/gfq383. Epub 2010 Jul 1. PMID: 20601369. 4. Resende L, Guerra J, Santana A, Mil-Homens C, Abreu F, da Costa AG. Impact of donor age on renal allograft function and survival. Transplant Proc. 2009 Apr;41(3):794-6. doi: 10.1016/j.transproceed.2009.01.064. PMID: 19376354.
Nazik Mahmoud
2 years ago
This old age donor he has definitely low GFR for such young donor it may be not a wise decision so we need to do DTPA or measure GFR to took the decision
Abdullah Raoof
2 years ago
According to BRTISH TRANSPLANT SOCIETY the recommendation regarding the donor age are :
1. Old age alone is not an absolute contraindication to donation .
2. The donor and recipient must be made aware that
· Are at greater risk of peri-operative complications and that
· the function and survival of the graft may be compromised especially in those above 60 y .
3. in Most centers do not consider donors aged <18 years and consider an age of 18-21 years as a relative contraindication to donation.
Summary
Most transplant programs are more flexible in older donors. Younger donors should be subjected to stringent exclusion criteria . According to studies :
Living donors provide shorter waiting times and better term outcomes for their recipients compared with deceased donors.
The studies report no an additional mortality risk for living kidney donors , but they report an increased risk of ESRD , especially in older donors . Some studies also report that there is increased graft failure among recipients as donor age increases.
The process of older (age,60 years)donor transplantation is increasing become doubled from 1994 to 2011.
Studies from UNOS data report that decreased graft and overall survival for recipients of older living donor kidneys; but still the older living donor kidneys perform equall or better than than deceased donor kidneys.
Berger et al found that living donors of 70 years or older has no significant differences in short-term graft failure or recipient survival when compared to recipients of 50- to 59- year-old deceased donors.
older LD kidneys had decreased graft survival, compared to younger LD kidneys.
When compared to SCD and ECD kidneys, these older living donor kidneys has better outcome.
graft failure is significantly increased in kidneys from donors of 70 years or older, but they did not have worse overall survival, this may be due to decrease dialysis exposure time .
Decreased dialysis exposure is an important advantage of living donor transplantation and a potential part of the causal pathway for better long-term outcomes in this patient population.
References:
1.Schechter MA, Irish WD, et al. Outcomes in kidney transplant recipients from older living donors. Transpl.,2015; 99: 309-15.
2.BTS/RA Living Donor Kidney Transpl.Guidelines 2018.
Nasrin Esfandiar
2 years ago
· The kidneys from older donors had poorer survival than younger donors (<40 years). The risk of acute rejection and graft failure is higher in older donors. Therefore, receiving a kidney from a younger living donor would be the best option. But if this recipient is on the waiting list for a long time, maybe this would also be considered as an option. On the other hand, donor’s evaluation should be carefully performed at this age, due to high probability for CVD or risk factors such as diabetes or HTN. If there is no contraindication, the donor’s age itself is not a contraindication for donation.
Hamdy Hegazy
2 years ago
There is no clear answer for this question. We need to weigh risks and benefits then counsel both donor and recipients about the potential risks and complications. As we know, the graft and patient outcomes of living donation are better than deceased donation and staying on dialysis. It is a good donation offer, 110 mismatches with no DSA. The donor is 71 y old father, with normal cardiac history, however he is prone to operative risks because of his age. And the survival of the graft taken from an old donor above 65 y is questionable. The options would be: 1- Accept this offer with potential donor complications and possible less graft survival. 2- Wait for another younger donor? For how long?? Dilemma of Mismatches and DSA again?? 3- Paired kidney donation scheme with old aged recipient (old for old and young for young). 4- Wait for deceased matched young aged donor.
I would prefer to accept this offer after proper conselling.
Manal Malik
2 years ago
the donor is the father with a good match at 71 years old I suggest this transplantation should proceed because it is better to remain in dialysis so need to explain to the recipient the implication of this donation.
the risk of this kidney should be evaluated.
if the eGFR is more than 60 and age 71 transplantation is superior to cadaveric and dialysis.
so the age is not a contraindication for donation
Balaji Kirushnan
2 years ago
elderly donors are not an absolute contraindication for organ donation… They have to be evaluated thoroughly for any end organ damage and cardiovascular risk before organ donation…According to BTS guidelines 2018, old aged donors are not contraindicated from donation and there is a increased peri operative risk to the donor with increased short term complications …
I would proceed rather than waiting on the deceased donor cadaver list
Ahmed Abd El Razek
2 years ago
According to KDIGO and British Transplantation Society guidelines ,the old age of the donor with excellent renal functions poses a good acceptable candidate for living donation as he is more likely will not suffer further renal disease, the concerning issue is that the graft survival would be less compared to younger living donors.
The other concern for donation rather than renal assessment, cardiological and anesthesiology evaluation for fitness for major operation.
rindhabibgmail-com
2 years ago
There is no age limitation except limitation is allograft mass(nephrons) eGFR at the time of donation. as every one has discussed and also the literature shows that, there is increased risk of DGF, increased ischemia time and overall graft loss.
So the father is better option for donation.
Filipe prohaska Batista
2 years ago
If there are no potential donors, high cPRA, no KPD available, we can proceed with the transplant.
The donor must be aware of the risks involved, after all, he is already old, despite not having any of the criteria that would contraindicate the donation (proteinuria, uncontrolled arterial hypertension, type 1 diabetes mellitus, high blood glucose).
Living donors with good matching are superior to deceased donors and decrease ischemia time.
Esraa Mohammed
2 years ago
YES ILL ACCEPT IT
• Expanded Criteria donor >60 or 50-60 with with at least 2 of the following co-morbidities: 1. Hypertension 2. Elevated creatinine >133μmol/l (>1.5mg/dl) 3. Death from cerebrovascular accident
Outcome of ECD Survival advantage of ECD kidney transplant recipients over dialysis patients remaining on transplant waiting list or cadaveric kidney
Wee Leng Gan
2 years ago
British Transplant Society 2018
Recommendations
1) Elder age is not the absolute contraindication to kidney donation but the medical work-up of older donors must be particularly rigorous to ensure they are suitable.
2) Both donor and recipient must be made aware that the older donor may be at greater risk of peri-operative complications and that the function and possibly the long-term survival of the graft may be compromised. This is particularly evident with donors >60 years of age.
Jamila Elamouri
2 years ago
yes, a living donor even older age is better than waiting for deceased donors in terms of graft survival as it has less cold ischemia time, less delayed graft function and less AR.
dina omar
2 years ago
*This candidate old donor 71 years old (ECD )with 110 mismatch , no DSA.
*The use of older kidney donors appears to be an equivalent or beneficial alternative to awaiting cadaveric kidneydonors. *The age is not considered an absolute contraindication for kidney donation, Although; older donor is associated with higher risk of 1.perioperative morbidity and mortality of donor. 2.Worse graft outcome. 4. here donor age has extended criteria for individuals older than 65 years old, but the recipient must be near that age group. * KPD is considered a suitable option to overcome the huge difference between the donor and recipient ages.
References:
1.Schechter MA, Irish WD, et al. Outcomes in kidney transplant recipients from older living donors. Transpl.,2015; 99: 309-15. 2.BTS/RA Living Donor Kidney Transpl.Guidelines 2018
Mu'taz Saleh
2 years ago
according to BTS/RA Living Donor Kidney Transplantation Guidelines 2018
Old age alone is not an absolute contraindication to donation but the medical work-up of older donors must be particularly rigorous to ensure they are suitable. (A1)
Both donor and recipient must be made aware that the older donor may be at greater risk of peri-operative complications and that the function and possibly the long-term survival of the graft may be compromised. This is particularly evident with donors >60 years of age. (B1)
Donors above 60 years of age need careful consideration with respect to the increased risk of peri-operative complications, existing comorbidities and residual function post-donation, and also the long-term transplant outcome in the recipient associated with reduced donor GFR and potential donor vasculopathy.
so after good evaluation and discussion with both the donor and recipient about the outcome and possible complication transplantation from this 71 year is better than cadaver
thanks
Shereen Yousef
2 years ago
One study has investigated LDKT outcomes from living donors aged >70 years. , Postnephrectomy survival of living donors aged >70 years has been reported to be significantly better than that of matched healthy controls. Nevertheless, the graft-loss rate among the recipients was significantly higher than that among recipients from living donors aged 50 to 59 years. Furthermore, a donor-recipient age difference of >30 years has been reported to increase the risk of graft loss within 12 months post-transplantation relative to an age difference of 10 to 20 years. Studing the impact of donor age on the outcomes of younger recipients showed that eGFR declined significantly as the donor age increased, and graft loss in younger groups increased as the donor age increased,
The study also concluded that although the lower graft function in the younger recipients who received a transplant from elderly donors could lead to worse graft survival than those from younger donors, LDKTs from the elderly donors to younger recipients could be a favorable life-saving treatment for chronic kidney diseases in clinical practice.
If there is a possibility of finding another matched younger donor with less age difference between donor and recipient this would give the donor a better chance for longer graft survival
Donor age is not absolute contraindication for donation, but older donor has:
-Higher risk of peri-operative complications
-less long-term graft survival
-less long-term graft function
· Inferior outcomes should be expected with donor >60 years
· Pre-donation cardio-respiratory function should be carefully assessed in older donors
· Most centres perform a stress echocardiogram and/or myocardial perfusion scan if indicated.
· Respiratory function tests may be indicated in smokers and those with airway disease.
· Cardiopulmonary exercise testing is a predictor of post-operative complications, particularly in elderly patients and can be used in the assessment of elderly donors
· As the recipient is very young, he still has long half-life with increased incidence of graft disfunction or CKD
· Kidney paired donation is an option to overcome the big difference between the donor and recipient ages.
BTS/RA Living Donor Kidney Transplantation Guidelines 2018
Nandita Sugumar
2 years ago
The donor has excellent kidney function and normal cardiac results. Evidence is present that there is no accelerated loss of kidney function following donation, and incidence of established renal failure (ERF) and hypertension among donors is the same as the general population.
However, it is to be noted that the risks of delayed graft function, acute rejection, and graft failure in transplants from living donors above 65 years of age are significantly higher than young donor kidneys.
In addition, elderly kidneys can have altered progenitor cell function, increased tendency for apoptosis, alterations in growth factor profiles, and important changes in immune responses all of which lead to decreased kidney reserve. A 2006 US renal data report expresses that the risk of DGF is twice as higher in kidney from elderly donor than younger donors. Furthermore, for every 10 year increase in living donor age above 65, risk of DGF is increased by 15%.
If a younger suitable donor is not found, I would accept this donor.
References :
Akoh J. Renal transplantation from elderly living donors. J Transplant, 2013; 2013: 475964. doi: 10.1155/2013/475964
Echterdiek F, Schwinger C, et al. Kidneys from elderly deceased donors – is 70 the new 60?.Front. Immunol., 27 November 2019. Sec. Alloimmunity and Transplantation. https://doi.org/10.3389/fimmu.2019.02701
Pérez-Sáez, M.J., Lafuente Covarrubias, O., Hernández, D. et al. Early outcomes of kidney transplantation from elderly donors after circulatory death (GEODAS study). BMC Nephrol 20, 233 (2019). https://doi.org/10.1186/s12882-019-1412-0
Berger J, Muzaale A, et al. Living kidney donors ages 70 and older : recipient and donor outcomes. CJASN 2011; 6 (12) : 2887-2893. DOI: https://doi.org/10.2215/CJN.04160511
Giulio Podda
2 years ago
Reply To Prof Ahmed Halawa
No, I don’t think that a cadaveric transplant would be better than a living kidney donor. Cadaveric transplant have an higher incidence of delayed graft function (prolonged ischaemia time), frequency of rejection and worse transplant outcome compared to living donors. Cadaveric transplant will also require more intense immunosuppressive regime (1). As use of older kidney donors increases, overall survival among kidney transplant recipients from older living donors was similar or even better than Standard criteria donors recipients, better than expanded criteria donors, but worse than younger LD recipients. With increasing kidney donation from older adults, the use of older kidney donors appears to be an equivalent or beneficial alternative to awaiting deceased donor kidneys (2).
