What is the level of evidence this study provides?
Level 1
In your own words, summarise the outcome of this study!
Renal transplantation is safe and effective in carefully selected elderly kidney transplant recipients .The donor source and waiting time on dialysis are important determinants of post transplant outcomes. The pre transplant assessment should take into account the presence of co-morbidities , frailty ,physical and cognitive function .
Overall outcomes;
1-Comparison of patient survival with patients remaining waitlisted on dialysis.
Most of studies showed better patient survival in kidney transplanted elderly recipient when compared to those remaining on dialysis .
2- Comparison with younger RTRs.
A-Patient survival.
Elderly recipients have a higher risk of death compared to younger RTRs.
B- Graft survival.
Graft survival (GS) in elderly patients is worse when compared to younger recipients.
C- Acute rejection.
Elderly recipients are associated with a reduced risk of AR.
D- Infection rates and associated complications.
Elderly recipients are at a higher risk of developing infections.
E- Quality of life .
Transplantation is associated with an improvement in the quality of life .
Outcomes based on donor source;
1-Waitlist mortality and impact of waiting time on dialysis on patient and graft survival.
Increased demand for DD renal transplantation has led to longer waiting periods and this is significant since the annual mortality rate for all patients on the waiting list varies between 5 and 10% worldwide but increases greatly in older patients on dialysis .
2-Strategies to increase the donor pool and impact on outcomes.
There has been a progressive increase in organs harvested from older donors .
3-Use of ECD kidneys.
Several studies have reported good results with ECD kidneys transplanted in elderly RTRs. Older recipients benefit from accepting a lower quality organ early after ESRD.
4-Use of donation after circulatory death kidneys and dual kidney transplants.
DKT is a reasonable option in elderly RTRs.
5-Allocation strategies.
In the Euro transplant Senior Programmed (ESP), RTRs aged 65 years and above are offered kidneys from DDs aged 65 years and older. Kidneys are allocated locally to unsensitized recipients without human leukocyte antigen (HLA) matching.
Benefit of high KDPI kidneys was greatest in recipients older than50 years and in those centers with a waiting time longer than 33 months.
A new scheme introduced in the UK will allocate all kidneys from both DBD and DCD donors and will more effectively match graft life expectancy with patient life expectancy.
6-Use of living donor kidneys .
LD renal transplantation is associated with better PS and GS.
Outcomes based on pre-transplant characteristics;
1-Comorbidities.
Co morbidity increases the mortality risk after transplantation.
2-Frailty.
Frailty is distinct from disability and co morbidity. It is associated with reduced physiologic function that increases an individual’s vulnerability for developing increased dependency and/or death.
3-Physical function .
Functional status can be assessed by measurements relying on patient’s self-report of ability to perform a certain task. Although patients with the worse PF had a worse post transplantation survival, transplantation was associated with survival benefit when compared to dialysis in every function quartile. Objective tests of physical performance include gait speed, grip strength or the short physical performance battery.
4-Cognitive function and non-adherence to medication.
Cognitive impairment does not necessarily preclude transplantation but it is important to recognize.
Alyaa Ali
3 years ago
1.Systematic review
2.Level of evidence : 1B
3.summarize the outcomes of this study
renal transplantation is safe in elderly patients , age is not contraindication of transplantation after good selection of recipient and donor.
renal transplantation improve patient survival in elderly patients when compared to those remaining on dialysis .many studies showed marked reduction in mortality rate .
after 4 years of follow up ,Karim et al., showed that mortality rate was 32% for those aged 70-79 years and 22% for those aged 60-69 and 6% for those aged less than 50 years . The main causes of death were cardiac , infection then malignancy
many studies showed elderly patients have a higher risk of death compared to younger patients.death with a functioning graft was the commonest cause of graft failure.
graft survival is worse in elderly patients when compared to younger recipients as the elderly patients receive kidneys from older donors ( which is associated with increased graft failure).
elderly recipients are associated with a reduced risk of acute rejection and this may be due to changes in the immune system that occur with aging referred to as immunosenescence .
the impact of acute rejection on patient and graft survival may be more severe in elderly recipients.
elderly recipients are at a higher risk of developing infection . Infection increase the risk of death – censored graft failure . both viral and bacterial infections is present , especially urinary infection , BK viremia and polyoma virus associated nephropathy.
transplantation is associated with improvement of quality of life in elderly recipients compared to those still on dialysis.
increased waiting time on dialysis is associated with worse patient and graft outcomes
there are good outcomes with ECD kidneys transplanted in elderly patients compared to those still on dialysis
ECD kidneys were associated with an increased risk of mortality in younger patients but not in the older patients and similar for graft loss , older donor kidneys would be better placed in older patients
LD renal transplantation is associated with better patient and graft survival when compared to those remaining on dialysis and even in older living donor but they are not available all the time so better to transplant patient with deceased donor compared to left them on dialysis
Ahmed Omran
3 years ago
Review article
Level of evidence 5
In UK 30 % of renal transplant recipients are elderly> 60 years
Renal transplantation leads to survival and QOL improvement of the majority of ESRD patients including elderly.
Mortality is higher in elderly compared to young transplant recipient, but it is lower than waitlisted patients on regular HD, which become apparent after 1 year post-Tx.
Elderly less than 70 years and not more than 70 years has higher mortality and higher incidence of graft loss if they receive ECD kidney compared to those who received deceased SCD kidney. LD kidney is always preferred, as it is associated with better graft survival. ECD kidneys are associated with perioperative complications, DGF, and mortality, despite that elderly are less likely to receive living donor kidney when compared to young.
Receiving kidneys from younger donor is associated with better graft survival.
Graft survival is lower in elderly compared to young, and this may reflect increase in risk of death with functioning graft rather than true graft failure since elderly are 7 fold more likely to die with functioning graft when compared to young.