References:
(1)CADAVERIC VERSUS LIVING DONOR KIDNEY TRANSPLANTATIONA Medicare Payment Analysis 1Smith, Craig R.2; Woodward, Robert S.3; Cohen, David S.3; Singer, Gary G.4; Brennan, Daniel C.4; Lowell, Jeffrey A.2; Howard, Todd K.2; Schnitzler, Mark A.35
No, I don’t think that a cadaveric transplant would be better than a living kidney donor. Cadaveric transplant have an higher incidence of delayed graft function (prolonged ischaemia time), frequency of rejection and worse transplant outcome compared to living donors. Cadaveric transplant will also require more intense immunosuppressive regime (1). As use of older kidney donors increases, overall survival among kidney transplant recipients from older living donors was similar or even better than Standard criteria donors recipients, better than expanded criteria donors, but worse than younger LD recipients. With increasing kidney donation from older adults, the use of older kidney donors appears to be an equivalent or beneficial alternative to awaiting deceased donor kidneys (2).
References:
(1)CADAVERIC VERSUS LIVING DONOR KIDNEY TRANSPLANTATIONA Medicare Payment Analysis 1Smith, Craig R.2; Woodward, Robert S.3; Cohen, David S.3; Singer, Gary G.4; Brennan, Daniel C.4; Lowell, Jeffrey A.2; Howard, Todd K.2; Schnitzler, Mark A.35
Old age is not a contraindication for kidney donation. However, donor and recipient must be informed about the increased risk of peri-operative complications and the fact that the long term survival of transplant in the recipient may be affected particularly with donors with age above 60 years old. However, the use of laparoscopy has reduced surgical complications with reduced morbidity and early recovery. Moreover, the risks of delayed graft function, acute rejection, and graft failure in transplants from living donors >65 years are higher when compared to transplants from younger donors.
Graft function and graft survival could be compromised in recipients from elderly deceased donors due to reduced nephron mass, ischemic injury, and acute rejection episodes which are more prevalent in the elderly. Moreover the risk of DGF in transplants recipients from living donors (age> 65 years) is double when compared to transplants from younger donors.
Also, with age there is a physiological decline of the kidney function. However, in this case, I would complete the donor work up pre-transplant assessment (e.g. PSA) and if they are normal I would consider this patient suitable for donation. Indeed, in this case, there is good mismatch with no DSA, no comorbidities and normal potential donor kidney function. Furthermore, leaving the recipient without transplant would increase his cardiovascular risk.
BTS 2018
MICHAEL Farag
2 years ago
Donors above 60 years of age need careful consideration with respect to the increased risk of peri-operative complications, existing comorbidities and residual function post-donation,and also the long-term transplant outcome in the recipient associated with reduced donor
GFR and potential donor vasculopathy
Donor Complication Rates Related to Age
– Although peri-operative outcomes such as operative time, blood loss and length of stay are shown in some recent studies to be no different from younger donors in carefully selected donors above 60 years, caution should be exercised in the evaluation, operation and postoperative management of the older donor.
– Pre-donation cardio-respiratory function should be carefully assessed in older donors. Most centers perform a stress echocardiogram and/or myocardial perfusion scan if indicated. Respiratory function tests may be indicated in smokers and those with airway disease. Cardiopulmonary exercise testing, and in particular the definition of the anaerobic threshold, has been validated as a predictor of postoperative complications, particularly in elderly patients.
– Screening of serum PSA is mandatory in males above 55 years. Although a mildly
elevated PSA may not preclude donation, a rising PSA over time may be of concern and there should be a low threshold for formal urological review.
– In women, an upto-date mammogram and relevant history should be reviewed.
– In all patients, there should be a careful review of bowel function, incorporating the results of up-to-date population screening tests such as tests for faecal occult blood. – Social, family and psychological support for elderly donors should be provided, particularly in the case of altruistic donation – Graft Outcome from Older Donors
poorer outcomes for kidneys from old donors compared to young donors.
However; the use of older kidney donors appears to be an equivalent or beneficial alternative to awaiting deceased donor kidneys Long Term Risk for Older Donors
Older donors with potential risk factors for kidney disease, such as hypertension or diabetes, are less likely than younger donors to have enough time for such risk factors to lead to progressive kidney disease, or for any kidney disease that develops to affect life expectancy.
My decision
I will not accept him as a donor unless there is long list waiting list for the patient because the graft has poor outcome and the patient mostly will need another graft later and he will be highly immunized due to the first graft
Reference
BTS/RA Living Donor Kidney Transplantation Guidelines 2018
Maksuda Begum
2 years ago
according to BTS guidelines, the age is not an absolute contraindications to donation (physiological age is more important than chronological age). However, older donor is associted with higher risk of perioperative morbidity and mortality for the donor in addition to worse graft longevity in the recipient with worse outcome especially if he is young as in our scenario. _ the 1st issue related to the donor survival, to decide if it is safe for him to donate or not depends on through evaluation of his cardiovascular system ( stress ecg and echo, Myocardial perfusion scan and CPET to determine or predict the perioperative cardiac risk) in addition to risk calculation to account for any asscoacited comorbidities. If he is fit for donation, it is ok ( whether for his son or to be enrolled in PKD if avialble ). _ second issue, for the recipient to get the best available graft so , the best option here ( if available) is enrollment in PKD to find better age matched donor and use his father old kidney for another older recipient. _ if no available PKD, accepting father as a donor can have advantage of preemptive transplantation and with good HLA mismatch. _ sure, LIving donor is better than waiting for deceased donor kidney transplantation as it allows for preemptive tranplanation, better matching, avoid prolonged cold ischemia time that can increase risk of DGF and rejection episodes with deceased donor
Mohamad Habli
2 years ago
Age more than 18 is not a contraindication for kidney donation, even in extreme ages, however potential donor’s comorbidities and risk factors for postsurgical complications indicated if the potential donor can donate.
Several studies have reported higher risk of postsurgical complications in donors age more than 50. Also living donation from donors elder than 50 was associated with poorer allograft outcomes when compared to younger donors.
However living donation with acceptable immunological barrier is much better than receiving kidney from deceased donor as perioperative complications are more common with urgent surgery when compared to elective kidney donation and transplantation.
In our clinical scenario, this elderly potential donor should undergo comprehensive evaluation other than cardiac and renal- diabetes and lipid panel. Risk factors like obesity and smoking should be managed before planning surgery.
If kidney donation is not warranted with KPD, LD from his father with low immunological risk is a good option.
Ahmed Fouad Omar
2 years ago
71-year-old male willing to donate his kidney to his 16-year-old son, 110 mismatch with no DSA. This donor has the advantage of being a living related transplant with excellent kidney functions and normal cardiac investigations.
However, we have to keep in mind the following:
1. The old donor age: Most transplant programs currently do not have an upper age limit for accepting donors and the donor function rather than age may be the most important determinant of outcome .However, older patients needs a more meticulous transplant work up to ensure their suitability for organ donation.
BTS indicates that prospective donors should not be considered for donation if the corrected GFR is predicted to fall below 37.5 mL/min/1.73 m2 at the age of 80.
Despite the reduced survival in older donors >60 years compared to younger donors but still it is comparable to the age and comorbid-matched participants indicating that poor survival was not clearly attributed to kidney donation.
2. The increased risk of perioperative complications, so both the donor and the recipient must be aware about that.
3. The donor long term risks like hypertension and diabetes are less likely than younger donors to have enough time to progressive kidney disease and the quality of life and established renal failure is comparable to the general population.
4. The graft outcome (graft function and survival) from the older donor is compromised by the aging process(reduced functional nephron mass, lower baseline GFR, and secondary glomerulosclerosis with ischemic changes and diffuse micro-vascular disease). So, we would expect a relatively lower graft function, increased rejection episodes and poor long-term graft survival compared to kidneys from younger donors.
Conclusion:
Older living donors is better than matched deceased donor kidneys and is comparable to deceased kidneys from younger donors.
After rigorous medical evaluation, this father can be accepted as a suitable donor if there is no other suitable younger alternative donor keeping in mind the psychological aspects and the risks behind this donation and that the benefits to both the donor and the recipient must outweigh the risks associated with donation(do not harm).
References:
1.BTS Guidelines 2018.
2. Jacob A. Akoh and Umasankar Mathuram Thiyagarajan. Renal Transplantation from Elderly Living Donors. Review article. Journal of Transplantation Volume 2013, Article ID 475964, 9 pages
AMAL Anan
2 years ago
The available donor is 71years old male with excellent kidney function and normal cardiac investigation to 16 years old son with II0 mismatches and no DSA .
– older donor is associated with increase risk of peri-operative complication decrease
Long term graft survival and long term graft function.
-It is also associated with inferior outcomes which expected with donor aged more than 70 years old.
so both donor and recipient should be aware that old donor has a greater risk of peri- operative complication and possibly long term survival of graft may be compromised
This particular when the donor age more than 60 years .
But this situation associated with psychological concern between father and son and it is really favorable from being on dialysis, staying on waiting list or deceased donor with age between 50-59 years.
I will accept the donor after vigorous . Counselling the donor and recipient about cost apposite to benefit.
Amna Khalifa
2 years ago
Yes I would accept. transplantation from live donor gives better results than deceased donor transplantation, even when the donor is old. Berger in 2011 showed In a series of 219 transplantations from >70-year-old LKDs , graft loss was significantly higher than in LKDs 50–59 but similar to matched standard 50–59 deceased donor allografts [1]. Similar results have been reported with LKD over 60 compared with <60 standard criteria deceased donors [2]. However the donor should be fully aware of the consequences especially that blood pressure expected to increases after nephrectomy. A meta-analysis having included data for one million adults with no previous vascular disease showed that in middle and old age, blood pressure, even in the normal range, is strongly associated with cardiovascular mortality [3]. Therefore, long-term mortality could be increased in the LKD as a direct consequence of donation.
1-Berger JC, Mazaale AD, James N, et al. Living kidney donor ages 70 and older: recipient and donor outcomes, Clin J Am Soc Nephrol, 2011
2-Young A, Kim SJ, Speechley MR, et al. Accepting kidneys from older living donors: Impact on transplant recipient outcomes, Am J Transplant, 2011, vol. 11 (pg. 743-750)
3-Prospective studies collaborationAge specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies, Lancet, 2002, vol. 360 (pg. 1903-1913)
Abdul Rahim Khan
2 years ago
Please substantiate your answer
Age itself is not a contraindication for donation but donation in older age groups in topic of controversy. Donation above age 60 may not increase the death rate as compared to controls but there can higher decline in GFR and hypertension.
There is also higher risk of peri operative complications. There risks and benefits should be carefully evaluated. Physiological age is more important than chronological age.
All such donors should be carefully assessed and careful consideration should be given to postoperative morbidity, higher risk of ESRD and cardiovascular complications.
In the index case where donor is 71 year old with excellent kidney functions and no end organ damage I will accept donation. However as regards recipient who is only 16 year old there is possibility of poor graft outcome most likely due to vasculopathy.
this should be considered while planning the transplant.
Other options like enrolment in paired kidney donation can be considered
Living donation is better than deceased donation as deceased donation is associated with prolonged ischemia time, higher complications, intense immune suppression and higher rate of rejections. But the principle of Do No harm should be adhered to
Rihab Elidrisi
2 years ago
I think in this scenario better to accept living donation which is better than deceased donor , but here donor age is little pit worrying speciall short graft survival of such age but still this is debatable
I think he may go for the transplant but the recipient need to be aware of all implications
Mahmud Islam
2 years ago
There is no upper limit for donation. A 71-year-old donor with acceptable eGFR (more than 60 ml/min) can be acceptable.
From the donor aspect, ESRD increases with age, but for this donor, otherwise fit, we can proceed to save the life of 16 son and give him a chance better than dialysis or unrelated cadaveric kidney.
mai shawky
2 years ago
– according to BTS guidelines, the age is not an absolute contraindications to donation (physiological age is more important than chronological age). However, older donor is associted with higher risk of perioperative morbidity and mortality for the donor in addition to worse graft longevity in the recipient with worse outcome especially if he is young as in our scenario.
_ the 1st issue related to the donor survival, to decide if it is safe for him to donate or not depends on through evaluation of his cardiovascular system ( stress ecg and echo, Myocardial perfusion scan and CPET to determine or predict the perioperative cardiac risk) in addition to risk calculation to account for any asscoacited comorbidities. If he is fit for donation, it is ok ( whether for his son or to be enrolled in PKD if avialble ).
_ second issue, for the recipient to get the best available graft so , the best option here ( if available) is enrollment in PKD to find better age matched donor and use his father old kidney for another older recipient.
_ if no available PKD, accepting father as a donor can have advantage of preemptive transplantation and with good HLA mismatch.
_ sure, LIving donor is better than waiting for deceased donor kidney transplantation as it allows for preemptive tranplanation, better matching, avoid prolonged cold ischemia time that can increase risk of DGF and rejection episodes with deceased donor
Yes Dr Shawky, I agree that ‘physiological age is more important than chronological age’.
Tahani Ashmaig
2 years ago
It is better to accept this kidney (from this 71years old male with excellent kidney function and normal cardiac investigations and good missmatch) than waiting for a cadaveric donor or another suitable donor with the problem of organ shortage.
A study reported that:
There were no significant differences in the course of donor nephrectomy, postoperative complications, or remnant kidney function. However, delayed graft function occurred more frequently in recipients of transplants from older donors. Improvement in graft function was also slower in recipients of kidneys from older donors, with significant differences in serum creatinine levels observed during the first 12 months after transplantation. More frequent acute complications and more progressive chronic graft failure, irrespective of the causes, occurred during the 1st post-transplant year in recipients with grafts from older donors. Five-year patient survival (77% vs 92%) and kidney graft survival differed significantly for the same period with worse results for patients receiving grafts from older donors.
Conclusion:
kidney grafts from donors older than 60 years — and especially those older than 70 years — may be used for living related kidney transplantation, but with precautions.
_______________________
Ref:
[1] V Lezaić et al. Living related kidney donors over 60 years old. Transpl Int. 1996.
* Yes, I would accept kidney donation from this 71 years old male with excellent kidney function, normal cardic investigation and low immunological risk (good HLA mismatch 1_1_0 with no DSA)who wish to donate to his son, so, based on this data it is preferably to choose him compared to long waiting time on list, unavailable offer from kidney paired donation.
Yes Dr Elaf, LRD, if safe for a prospective donor, is always better than cadaveric transplant. But the main and the sole determinant is the principle of primum non nocere (‘do no harm’).
Abdulrahman Ishag
2 years ago
The following considerations will help us to accept or exclude old age individuals from donation ;
1-The use of older kidney donors appears to be an equivalent or beneficial alternative to awaiting deceased donor kidneys .
2- if the older donor is judged fit after rigorous medical evaluation, and if the renal function of the donor is normal after correction for age and gender, there is no compelling evidence for excluding donation on the basis of chronological age alone .
3-Older donors with potential risk factors for kidney disease, such as hypertension or diabetes, are less likely than younger donors to have enough time for such risk factors to lead to progressive kidney disease, or for any kidney disease that develops to affect life expectancy .
According to the above justification I will accept this potential donor .
Old age alone is not an absolute contraindication to donation but the medical work-up of older donors must be particularly rigorous to ensure they are suitable.
Donors above 60 years of age need careful consideration with respect to the increased risk of peri-operative complications, existing comorbidities and residual function post-donation, and also the long-term transplant outcome in the recipient associated with reduced donor GFR and potential donor vasculopathy.
Reference ;
1-BTS/RA Living Donor Kidney Transplantation Guidelines 201
Hi Dr Ishag, LRD, if safe for a prospective donor, is always better than cadaveric transplant. But the main and the sole determinant is the principle of primum non nocere (‘do no harm’).
Abdullah hindawy
2 years ago
Our donor is 71 old male with excellent kidney function and normal cardiac investigation.
Please substantiate your answer
All new approaches try to increase the donors pool .
Age now is not an absolute contraindication for donation.
The best important thing is the carefully assesment of cardiorespiratory system.
Cpet and stress test ,ecg and echocardiography.
Screen cancer is also important (age related)
Mental health assessment is also important in this age patients with neurologist and psychiatrist consultation.
I think after good evaluation of this old patient ,he will be an acceptable donor .
Dear Dr HIndawy, I appreciate balanced decision-making.
Ahmed Omran
2 years ago
According to BTS guidelines: old age only is not considered absolute contraindication to donation.
Higher prevalence of comorbidities makes decision for donation not easy .Elderly donor should be evaluated as recipient with consideration of kidney function and associated comorbidities.
As donor age is more than 60,donor may be at higher risk of peri-operative complications and function and possibly the long-term survival of the graft may be affected..
Following thorough medical evaluation, with renal function of the donor within normal for age and gender, he can be accepted for donation if there no alternative donor, as use of older kidney donors appears to better than awaiting deceased donor kidneys on dialysis.
Parents usually accept the risk when they donated to their children for psychosocial reasons. Otherwise, to consider paired kidney donation to get better age matching. References;
– Jacob A., et al. Review Article: Renal Transplantation from Elderly Living Donors. Journal of Transplantation Volume 201.
– BTS Guidelines 2018.
Hi Dr Omran, I understand your argument when you suggest paired kidney donation in this instance. My focus is on prospective donor and nothing else! If the donor is fit then this is better for the cadaveric kidney could be used for someone else (refer to utilitarian approach).
Asmaa Khudhur
2 years ago
According to BTS :
1-Old age alone is not an absolute contraindication to donation but the medical work-up of older donors must be particularly rigorous to ensure they are suitable. (A1)
2-Both donor and recipient must be made aware that the older donor may be at greater risk of peri-operative complications and that the function and possibly the long-term survival of the graft may be compromised. This is particularly evident with donors >60 years of age.
>>based on BTS/RA living donor kidney transplant guidelines 2018 :
Old age alone is not an absolute contraindication to donation but the medical work-up of older donors must be particularly rigorous to ensure they are suitable. (A1)
Both donor and recipient must be made aware that the older donor may be at greater risk of peri-operative complications and that the function and possibly the long-term survival of the graft may be compromised. This is particularly evident with donors >60 years of age. (B1)
so , this potential donor can be accepted with this excellent kidney function and normal cardiac investigations considering the following:1- explain to the donor & recipient the perioperative risks in this age .
2- screening to PSA . >>regarding option of cadaveric kidney:
it can be a comparable option if there no other available living donor & provided that not to be on prolonged waiting list considering the fact that transplantation is the best option for ESRD .
overall, the use of older kidney donors appears to be an equivalent or beneficial alternative to awaiting deceased donor kidneys ( Englum BR, Schechter MA, Irish WD, et al. Outcomes in kidney transplant recipients from older living donors. Transplantation 2015; 99: 309-15. )
I understand your arguments in this debate, dear Dr Mohamed.
Eusha Ansary
2 years ago
I think he can donate.
According to BTS/RA Living Donor Kidney Transplantation Guidelines 2018
In the last five years there has been a significant increase in the number of living donations in the UK from the 60-69 and >70 year groups. Donors above 60 years of age need careful consideration with respect to the increased risk of peri-operative complications, existing comorbidities and residual function post-donation, and also the long-term transplant outcome in the recipient associated with reduced donor GFR and potential donor vasculopathy.
Much of the change in attitude towards accepting older donors is due to the wide and almost universal use of laparoscopic kidney donation in the UK and the resultant reduction in morbidity and improved recovery. Although peri-operative outcomes such as operative time, blood loss and length of stay are shown in some recent studies to be no different from younger donors in carefully selected donors above 60 years, caution should be exercised in the evaluation, operation and postoperative management of the older donor .
Pre-donation cardio-respiratory function should be carefully assessed in older donors. Most centres perform a stress echocardiogram and/or myocardial perfusion scan if indicated. Respiratory function tests may be indicated in smokers and those with airway disease. Cardiopulmonary exercise testing, and in particular the definition of the anaerobic threshold, has been validated as a predictor of postoperative complications, particularly in elderly patients. If available, it may be of particular use in the assessment of elderly donors.
Screening of serum PSA is mandatory in males above 55 years. Although a mildly elevated PSA may not preclude donation, a rising PSA over time may be of concernand there should be a low threshold for formal urological review. In women, an upto-date mammogram and relevant history should be reviewed. In all patients, there should be a careful review of bowel function, incorporating the results of up-to-date population screening tests such as tests for faecal occult blood. Social, family and psychological support for elderly donors should be provided, particularly in the case of altruistic donation.
Transplant recipients with older LD kidneys had significantly lower graft and patient survival compared to younger LD recipients. Compared to SCD recipients, graft survival was decreased in recipients with living donors 70 years or older, but patient survival was similar. Older LD kidney recipients had better graft and patient survival than ECD recipients
Dear Dr Ansary,
I like your comprehensive, well thought logical approach.
Ajay
Mohamed Fouad
2 years ago
In the current scenario of 71-year-old male with excellent kidney function and normal cardiac investigations offered kidney to his 16-year-old son, 110 mismatch with no DSA,I will accept the offer it is better than waiting long time in waiting list or to receive a deceased donor offer. Acceptance of elderly living kidney donors remains controversial due to the higher incidence of comorbidity and greater risk of postoperative complications. In last decade ,there is increase in number of donors >60 years.
Elderly donors require extensive assessment and should have a predicted glomerular filtration rate of at least 37.5 mL/min/1.73 m2 at the age of 80. It is known that the risks of delayed graft function, acute rejection, and graft failure in transplants from living donors >65 years are significantly higher than transplants from younger donors. In response to the increasing need for organs, deceased donor programs (donation after circulatory death (DCD) and donation after brain death (DBD)) are being optimized and living kidney donation expanded in several countries to include both related and unrelated donation. ABO incompatible transplantation, legalised altruistic nondirected living donation, and paired kidney donation programs. The use of grafts from elderly deceased donors (DD) is associated with less-than-ideal graft function and graft survival in recipients. This is attributed to reduced nephron mass, greater susceptibility to ischemic injury, and acute rejection episodes which is more prevalent in the elderly. In the other side, the relationship between living donor age and graft survival is less clear. the risk of DGF in transplants from living donors above the age of 65 years is double that of transplants from younger donors.
Dear All
Do you think that a cadaveric kidney would be better?
Please support your answer by evidence.
Yes Dr Omar,
I like you emphasis on risk/benefit ratio.
Living donor transplantation is generally superior to cavaderic kidney transplantation due to less rejection rate, less delayed graft function and therefore better graft and patient outcomes, as well as other factors like cost saving.
Cadaver versus living donor kidneys: Impact of donor factors on antigen induction before transplantationAuthor links open overlay panel
Dicken D.H.KooKenneth I.WelshAndrew J.MclarenJustin A.RoakePeter J.MorrisSusan V.Fuggle
CADAVERIC VERSUS LIVING DONOR KIDNEY TRANSPLANTATIONA Medicare Payment Analysis 1Smith, Craig R.2; Woodward, Robert S.3; Cohen, David S.3; Singer, Gary G.4; Brennan, Daniel C.4; Lowell, Jeffrey A.2; Howard, Todd K.2; Schnitzler, Mark A.35
Author Information
Transplantation: January 27, 2000 – Volume 69 – Issue 2 – p 31
Yes, Dr Ben,
LRD, if safe for a prospective donor, is always better than cadaveric transplant. But the main and the sole determinant is the principle of primum non nocere (‘do no harm’).
as most of us know that Living donor transplantation is generally superior to cavaderic kidney transplantation due to less rejection rate, less delayed graft function and therefore better graft and patient outcomes, even if the donor age is old ( no significant change between50-60 age group and 60-70 age group )
but i found an interesting study for long term graft survival follow up ( almost 25 years after transplant which can’t be apply on old age donors and it is a single centre study )
it says :
Kidney function was found to be better in recipients having received a transplant from a cadaveric donor at 10, 15, and 20 years after kidney transplantation.
The mean age of cadaveric donors (23.84 years) was found to be lower that of the living ones (52.75 years).
No statistically important difference was found in relation to any other investigated factor.
Long-Term (≥25 Years) Kidney Allograft Survivors: Retrospective Analysis at a Single Center
https://www.sciencedirect.com/science/article/pii/S0041134519312412
Dear Dr Farah,
My reply to you is same as that in respose to Dr Ben, as above.
Cadaveric grafts have higher complications including delayed graft function, acute and chronic rejections, the need for more intensive immunosuppression,
According to BTS/RA Living Donor Kidney Transplantation Guidelines 2018
Most US transplant programs currently do not have an upper age limit for accepting
donors and are more flexible in applying exclusion criteria for renal risk factors in
older donors (20). UK practice also tends to this conclusion.
>>regarding option of cadaveric kidney:
I like your reply dear Dr Mohamed.
I think it is better to have this kidney from his old age father in terms of graft outcome and survival, as the cold ischemia time will be less in living donor kidney transplant, there will be less delayed graft function, inspite of increased risk in recipients of old age donor, the concern about the long term reduced GFR and vasculopathy in recepient of older age donors.
[1] Squifflet JP, Pirson Y, van Cangh P, Otte JB, van Ypersele de Strihou C, Alexandre GP. Renal transplantation in children: a comparative study between parental and well-matched cadaveric grafts. Transplantation. 1981 Oct;32(4):278-81. PMID: 7036444.
[2] Fritsche L, Hoerstrup J, Budde K, Frei U, Kahl A, Loening S, May G, Neuhaus P, Neumayer HH, Reinke P, Schoenberger B, Schoenemann C. Kidney transplantation at the Charité: long tradition, elderly patients and the duration of hospitalization. Clin Transpl. 2002:171-9. PMID: 12971447.
[3] Andrews PA, Burnapp L. British Transplantation Society / Renal Association UK Guidelines for Living Donor Kidney Transplantation 2018: Summary of Updated Guidance. Transplantation. 2018 Jul;102(7):e307. doi: 10.1097/TP.0000000000002253. PMID: 29688993; PMCID: PMC7228639.
Dear Dr Alshaikh,
in 4 lines plus 3 references, I note of clarity of your decision-making.
Not all cadaveric kidneys are the same. Standard criteria donor (SCD), expanded criteria donor (ECD) or donation from non heart beating donor. In study using the UNOS data from 1994 to 2012, 250,827 kidney transplant recipients were categorised by donor status: standard criteria donor (SCD), expanded criteria donor (ECD), or living donor (LD); and by donor age: <60, 60-64, 65-69, ≥70 years. 92,646 of the transplants studied from living donors, with 4.5% of the recipients (4,186) transplanted with older LD kidneys. Transplant recipients with older LD kidneys had significantly lower graft and patient survival compared to younger LD recipients. Compared to SCD recipients, graft survival was decreased in recipients with living donors 70 years or older, but patient survival was similar. Older LD kidney recipients had better graft and patient survival than ECD recipients.
So, the short answer SCD could be better than this elderly donor in terms of graft survival but same patient survival
Englum BR, Schechter MA, Irish WD, et al. Outcomes in kidney transplant
recipients from older living donors. Transplantation 2015; 99: 309-15
I understand your argument, Dr Mohamed. My focus is on prospective donor and nothing else! If the donor is fit then this is better for the cadaveric kidney could be used for someone else (refer to utilitarian approach).
Older LD kidney recipients had better graft and patient survival than ECD recipients .
use of older kidney donors appears to be an equivalent or beneficial alternative to awaiting deceased donor kidneys
Reference:
Englum BR, Schechter MA, Irish WD, et al. Outcomes in kidney transplant recipients from older living donors. Transplantation 2015; 99: 309-15.
I like your lucid response, dear Dr Khudur
Potential benefits and risks of living kidney donation.
Improved graft and patient survival, primarily due to superior organ quality, better HLA matching, shorter cold ischemia time, negation of negative donor-related factors (e.g. brain death, cardiovascular instability, use of vasopressins), short waiting time on dialysis, and feasibility of pre-emptive transplantation
Facilitation of pre-emptive transplantation, which allows avoidance of dialysis-related complications, provides optimal medical and psychological condition of the recipient at the time of surgery, reduces risk of acute rejection, and improves graft and patient survival
Expansion of total donor pool
Potential risks (to the donor)
Perioperative morbidity and mortality
Renal dysfunction in the long-term
Financial penalties from loss of work-time
Living donor renal transplantation: recent developments and perspectives
Seema Baid-Agrawal & Ulrich A Frei Nature Clinical Practice Nephrology volume 3, pages31–41 (2007)
That is a superb reply, Dr Elaf.
Donors above 60 years of age have :
** increased risk of peri-operative complications
** existing comorbidities and residual function post-donation
** the long-term transplant outcome in the recipient associated with reduced donor GFR and potential donor vasculopathy.
So in this case the father is not absolute contraindication but if there is another donor as pair kidney donor or cadaveric
Kidney I will proceed with it
Yes, Dr Huda
Ross LF, Rubin DT, Siegler M, Josephson MA, Thistlethwaite JR, Woodle ES. Ethics of a paired-kidney-exchange program. N Engl J Med 1997; 36: 1752.
Yes, for the reasons that we discussed earlier in the week, it may be worthwhile discussing in paired exchange scheme but I know most clinicians might raise eye brows on this suggestion that, in my opinion, might help this patient getting a younger kidney and other recipient who can not have the donor due to immunological reasons.
Old age not contraindication to donation especially those with no co morbids but needs intensive evaluation with full explanation to the donor and recipient all the risk
Proceeding in kidney transplantation is preferable than being in waiting list several years
Also receiving kidney donation from live donor is much better than deceased donors.
Effect on donor :
Has high risk of peri operative complications.
In spite they have low GFR but decline if GFR after donation is same as general population
Effect on recipient:
There is increased risk of acute rejection delayed graft function and graft failure from old aged donor compared to thoses received from young donors.
I will accept this donor if no other options also after full discussion with donor and recipient regarding all the risk
No.
The overall survival of patient receiving a kidney from an elderly living donor is lower than that from a younger living donor. But the results are similar to or better than receiving a younger deceased donor, be it a standard criteria donor or an extended criteria donor (1).
Although the risks for delayed graft function, acute rejection and graft failure from a living donor aged more than 65 years is higher as compared to a younger live donor, the results are comparable to a deceased donor graft outcome (2).
Reference:
1) Englum BR, Schechter MA, Irish WD, Ravindra KV, Vikraman DS, Sanoff SL, Ellis MJ, Sudan DL, Patel UD. Outcomes in kidney transplant recipients from older living donors. Transplantation. 2015 Feb;99(2):309-15. doi: 10.1097/TP.0000000000000607. PMID: 25594554.
2) Akoh JA, Mathuram Thiyagarajan U. Renal transplantation from elderly living donors. J Transplant. 2013;2013:475964. doi: 10.1155/2013/475964. Epub 2013 Sep 12. PMID: 24163758; PMCID: PMC3791791.
Whenever, you say no I would not dare to ignore your judgement, Dr Amit Sharma.
Recent Studies demonstrate that within only one decade the 5-year death censored graft survival rates of kidneys from deceased donors aged ≥70 years improved to a level that was comparable to the graft survival of kidneys from donors aged 60–69 years in the previous decade.Remarkably, the proportion of deceased donors aged≥70 years more than doubled from 6.7 to 15.4%.
Nonetheless, we were able to show that the graft survival of kidneys from deceased donors aged ≥70 years improved, in the short time interval of one decade, to the level previously seen for kidneys from donors aged 60–69 years.At the same time, the graft survival of kidneys from 60 to 69-year-old donors improved to the level of 50–59-year old donors from the previous decade.
These results may help to further expand the kidney donor pool especially for recipients aged ≥45 years.
Reference ;
by F Echterdiek · 2019 · Cited by 18 — Therefore, if kidneys from older donors (age ≥60 years) are transplanted into younger recipients (<65 years), they should be chosen primarily .
I like that expanding donor pool is on you mind, if the donor operation is safe.
Living donation is better than deceased donation as deceased donation is associated with prolonged ischemia time, higher complications, intense immune suppression and higher rate of rejections. But the principle of Do No harm should be adhered to.
transplantation after living donor nephrectomy is one option in
order to reduce the waiting time for a deceased organ and offers the access to
transplantation.
in addition LKT is associated with less ischemia time ,less rejection and
longer graft and patient survival ,no difference between elderly LKT and younger ones
,as shown in study of Gulay Yilmis et al.
I will prefer accepting a kidney from his old age father rather than keeping him on the waitlist for many years and exposing him to the risk of staying on dialysis and increasing the risk of CV mortality and infections.
The cadaveric Kidney carry high complication in form of rejection deceased graft survival and function may need aggressive induction therapy.
Living donor transplantation is generally superior to cavaderic kidney transplantation due to less rejection rate, less delayed graft function and therefore better graft and patient outcomes, as well as other factors like cost saving.
However, the graft survival is better than that of marginal kidneys.
some other related factors are needed to evaluate the risk/benefit ratio of transplanting cadaveric grafts rather than marginal grafts.
I think if the GFR of this elderly healthy male is good enough for donation, then I would prefer him over cadaveric donation.
This is due to:
Ref:
living kidney donation is surpassing the cadaveric kidney donation even in the setting of marginal donor for several reasons:
1} shorter waiting time.
2} pre-emptive transplantation.
3} Precluding the drawbacks of cold ischemia time integral to cadaveric kidney donation.
4} Avoiding the detrimental consequences of hemodialysis therapy.
5} Despite the fact that Marginal donor kidney is inferior in survival than standard donor kidney, its still preferable to cadaveric kidney due to the advantageous survival.
6} Emotional background of the donor is playing a pivotal role in successful transplantation.
references:
British transplant guideline : bts.org.uk
I agree with Dr Wael Jebur contribution. However, I want to add that the paired kidney donation program can be of great value in such a case scenario as it may help to provide a more suitable kidney from a living donor to the recipient.
There is no study compare the outcome of graft between cadaveric and elderly donors. But one study concluded that LRD allograft have superior outcome compared to cadaveric allograft.
According to BTS 2018, old age donor has less long-term graft survival and function. I think the net result could be equal for both.
We need a comparison study between both groups for a long time
Living renal donation is by far better than deceased donation in many aspects,
First regarding the timing, it could be preemptive renal transplantation for better life quality of the recipient or even interventional during the dialytic support for the recipient, provided that in cases of desensitization this becomes more flexible compared to deceased renal donation.
The other advantage of living donation over the deceased donation ,is avoiding much worse effects of delayed graft function, longer ischemia time ,marginal kidneys or other events that might affect graft survival or even patient’s survival and quality of life expected.
According to KDIGO and British Transplantation Society guidelines
a cadaveric kidney transplant has high risk for DGF and rejection but living donor less DGF and less rejection but if the kidney is marginal the benefit need to be weight versus the disadvantage
Graft survival for deceased donor (standard criteria) will be better than this elder donor living transplant.
Englum BR, Schechter MA, Irish WD, Ravindra KV, Vikraman DS, Sanoff SL, Ellis MJ, Sudan DL, Patel UD. Outcomes in kidney transplant recipients from older living donors. Transplantation. 2015 Feb;99(2):309-15.
no because the studies report that older living ( older than 70 y) has better or at least equal outcome when compared to deceased donor.
Studies from UNOS data report that decreased graft and overall survival for recipients of older living donor kidneys; but still the older living donor kidneys perform equall or better than than deceased donor kidneys.
Berger et al found that living donors of 70 years or older has no significant differences in short-term graft failure or recipient survival when compared to recipients of 50- to 59- year-old deceased donors.
When compared to SCD and ECD kidneys, these older living donor kidneys has better outcome.
references:
1- Gill JS, Gill J, Rose C, Zalunardo N, Landsberg D. The older living kidney
donor: Part of the solution to the organ shortage. Transplantation.
2006;82:1662–1666.
2- Berger JC, Muzaale AD, James N, et al. Living kidney donors ages 70
and older: recipient and donor outcomes. Clin J Am Soc Nephrol.
2011;6:2887–2893.
Yes, I would. We have a low missmatch .
Despite being healthy, the expectation of viability of this kidney is a few years, due to normal aging itself. However, the recipient is very young and will inevitably need another transplant later on.
With regard to the donor, despite his advanced age, he is quite healthy and unilateral nephrectomy will have little impact on his life expectancy.
can be accepted if there is no other comorbiditie,and if he is the only donor
BTS recommendations:
Old age alone is not an absolute contraindication to donation but the
medical work-up of older donors must be particularly rigorous to
ensure they are suitable. (A1)
71 year old donor with normal kidney function , normal cardiac investigations, is still a relative contraindication for Tx due to his age
Regarding graft survival : old age graft has high incidence of glomerulosclerosis as well as delayed graft function
Regarding receipt: relatively poor outcome yet better than deceased-donor
Regarding donor : the main risk is due to perioperative complications and risk of surgery .. after Exclusion of the donor’s original risk factors .
Although advanced age alone does not always rule out donation, older donors must undergo more intensive medical screening to ensure they are acceptable
Donors over the age of 60 should be carefully considered due to the increased risk of peri-operative complications, pre-existing comorbidities, residual function following donation, as well as the long-term transplant outcome in the recipient due to decreased donor GFR and potential donor vasculopathy
Pre donation assessment
Pre-donation In elderly donors, cardio-respiratory function needs to be carefully evaluated. If necessary, the majority of facilities do a stress echocardiography and/or a cardiac perfusion scan
It may be necessary to do respiratory function testing for smokers and those who have airway illness
The potential of cardiopulmonary exercise testing to predict postoperative problems
Screening of serum PSA is mandatory in males above 55 years
Graft Outcome
Renal function declines progressively with age and kidneys from older living donors have reduced function
After a living donor transplant, the 5-year graft survival rate was 76% for kidneys from donors older than 60 (n=241) and 79% for kidneys from donors younger than 60 (n=518). However, serum creatinine levels in recipients of kidneys from younger donors remained much lower, and graft survival was significantly greater after 5 years following transplantation
Ref :
BTS guidelines for living kidney donation
Benefit of getting ECD kidneys
Complications / risk
Having analysed the situation, I would like to proceed with the transplantation if there is no other suitable donor available to reduce the dialysis vintage or better if could be done pre-emptively.
Reference
Due to his healthy kidney for age, this donor is accepted for donation (1).
In this case, a cadaveric donor is another option. Living donor kidneys is more suitable than cadaveric because they it is genetically related with a 4/6 match, shorter cold ischemia time, and shorter waiting time.
At the same time, age related graft function decline due to elderly donor and slightly increased chance of graft dysfunction due to any insult intra or post-operatively compared to relatively young donors must be explained.
Reference:
According to BTS guidelines 2018
Old age alone is not an absolute contraindication to donation, but the medical work-up of older donors must be extremely meticulous to ensure they are suitable.
Both donor and recipient must be made aware that the older donor may be at greater risk of peri-operative complications and that the function and long term survival of the graft may be compromised especially if the age more than 60 years.
Workup of the older donor
Pre-donation cardiopulmonary function through
Stress echocardiogram and/or myocardial perfusion scan if indicated.
Respiratory function tests are indicated in smokers and in those with airway diseases
Cardiopulmonary exercise testing especially the definition of anaerobic threshold.
Screening of serum PSA is mandatory in males above 55 years.
Review of bowel function and doing tests for faecal occult blood.
Estimation of renal function.
If the older donor is judged fit, after meticulous medical evaluation, and if the renal function is normal after correction for age and gender,the donor can be considered for donation.
In this case , the old father has excellent renal function and normal cardiac function can be considered for donation. Both donor and recipient must be made aware that the older donor may be at greater risk of peri-operative complications and that the function and long term survival of the graft may be compromised especially if the age more than 60 years.
.
Transplant recipients with older LD kidney had significantly lower graft and patient survival compared to younger LD recipients,
Compared to standard criteria donor recipients , graft survival was decreased in recipients with living donors 70 years or olders,but patient survival was similar.
Older LD kidney recipients had better graft and patient survival than ECD recipients.
The use of older donors appears to beneficial alternative to awaiting deceased donor kidneys.
As the organ shortage increases, inherently the demand for donor kidneys continues to rise. Thus, live kidney donation is essential for increasing the donor pool. In order to create successful expansion, extended criteria live kidney donors should be considered. Based on the literature search, live kidney donation in older donors (up to 70 years of age) seems to be safe as outcome is comparable to younger donors. (1) Studies have estimated the average risk of post donation ESRD for living kidney donors in the United States, but personalized estimation on the basis of donor characteristics remains unavailable. 133,824 living kidney donors were studied from 1987 to 2015, as reported to the Organ Procurement and Transplantation Network, with ESRD ascertainment via Centers for Medicare and Medicaid Services linkage, using Cox regression with late entries. Black race (hazard ratio [HR], 2.96; 95% confidence interval [95% CI], 2.25 to 3.89; P<0.001) and male sex (HR, 1.88; 95% CI, 1.50 to 2.35; P<0.001) was associated with higher risk of ESRD in donors. Among nonblack donors, older age was associated with greater risk (HR per 10 years, 1.40; 95% CI, 1.23 to 1.59; P<0.001). Among black donors, older age was not significantly associated with risk (HR, 0.88; 95% CI, 0.72 to 1.09; P=0.3). Greater permissiveness may be warranted in older black candidate donors; young black candidates should be evaluated carefully.(5) End-Stage Renal Disease (ESRD) risk was studied in living kidney donors (LKDs) who donated in the United States between 1994 and 2016 (n = 123 526).Two hundred eighteen LKDs developed ESRD, with a median of 11.1 years between donation and ESRD. Absolute 20-year risk was low but not uniform, with risk associated with race, age, and sex and increasing exponentially over time. LKDs had increased risk of ESRD if they were male , had higher BMI or lower estimated GFR , were first-degree relatives of the recipient ; full sibling ; identical twin , or lived in lower socioeconomic status neighborhoods at donation . there was a significant interaction between donation age and race, with higher risk at older ages for white LKDs , but higher risk at younger ages for black LKDs(2)
Factors associated with transplantation from older living donors and the association of living donor age with allograft function and survival were studied in 73,073 donors.it revealed that the outcomes are excellent with living donors <65 years. Expanded use of older living donors may help meet the demand for transplantation.(3)
Individuals with isolated medical abnormalities (IMAs) are undergoing living donor nephrectomy more frequently. Knowledge of health risks for these living donors is important for donor selection, informed consent and follow-up. A systematic review studies living kidney donors with preexisting IMAs, including older age, obesity, hypertension, reduced glomerular filtration rate (GFR), proteinuria, microscopic hematuria and nephrolithiasis. 22 studies were on older donors (n = 987), 10 on obese donors (n = 484), 6 on hypertensive donors (n = 125), 4 on donors with nephrolithiasis (n = 32), 2 on donors with microscopic hematuria and one study each on donors with proteinuria or reduced GFR. Perioperative outcomes for donors with and without IMAs were similar. Few studies reported longer term (≥1 year) rates of hypertension, proteinuria or renal function. Studies were frequently retrospective and without a comparison group. Given the variability among studies and their methodological limitations, uncertainties remain regarding long-term medical outcomes for IMA donors. As transplant centers continue to cautiously screen and counsel potential IMA donors, rigorously conducted, longer term prospective cohort studies are needed.(4)
In the United States, 219 healthy adults aged ≥70 have donated kidneys at 80 of 279 transplant centers. Competing risks models with matched controls were used to study the independent association between older donor age and allograft survival, accounting for the competing risk of recipient mortality as well as other transplant factors. Among recipients of older live donor allografts, graft loss was significantly higher than matched 50-to 59-year-old live donor allografts (subhazard ratio [SHR] 1.62, 95% confidence interval [CI] 1.16 to 2.28, P = 0.005) but similar to matched nonextended criteria 50-to 59-year-old deceased donor allografts (SHR 1.19, 95% CI 0.87 to 1.63, P = 0.3). Mortality among living kidney donors aged ≥70 was no higher than healthy matched controls drawn from the NHANES-III cohort; in fact, mortality was lower, probably reflecting higher selectivity among older live donors than could be captured in National Health and Nutrition Examination Survey III (NHANES-III; HR 0.37, 95% CI 0.21 to 0.65, P < 0.001).(6)
So these findings support living donation among older adults but highlight the advantages of finding a younger donor, particularly for younger recipients.
Ref:
1-Ali R. Ahmadi, Jeffrey A. Lafranca, Laura A. Claessens, Raoul M.S. Imamdi, Jan N.M. Ijzermans, Michiel G.H. Betjes, Frank J.M.F. Dor,Shifting paradigms in eligibility criteria for live kidney donation: a systematic review,Kidney International,Volume 87, Issue 1,2015,Pages 31-45,
2-Wainright, JL, Robinson, AM, Wilk, AR, Klassen, DK, Cherikh, WS, Stewart, DE. Risk of ESRD in prior living kidney donors. Am J Transplant. 2018; 18: 1129– 1139. https://doi.org/10.1111/ajt.14678
30Gill, John S.; Gill, Jagbir; Rose, Caren; Zalunardo, Nadia; Landsberg, David, The Older Living Kidney Donor: Part of the Solution to the Organ Shortage,Transplantation: December 27, 2006 – Volume 82 – Issue 12 – p 1662-1666 doi: 10.1097/01.tp.0000250715.32241.8a4-Young, A., Storsley, L., Garg, A.X., Treleaven, D., Nguan, C.Y., Cuerden, M.S. and Karpinski, M. (2008), Health Outcomes for Living Kidney Donors with Isolated Medical Abnormalities: A Systematic Review. American Journal of Transplantation, 8: 1878-1890. https://doi.org/10.1111/j.1600-6143.2008.02339.x
5-Allan B. Massie, Abimereki D. Muzaale, Xun Luo, Eric K.H. Chow, Jayme E. Locke, Anh Q. Nguyen, Macey L. Henderson, Jon J. Snyder, Dorry L. Segev, Quantifying Postdonation Risk of ESRD in Living Kidney Donors, JASN Sep 2017, 28 (9) 2749-2755; DOI: 10.1681/ASN.2016101084
6- Living Kidney Donors Ages 70 and Older: Recipient and Donor Outcomes
Jonathan C. Berger, Abimereki D. Muzaale, Nathan James, Mohammed Hoque, Jacqueline M. Garonzik Wang, Robert A. Montgomery, Allan B. Massie, Erin C. Hall, Dorry L. Segev
CJASN Dec 2011, 6 (12) 2887-2893; DOI: 10.2215/CJN.04160511
71 years old potential donor with normal kidney functions is willing to donate for his son.
Physiological age is more relevant than chronological age and donation at such age is not a contraindication but 2 points need to be fulfilled:
1-donor safety: Studies showed older donors are more exposed to perioperative complications so intensive evaluation should be addressed.
2-regarding quality of the organ: advanced age-related glomerular sclerosis is expected so, measurement of eGFR by 24h creatinine clearance and renal isotope scan with split kidney functions will afford a better picture of the actual kidney functions. affording grafts with poor quality for potential young recipients associated with short graft survival. Furthermore, a donor-recipient age difference of >30 years increases the risk of graft loss within 12 months post-transplantation.
My final decision is not to accept the donor but not for this particular potential recipient and it’s better to provide them with paired kidney exchange to the older recipient.
according to our center policy, we don’t accept donors aged more than 55 years old.
References:
TakahisaHiramitsu,u1ToshihideTomosu.et al.Adult Living-Donor Kidney Transplantation, Donor Age, and Donor–Recipient Age Kidney International ReportsVolume 6, Issue 12, December 2021, Pages 3026-3034
According to British transplantation society Old age alone is not an absolute contraindication to donation but the medical work-up of older donors must be particularly rigorous to ensure they are suitable. (A1) and both donor and recipient must be made aware that the older donor maybe at greater risk of peri-operative complications and that the function and possibly the long-term survival of the graft may be compromised. This is particularly evident with donors >60 years of age. (B1) as in this case.
The older donor needs more careful consideration with respect to the increased risk of peri-operative complications, existing comorbidities and residual function post-donation, and also
the long-term transplant outcome in the recipient associated with reduced donor GFR and potential donor vasculopathy.
Graft Outcome from Older Donors:
Ø higher incidence of delayed graft function
Ø increased risk of graft failure
Despite being immunologically good match, both donor and recipient should be counselled of all possible risk regarding age difference.
So better option is younger donor if not available, his father can donate if medical evaluation is satisfactory living is superior to deceased and waiting list.
Reference:
1. BTS/RA Living Donor Kidney Transplantation Guidelines 2018
2. Foley DP, Patton PR, Meier-Kriesche HU, Li Q, Shenkman B, Fujita S, Reed A, Hemming AW, Kim RD, Howard RJ. Long-term outcomes of kidney transplantation in recipients 60 years of age and older at the University of Florida. Clin Transpl. 2005:101-9. PMID: 17424728.
3. Ferrari P, Lim W, Dent H, McDonald SP. Effect of donor-recipient age difference on graft function and survival in live-donor kidney transplantation. Nephrol Dial Transplant. 2011 Feb;26(2):702-8. doi: 10.1093/ndt/gfq383. Epub 2010 Jul 1. PMID: 20601369.
4. Resende L, Guerra J, Santana A, Mil-Homens C, Abreu F, da Costa AG. Impact of donor age on renal allograft function and survival. Transplant Proc. 2009 Apr;41(3):794-6. doi: 10.1016/j.transproceed.2009.01.064. PMID: 19376354.
This old age donor he has definitely low GFR for such young donor it may be not a wise decision so we need to do DTPA or measure GFR to took the decision
According to BRTISH TRANSPLANT SOCIETY the recommendation regarding the donor age are :
1. Old age alone is not an absolute contraindication to donation .
2. The donor and recipient must be made aware that
· Are at greater risk of peri-operative complications and that
· the function and survival of the graft may be compromised especially in those above 60 y .
3. in Most centers do not consider donors aged <18 years and consider an age of 18-21 years as a relative contraindication to donation.
Summary
Most transplant programs are more flexible in older donors. Younger donors should be subjected to stringent exclusion criteria .
According to studies :
Living donors provide shorter waiting times and better term outcomes for their recipients compared with deceased donors.
The studies report no an additional mortality risk for living kidney donors , but they report an increased risk of ESRD , especially in older donors . Some studies also report that there is increased graft failure among recipients as donor age increases.
The process of older (age,60 years)donor transplantation is increasing become doubled from 1994 to 2011.
Studies from UNOS data report that decreased graft and overall survival for recipients of older living donor kidneys; but still the older living donor kidneys perform equall or better than than deceased donor kidneys.
Berger et al found that living donors of 70 years or older has no significant differences in short-term graft failure or recipient survival when compared to recipients of 50- to 59- year-old deceased donors.
older LD kidneys had decreased graft survival, compared to younger LD kidneys.
When compared to SCD and ECD kidneys, these older living donor kidneys has better outcome.
graft failure is significantly increased in kidneys from donors of 70 years or older, but they did not have worse overall survival, this may be due to decrease dialysis exposure time .
Decreased dialysis exposure is an important advantage of living donor transplantation and a potential part of the causal pathway for better long-term outcomes in this patient population.
References:
1.Schechter MA, Irish WD, et al. Outcomes in kidney transplant recipients from older living donors. Transpl.,2015; 99: 309-15.
2.BTS/RA Living Donor Kidney Transpl.Guidelines 2018.
· The kidneys from older donors had poorer survival than younger donors (<40 years). The risk of acute rejection and graft failure is higher in older donors. Therefore, receiving a kidney from a younger living donor would be the best option. But if this recipient is on the waiting list for a long time, maybe this would also be considered as an option.
On the other hand, donor’s evaluation should be carefully
performed at this age, due to high probability for CVD or risk factors such as
diabetes or HTN. If there is no contraindication, the donor’s age itself is not
a contraindication for donation.
There is no clear answer for this question.
We need to weigh risks and benefits then counsel both donor and recipients about the potential risks and complications.
As we know, the graft and patient outcomes of living donation are better than deceased donation and staying on dialysis.
It is a good donation offer, 110 mismatches with no DSA.
The donor is 71 y old father, with normal cardiac history, however he is prone to operative risks because of his age. And the survival of the graft taken from an old donor above 65 y is questionable.
The options would be:
1- Accept this offer with potential donor complications and possible less graft survival.
2- Wait for another younger donor? For how long?? Dilemma of Mismatches and DSA again??
3- Paired kidney donation scheme with old aged recipient (old for old and young for young).
4- Wait for deceased matched young aged donor.
I would prefer to accept this offer after proper conselling.
the donor is the father with a good match at 71 years old I suggest this transplantation should proceed because it is better to remain in dialysis so need to explain to the recipient the implication of this donation.
the risk of this kidney should be evaluated.
if the eGFR is more than 60 and age 71 transplantation is superior to cadaveric and dialysis.
so the age is not a contraindication for donation
elderly donors are not an absolute contraindication for organ donation… They have to be evaluated thoroughly for any end organ damage and cardiovascular risk before organ donation…According to BTS guidelines 2018, old aged donors are not contraindicated from donation and there is a increased peri operative risk to the donor with increased short term complications …
I would proceed rather than waiting on the deceased donor cadaver list
According to KDIGO and British Transplantation Society guidelines ,the old age of the donor with excellent renal functions poses a good acceptable candidate for living donation as he is more likely will not suffer further renal disease, the concerning issue is that the graft survival would be less compared to younger living donors.
The other concern for donation rather than renal assessment, cardiological and anesthesiology evaluation for fitness for major operation.
There is no age limitation except limitation is allograft mass(nephrons) eGFR at the time of donation. as every one has discussed and also the literature shows that, there is increased risk of DGF, increased ischemia time and overall graft loss.
So the father is better option for donation.
If there are no potential donors, high cPRA, no KPD available, we can proceed with the transplant.
The donor must be aware of the risks involved, after all, he is already old, despite not having any of the criteria that would contraindicate the donation (proteinuria, uncontrolled arterial hypertension, type 1 diabetes mellitus, high blood glucose).
Living donors with good matching are superior to deceased donors and decrease ischemia time.
YES ILL ACCEPT IT
• Expanded Criteria donor >60 or 50-60 with with at least 2 of the following co-morbidities: 1. Hypertension 2. Elevated creatinine >133μmol/l (>1.5mg/dl) 3. Death from cerebrovascular accident
Outcome of ECD Survival advantage of ECD kidney transplant recipients over dialysis patients remaining on transplant waiting list or cadaveric kidney
British Transplant Society 2018
Recommendations
1) Elder age is not the absolute contraindication to kidney donation but the medical work-up of older donors must be particularly rigorous to ensure they are suitable.
2) Both donor and recipient must be made aware that the older donor may be at greater risk of peri-operative complications and that the function and possibly the long-term survival of the graft may be compromised. This is particularly evident with donors >60 years of age.
yes, a living donor even older age is better than waiting for deceased donors in terms of graft survival as it has less cold ischemia time, less delayed graft function and less AR.
*This candidate old donor 71 years old (ECD )with 110 mismatch , no DSA.
*The use of older kidney donors appears to be an equivalent or beneficial alternative to awaiting cadaveric kidney donors.
*The age is not considered an absolute contraindication for kidney donation, Although; older donor is associated with higher risk of
1.perioperative morbidity and mortality of donor.
2.Worse graft outcome. 4. here donor age has extended criteria for individuals older than 65 years old, but the recipient must be near that age group.
* KPD is considered a suitable option to overcome the huge difference between the donor and recipient ages.
References:
1.Schechter MA, Irish WD, et al. Outcomes in kidney transplant recipients from older living donors. Transpl.,2015; 99: 309-15.
2.BTS/RA Living Donor Kidney Transpl.Guidelines 2018
according to BTS/RA Living Donor Kidney Transplantation Guidelines 2018
so after good evaluation and discussion with both the donor and recipient about the outcome and possible complication transplantation from this 71 year is better than cadaver
thanks
One study has investigated LDKT outcomes from living donors aged >70 years.
, Postnephrectomy survival of living donors aged >70 years has been reported to be significantly better than that of matched healthy controls.
Nevertheless, the graft-loss rate among the recipients was significantly higher than that among recipients from living donors aged 50 to 59 years.
Furthermore, a donor-recipient age difference of >30 years has been reported to increase the risk of graft loss within 12 months post-transplantation relative to an age difference of 10 to 20 years.
Studing the impact of donor age on the outcomes of younger recipients showed
that eGFR declined significantly as the donor age increased, and graft loss in younger groups increased as the donor age increased,
The study also concluded that although the lower graft function in the younger recipients who received a transplant from elderly donors could lead to worse graft survival than those from younger donors, LDKTs from the elderly donors to younger recipients could be a favorable life-saving treatment for chronic kidney diseases in clinical practice.
If there is a possibility of finding another matched younger donor with less age difference between donor and recipient this would give the donor a better chance for longer graft survival
TakahisaHiramitsu,u1ToshihideTomosu.et al.Adult Living-Donor Kidney Transplantation, Donor Age, and Donor–Recipient Age Kidney International ReportsVolume 6, Issue 12, December 2021, Pages 3026-3034
-Higher risk of peri-operative complications
-less long-term graft survival
-less long-term graft function
· Inferior outcomes should be expected with donor >60 years
· Pre-donation cardio-respiratory function should be carefully assessed in older donors
· Most centres perform a stress echocardiogram and/or myocardial perfusion scan if indicated.
· Respiratory function tests may be indicated in smokers and those with airway disease.
· Cardiopulmonary exercise testing is a predictor of post-operative complications, particularly in elderly patients and can be used in the assessment of elderly donors
· As the recipient is very young, he still has long half-life with increased incidence of graft disfunction or CKD
· Kidney paired donation is an option to overcome the big difference between the donor and recipient ages.
BTS/RA Living Donor Kidney Transplantation Guidelines 2018
The donor has excellent kidney function and normal cardiac results. Evidence is present that there is no accelerated loss of kidney function following donation, and incidence of established renal failure (ERF) and hypertension among donors is the same as the general population.
However, it is to be noted that the risks of delayed graft function, acute rejection, and graft failure in transplants from living donors above 65 years of age are significantly higher than young donor kidneys.
In addition, elderly kidneys can have altered progenitor cell function, increased tendency for apoptosis, alterations in growth factor profiles, and important changes in immune responses all of which lead to decreased kidney reserve. A 2006 US renal data report expresses that the risk of DGF is twice as higher in kidney from elderly donor than younger donors. Furthermore, for every 10 year increase in living donor age above 65, risk of DGF is increased by 15%.
If a younger suitable donor is not found, I would accept this donor.
References :
Reply To Prof Ahmed Halawa
No, I don’t think that a cadaveric transplant would be better than a living kidney donor. Cadaveric transplant have an higher incidence of delayed graft function (prolonged ischaemia time), frequency of rejection and worse transplant outcome compared to living donors. Cadaveric transplant will also require more intense immunosuppressive regime (1). As use of older kidney donors increases, overall survival among kidney transplant recipients from older living donors was similar or even better than Standard criteria donors recipients, better than expanded criteria donors, but worse than younger LD recipients. With increasing kidney donation from older adults, the use of older kidney donors appears to be an equivalent or beneficial alternative to awaiting deceased donor kidneys (2).
References:
(1)CADAVERIC VERSUS LIVING DONOR KIDNEY TRANSPLANTATIONA Medicare Payment Analysis 1Smith, Craig R.2; Woodward, Robert S.3; Cohen, David S.3; Singer, Gary G.4; Brennan, Daniel C.4; Lowell, Jeffrey A.2; Howard, Todd K.2; Schnitzler, Mark A.35
(2)Outcomes in kidney transplant recipients from older living donors: Brian R Englum 1, Matthew A Schechter, William D Irish, Kadiyala V Ravindra, Deepak S Vikraman, Scott L Sanoff, Matthew J Ellis, Debra L Sudan, Uptal D Patel
No, I don’t think that a cadaveric transplant would be better than a living kidney donor. Cadaveric transplant have an higher incidence of delayed graft function (prolonged ischaemia time), frequency of rejection and worse transplant outcome compared to living donors. Cadaveric transplant will also require more intense immunosuppressive regime (1). As use of older kidney donors increases, overall survival among kidney transplant recipients from older living donors was similar or even better than Standard criteria donors recipients, better than expanded criteria donors, but worse than younger LD recipients. With increasing kidney donation from older adults, the use of older kidney donors appears to be an equivalent or beneficial alternative to awaiting deceased donor kidneys (2).
References:
(1)CADAVERIC VERSUS LIVING DONOR KIDNEY TRANSPLANTATIONA Medicare Payment Analysis 1Smith, Craig R.2; Woodward, Robert S.3; Cohen, David S.3; Singer, Gary G.4; Brennan, Daniel C.4; Lowell, Jeffrey A.2; Howard, Todd K.2; Schnitzler, Mark A.35
(2)Outcomes in kidney transplant recipients from older living donors: Brian R Englum 1, Matthew A Schechter, William D Irish, Kadiyala V Ravindra, Deepak S Vikraman, Scott L Sanoff, Matthew J Ellis, Debra L Sudan, Uptal D Patel
Old age is not a contraindication for kidney donation. However, donor and recipient must be informed about the increased risk of peri-operative complications and the fact that the long term survival of transplant in the recipient may be affected particularly with donors with age above 60 years old. However, the use of laparoscopy has reduced surgical complications with reduced morbidity and early recovery. Moreover, the risks of delayed graft function, acute rejection, and graft failure in transplants from living donors >65 years are higher when compared to transplants from younger donors.
Graft function and graft survival could be compromised in recipients from elderly deceased donors due to reduced nephron mass, ischemic injury, and acute rejection episodes which are more prevalent in the elderly. Moreover the risk of DGF in transplants recipients from living donors (age> 65 years) is double when compared to transplants from younger donors.
Also, with age there is a physiological decline of the kidney function. However, in this case, I would complete the donor work up pre-transplant assessment (e.g. PSA) and if they are normal I would consider this patient suitable for donation. Indeed, in this case, there is good mismatch with no DSA, no comorbidities and normal potential donor kidney function. Furthermore, leaving the recipient without transplant would increase his cardiovascular risk.
BTS 2018
Donors above 60 years of age need careful consideration with respect to the increased risk of peri-operative complications, existing comorbidities and residual function post-donation, and also the long-term transplant outcome in the recipient associated with reduced donor
GFR and potential donor vasculopathy
Donor Complication Rates Related to Age
– Although peri-operative outcomes such as operative time, blood loss and length of stay are shown in some recent studies to be no different from younger donors in carefully selected donors above 60 years, caution should be exercised in the evaluation, operation and postoperative management of the older donor.
– Pre-donation cardio-respiratory function should be carefully assessed in older donors. Most centers perform a stress echocardiogram and/or myocardial perfusion scan if indicated. Respiratory function tests may be indicated in smokers and those with airway disease. Cardiopulmonary exercise testing, and in particular the definition of the anaerobic threshold, has been validated as a predictor of postoperative complications, particularly in elderly patients.
– Screening of serum PSA is mandatory in males above 55 years. Although a mildly
elevated PSA may not preclude donation, a rising PSA over time may be of concern and there should be a low threshold for formal urological review.
– In women, an upto-date mammogram and relevant history should be reviewed.
– In all patients, there should be a careful review of bowel function, incorporating the results of up-to-date population screening tests such as tests for faecal occult blood.
– Social, family and psychological support for elderly donors should be provided, particularly in the case of altruistic donation
–
Graft Outcome from Older Donors
poorer outcomes for kidneys from old donors compared to young donors.
However; the use of older kidney donors appears to be an equivalent or beneficial
alternative to awaiting deceased donor kidneys
Long Term Risk for Older Donors
Older donors with potential risk factors for kidney disease, such as hypertension or diabetes, are less likely than younger donors to have enough time for such risk factors to lead to progressive kidney disease, or for any kidney disease that develops to affect life expectancy.
My decision
I will not accept him as a donor unless there is long list waiting list for the patient because the graft has poor outcome and the patient mostly will need another graft later and he will be highly immunized due to the first graft
Reference
BTS/RA Living Donor Kidney Transplantation Guidelines 2018
according to BTS guidelines, the age is not an absolute contraindications to donation (physiological age is more important than chronological age). However, older donor is associted with higher risk of perioperative morbidity and mortality for the donor in addition to worse graft longevity in the recipient with worse outcome especially if he is young as in our scenario.
_ the 1st issue related to the donor survival, to decide if it is safe for him to donate or not depends on through evaluation of his cardiovascular system ( stress ecg and echo, Myocardial perfusion scan and CPET to determine or predict the perioperative cardiac risk) in addition to risk calculation to account for any asscoacited comorbidities. If he is fit for donation, it is ok ( whether for his son or to be enrolled in PKD if avialble ).
_ second issue, for the recipient to get the best available graft so , the best option here ( if available) is enrollment in PKD to find better age matched donor and use his father old kidney for another older recipient.
_ if no available PKD, accepting father as a donor can have advantage of preemptive transplantation and with good HLA mismatch.
_ sure, LIving donor is better than waiting for deceased donor kidney transplantation as it allows for preemptive tranplanation, better matching, avoid prolonged cold ischemia time that can increase risk of DGF and rejection episodes with deceased donor
Age more than 18 is not a contraindication for kidney donation, even in extreme ages, however potential donor’s comorbidities and risk factors for postsurgical complications indicated if the potential donor can donate.
Several studies have reported higher risk of postsurgical complications in donors age more than 50. Also living donation from donors elder than 50 was associated with poorer allograft outcomes when compared to younger donors.
However living donation with acceptable immunological barrier is much better than receiving kidney from deceased donor as perioperative complications are more common with urgent surgery when compared to elective kidney donation and transplantation.
In our clinical scenario, this elderly potential donor should undergo comprehensive evaluation other than cardiac and renal- diabetes and lipid panel. Risk factors like obesity and smoking should be managed before planning surgery.
If kidney donation is not warranted with KPD, LD from his father with low immunological risk is a good option.
71-year-old male willing to donate his kidney to his 16-year-old son, 110 mismatch with no DSA. This donor has the advantage of being a living related transplant with excellent kidney functions and normal cardiac investigations.
However, we have to keep in mind the following:
1. The old donor age: Most transplant programs currently do not have an upper age limit for accepting donors and the donor function rather than age may be the most important determinant of outcome .However, older patients needs a more meticulous transplant work up to ensure their suitability for organ donation.
BTS indicates that prospective donors should not be considered for donation if the corrected GFR is predicted to fall below 37.5 mL/min/1.73 m2 at the age of 80.
Despite the reduced survival in older donors >60 years compared to younger donors but still it is comparable to the age and comorbid-matched participants indicating that poor survival was not clearly attributed to kidney donation.
2. The increased risk of perioperative complications, so both the donor and the recipient must be aware about that.
3. The donor long term risks like hypertension and diabetes are less likely than younger donors to have enough time to progressive kidney disease and the quality of life and established renal failure is comparable to the general population.
4. The graft outcome (graft function and survival) from the older donor is compromised by the aging process(reduced functional nephron mass, lower baseline GFR, and secondary glomerulosclerosis with ischemic changes and diffuse micro-vascular disease). So, we would expect a relatively lower graft function, increased rejection episodes and poor long-term graft survival compared to kidneys from younger donors.
Conclusion:
References:
1.BTS Guidelines 2018.
2. Jacob A. Akoh and Umasankar Mathuram Thiyagarajan. Renal Transplantation from Elderly Living Donors. Review article. Journal of Transplantation Volume 2013, Article ID 475964, 9 pages
The available donor is 71years old male with excellent kidney function and normal cardiac investigation to 16 years old son with II0 mismatches and no DSA .
– older donor is associated with increase risk of peri-operative complication decrease
Long term graft survival and long term graft function.
-It is also associated with inferior outcomes which expected with donor aged more than 70 years old.
so both donor and recipient should be aware that old donor has a greater risk of peri- operative complication and possibly long term survival of graft may be compromised
This particular when the donor age more than 60 years .
But this situation associated with psychological concern between father and son and it is really favorable from being on dialysis, staying on waiting list or deceased donor with age between 50-59 years.
I will accept the donor after vigorous . Counselling the donor and recipient about cost apposite to benefit.
Yes I would accept.
transplantation from live donor gives better results than deceased donor transplantation, even when the donor is old. Berger in 2011 showed In a series of 219 transplantations from >70-year-old LKDs , graft loss was significantly higher than in LKDs 50–59 but similar to matched standard 50–59 deceased donor allografts [1]. Similar results have been reported with LKD over 60 compared with <60 standard criteria deceased donors [2].
However the donor should be fully aware of the consequences especially that blood pressure expected to increases after nephrectomy. A meta-analysis having included data for one million adults with no previous vascular disease showed that in middle and old age, blood pressure, even in the normal range, is strongly associated with cardiovascular mortality [3]. Therefore, long-term mortality could be increased in the LKD as a direct consequence of donation.
1-Berger JC, Mazaale AD, James N, et al. Living kidney donor ages 70 and older: recipient and donor outcomes, Clin J Am Soc Nephrol, 2011
2-Young A, Kim SJ, Speechley MR, et al. Accepting kidneys from older living donors: Impact on transplant recipient outcomes, Am J Transplant, 2011, vol. 11 (pg. 743-750)
3-Prospective studies collaborationAge specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies, Lancet, 2002, vol. 360 (pg. 1903-1913)
Please substantiate your answer
Age itself is not a contraindication for donation but donation in older age groups in topic of controversy. Donation above age 60 may not increase the death rate as compared to controls but there can higher decline in GFR and hypertension.
There is also higher risk of peri operative complications. There risks and benefits should be carefully evaluated. Physiological age is more important than chronological age.
All such donors should be carefully assessed and careful consideration should be given to postoperative morbidity, higher risk of ESRD and cardiovascular complications.
In the index case where donor is 71 year old with excellent kidney functions and no end organ damage I will accept donation. However as regards recipient who is only 16 year old there is possibility of poor graft outcome most likely due to vasculopathy.
this should be considered while planning the transplant.
Other options like enrolment in paired kidney donation can be considered
Living donation is better than deceased donation as deceased donation is associated with prolonged ischemia time, higher complications, intense immune suppression and higher rate of rejections. But the principle of Do No harm should be adhered to
I think in this scenario better to accept living donation which is better than deceased donor , but here donor age is little pit worrying speciall short graft survival of such age but still this is debatable
I think he may go for the transplant but the recipient need to be aware of all implications
There is no upper limit for donation. A 71-year-old donor with acceptable eGFR (more than 60 ml/min) can be acceptable.
From the donor aspect, ESRD increases with age, but for this donor, otherwise fit, we can proceed to save the life of 16 son and give him a chance better than dialysis or unrelated cadaveric kidney.
– according to BTS guidelines, the age is not an absolute contraindications to donation (physiological age is more important than chronological age). However, older donor is associted with higher risk of perioperative morbidity and mortality for the donor in addition to worse graft longevity in the recipient with worse outcome especially if he is young as in our scenario.
_ the 1st issue related to the donor survival, to decide if it is safe for him to donate or not depends on through evaluation of his cardiovascular system ( stress ecg and echo, Myocardial perfusion scan and CPET to determine or predict the perioperative cardiac risk) in addition to risk calculation to account for any asscoacited comorbidities. If he is fit for donation, it is ok ( whether for his son or to be enrolled in PKD if avialble ).
_ second issue, for the recipient to get the best available graft so , the best option here ( if available) is enrollment in PKD to find better age matched donor and use his father old kidney for another older recipient.
_ if no available PKD, accepting father as a donor can have advantage of preemptive transplantation and with good HLA mismatch.
_ sure, LIving donor is better than waiting for deceased donor kidney transplantation as it allows for preemptive tranplanation, better matching, avoid prolonged cold ischemia time that can increase risk of DGF and rejection episodes with deceased donor
Yes Dr Shawky,
I agree that ‘physiological age is more important than chronological age’.
It is better to accept this kidney (from this 71years old male with excellent kidney function and normal cardiac investigations and good missmatch) than waiting for a cadaveric donor or another suitable donor with the problem of organ shortage.
A study reported that:
There were no significant differences in the course of donor nephrectomy, postoperative complications, or remnant kidney function. However, delayed graft function occurred more frequently in recipients of transplants from older donors. Improvement in graft function was also slower in recipients of kidneys from older donors, with significant differences in serum creatinine levels observed during the first 12 months after transplantation. More frequent acute complications and more progressive chronic graft failure, irrespective of the causes, occurred during the 1st post-transplant year in recipients with grafts from older donors. Five-year patient survival (77% vs 92%) and kidney graft survival differed significantly for the same period with worse results for patients receiving grafts from older donors.
Conclusion:
kidney grafts from donors older than 60 years — and especially those older than 70 years — may be used for living related kidney transplantation, but with precautions.
_______________________
Ref:
[1] V Lezaić et al. Living related kidney donors over 60 years old. Transpl Int. 1996.
Dear Dr Ashmaig,
I appreciate balanced decision-making.
Thanks Prof Ajay
* Yes, I would accept kidney donation from this 71 years old male with excellent kidney function, normal cardic investigation and low immunological risk (good HLA mismatch 1_1_0 with no DSA)who wish to donate to his son, so, based on this data it is preferably to choose him compared to long waiting time on list, unavailable offer from kidney paired donation.
Living donor renal transplantation: recent developments and perspectives
Seema Baid-Agrawal &
Ulrich A Frei
Nature Clinical Practice Nephrology volume 3, pages31–41 (2007)
Yes Dr Elaf,
LRD, if safe for a prospective donor, is always better than cadaveric transplant. But the main and the sole determinant is the principle of primum non nocere (‘do no harm’).
The following considerations will help us to accept or exclude old age individuals from donation ;
1-The use of older kidney donors appears to be an equivalent or beneficial alternative to awaiting deceased donor kidneys .
2- if the older donor is judged fit after rigorous medical evaluation, and if the renal function of the donor is normal after correction for age and gender, there is no compelling evidence for excluding donation on the basis of chronological age alone .
3-Older donors with potential risk factors for kidney disease, such as hypertension or diabetes, are less likely than younger donors to have enough time for such risk factors to lead to progressive kidney disease, or for any kidney disease that develops to affect life expectancy .
According to the above justification I will accept this potential donor .
Old age alone is not an absolute contraindication to donation but the medical work-up of older donors must be particularly rigorous to ensure they are suitable.
Donors above 60 years of age need careful consideration with respect to the increased risk of peri-operative complications, existing comorbidities and residual function post-donation, and also the long-term transplant outcome in the recipient associated with reduced donor GFR and potential donor vasculopathy.
Reference ;
1-BTS/RA Living Donor Kidney Transplantation Guidelines 201
Hi Dr Ishag,
LRD, if safe for a prospective donor, is always better than cadaveric transplant. But the main and the sole determinant is the principle of primum non nocere (‘do no harm’).
Our donor is 71 old male with excellent kidney function and normal cardiac investigation.
All new approaches try to increase the donors pool .
Age now is not an absolute contraindication for donation.
The best important thing is the carefully assesment of cardiorespiratory system.
Cpet and stress test ,ecg and echocardiography.
Screen cancer is also important (age related)
Mental health assessment is also important in this age patients with neurologist and psychiatrist consultation.
I think after good evaluation of this old patient ,he will be an acceptable donor .
Reference:
Bts guidelines.
Dear Dr HIndawy,
I appreciate balanced decision-making.
According to BTS guidelines: old age only is not considered absolute contraindication to donation.
Higher prevalence of comorbidities makes decision for donation not easy .Elderly donor should be evaluated as recipient with consideration of kidney function and associated comorbidities.
As donor age is more than 60,donor may be at higher risk of peri-operative complications and function and possibly the long-term survival of the graft may be affected..
Following thorough medical evaluation, with renal function of the donor within normal for age and gender, he can be accepted for donation if there no alternative donor, as use of older kidney donors appears to better than awaiting deceased donor kidneys on dialysis.
Parents usually accept the risk when they donated to their children for psychosocial reasons. Otherwise, to consider paired kidney donation to get better age matching.
References;
– Jacob A., et al. Review Article: Renal Transplantation from Elderly Living Donors. Journal of Transplantation Volume 201.
– BTS Guidelines 2018.
Hi Dr Omran,
I understand your argument when you suggest paired kidney donation in this instance. My focus is on prospective donor and nothing else! If the donor is fit then this is better for the cadaveric kidney could be used for someone else (refer to utilitarian approach).
According to BTS :
1-Old age alone is not an absolute contraindication to donation but the medical work-up of older donors must be particularly rigorous to ensure they are suitable. (A1)
2-Both donor and recipient must be made aware that the older donor may be at greater risk of peri-operative complications and that the function and possibly the long-term survival of the graft may be compromised. This is particularly evident with donors >60 years of age.
Yes Dr Asmaa,
Short and sweet answer.
>>based on BTS/RA living donor kidney transplant guidelines 2018 :
so , this potential donor can be accepted with this excellent kidney function and normal cardiac investigations considering the following:1- explain to the donor & recipient the perioperative risks in this age .
2- screening to PSA .
>>regarding option of cadaveric kidney:
I understand your arguments in this debate, dear Dr Mohamed.
I think he can donate.
According to BTS/RA Living Donor Kidney Transplantation Guidelines 2018
In the last five years there has been a significant increase in the number of living
donations in the UK from the 60-69 and >70 year groups. Donors above 60 years of age need careful consideration with respect to the increased risk of peri-operative
complications, existing comorbidities and residual function post-donation, and also
the long-term transplant outcome in the recipient associated with reduced donor
GFR and potential donor vasculopathy.
Much of the change in attitude towards accepting older donors is due to the wide
and almost universal use of laparoscopic kidney donation in the UK and the resultant
reduction in morbidity and improved recovery. Although peri-operative outcomes
such as operative time, blood loss and length of stay are shown in some recent
studies to be no different from younger donors in carefully selected donors above
60 years, caution should be exercised in the evaluation, operation and postoperative management of the older donor
.
Pre-donation cardio-respiratory function should be carefully assessed in older
donors. Most centres perform a stress echocardiogram and/or myocardial perfusion
scan if indicated. Respiratory function tests may be indicated in smokers and those
with airway disease. Cardiopulmonary exercise testing, and in particular the
definition of the anaerobic threshold, has been validated as a predictor of postoperative complications, particularly in elderly patients. If available, it may be of
particular use in the assessment of elderly donors.
Screening of serum PSA is mandatory in males above 55 years. Although a mildly
elevated PSA may not preclude donation, a rising PSA over time may be of concernand there should be a low threshold for formal urological review. In women, an upto-date mammogram and relevant history should be reviewed. In all patients, there
should be a careful review of bowel function, incorporating the results of up-to-date
population screening tests such as tests for faecal occult blood. Social, family and
psychological support for elderly donors should be provided, particularly in the case
of altruistic donation.
Transplant recipients with older LD kidneys had significantly lower graft and patient survival compared to younger LD recipients. Compared to SCD recipients, graft survival was decreased in recipients with living donors 70 years or older, but patient survival was similar. Older LD kidney recipients had better graft and patient survival than ECD recipients
Dear Dr Ansary,
I like your comprehensive, well thought logical approach.
Ajay
In the current scenario of 71-year-old male with excellent kidney function and normal cardiac investigations offered kidney to his 16-year-old son, 110 mismatch with no DSA,I will accept the offer it is better than waiting long time in waiting list or to receive a deceased donor offer. Acceptance of elderly living kidney donors remains controversial due to the higher incidence of comorbidity and greater risk of postoperative complications. In last decade ,there is increase in number of donors >60 years.
Elderly donors require extensive assessment and should have a predicted glomerular filtration rate of at least 37.5 mL/min/1.73 m2 at the age of 80. It is known that the risks of delayed graft function, acute rejection, and graft failure in transplants from living donors >65 years are significantly higher than transplants from younger donors.
In response to the increasing need for organs, deceased donor programs (donation after circulatory death (DCD) and donation after brain death (DBD)) are being optimized and living kidney donation expanded in several countries to include both related and unrelated donation. ABO incompatible transplantation, legalised altruistic nondirected living donation, and paired kidney donation programs.
The use of grafts from elderly deceased donors (DD) is associated with less-than-ideal graft function and graft survival in recipients. This is attributed to reduced nephron mass, greater susceptibility to ischemic injury, and acute rejection episodes which is more prevalent in the elderly. In the other side, the relationship between living donor age and graft survival is less clear. the risk of DGF in transplants from living donors above the age of 65 years is double that of transplants from younger donors.
Dear Dr Fouad,
I like your comprehensive, well thought logical approach.
Ajay