Elderly has lower rate of acute rejection episodes than young because of immunosenecense, but the outcome related to acute rejection is more severe.
Elderly recipients are at a higher risk of developing infection which with cardiovascular disease include most common causes of death in renal transplant recipients
Pre-emptive renal transplantation is associated with better outcomes compared to those who on hemodialysis.
Assessment of co-morbidities, frailty and cognitive impairment is very important since they are associated with poor graft survival and high mortality.
Ofonime Udoh
3 years ago
Systematic review
Level 1 evidence
Summary
Renal transplantation is safe in the elderly, and is increasingly being done in transplant centers. There are certain factors that influence patient survival and graft survival, but overall patient survival is better in the eldelry recipients than being on the waiting list for a tranplant and continuing on dialysis.
Patient survival also depends on co- morbidites present in the recipient, the donor organ [ECD versus LD] type and age of the donor. Infection rates are lower than in younger recipients irrespective of immunosuppression and this is related to immunosenescence in the elderly.
Renal transplant is safe and has good effect on elderly recipients, but these recipients too have to be carefully selected and prepared.
Ben Lomatayo
3 years ago
Narrative review
Level 5
Summary of the overall outcome ;
Comparison of patient survival with patients remaining waited on dialysis ; Wolf et al.(6) reported survival advantage in elderly patients than remaining on dialysis. Initially mortality is high with kidney transplantation in elderly compared to remaining on WL , but after some times survival became equal(20).
Comparison with younger RTRs ; Higher risk of death is seen in elderly than younger RTRs due to to increased cardiac event, infection, and malignancy(21). Elderly recipients are at risk death with functioning graft than younger RTRs
Graft survival ; Elderly patient has worse graft survival than younger patient. Elderly recipient is more likely to get older donor kidney(25)
Acute rejection ; Less rates of acute rejections is observed in elderly due immunosenescence (13). This has no thing to do with immunosuppression
Infection rates and associated complications ; More infections are occurring in elderly specially urinary tract infections, BK virus nephropathy(37),(38)
Quality of life ; Regardless of the age, kidney transplantation improves quality of life
Outcomes based on donor source ;
Waitlist mortality and impact of waiting time on dialysis on patient and graft survival ; More mortality rates is noticed in waiting list on dialysis(46)
Strategies to increase the donor pool and impact on outcome ;
Use of ECD kidneys ; Good outcomes
Use of donation after circulatory death kidneys and dual kidney transplants ;
Allocation strategies ; DKPI, and EPTS
Use of living donor kidneys
Outcomes based on pre-transplant characteristics ; All associated with increased mortality(81), (88), (90)
Comorbidities
Frailty
Physical function
Cognitive function and non-adherence
saja Mohammed
3 years ago
systematic review article with good evidence from pool of registry studies and cohort studies from different centers , level 1B,11 of evidence
aim of this review to assess the risk and benefit of kidney transplantation in elderly patients by assessing for over all outcome , patient and graft survival in association with many factors like comorbid diseases , donor source criteria quality of life , fragility, physical function , cognitive function. type of immunosuppression medication not included as part of assessment in this systematic review .
in summary
this review study comparing elderly patients receiving RT with those waitlisted on dialysis and shows overall survival advantage in the RT group over those on dialysis with reduced mortality rate in the range of 25-78% , in pool of RT from EDC the mortality rate was lower by 25% only ,also survival rate in better in RTS from LD as compared to DD , EDC . For those older than 70 years, renal transplantation reduced mortality by 41% compared to remaining Waiting list in which the mortality was higher 33%(1) ,but some studies shows higher death in elderly RT with RR of 2.8 in the initial two weeks post RT this can be explained by the surgical complication pre-transplant ,associated comorbid diseases ,and higher infection rate
-comparing outcomes in elderly patients receiving renal transplantation with younger RTRs ,both PS and GS worse in older patients due to complications related to age
and pre transplant comorbidity.GS at 8–10 years was
31–32% in the elderly compared to 55–60% in younger RTRs(3)The main causes of death were cardiac (21%), infection(21%) and malignancy (20%)(4).
-Acute rejection rate
the rate of acute rejection is lower in the old recipients compared to younger transplant recipient in one study the AR rate was 28% in those aged 18–
29 years compared to 19.7% in those aged 65 years and older. The effect
of age on AR was independent of baseline immunosuppression (3) ,this can be explained by low immune response in elderly patient also the AR rate can be influenced by donor age due to increased immunogenicity with ischemic hypo perfusion injuries the acute rejection can impact both PS and GS in old recipients with increased graft loss and mortality .
-Outcome based on donor source
LD source associated with better PS , GS outcome compared to DD especially for elderly recipients with pre-transplant comorbid , the mortality rate reduced by 57% in recipient from living donor, however old recipient get less access to LD compared to young recipients ,older LD may be more available, and have been shown to be similar outcome to younger LDs
old recipient transplant from ECD kidneys require longer time to equal survival.
However, elderly patients receiving an ECD kidney within 2 years of starting dialysis
had better survival than those waiting years longer
and it is better than staying on dialysis.
-Infection rate and comorbid conditions were higher in old RT recipient that contribute to higher morbidity and mortality, Elderly recipients have increased risk of
immunosuppression-related complications and mortality.
-Quality of life , improved post transplant in old recipients with better physical and social activity and good health
-Cognitive function and non-adherence to medication more in elderly that put them at risk of rejection
-Frailty associated with increasing risk of early hospital
readmission and a 2.17-fold higher risk of death,
recommendation from this review that can contribute to change our practice
Chronological age is not a barrier to transplantation, and there is currently no age
limit for access to transplantation .
renal transplantation for elderly patient safe and promising in term of over all patient and graft survival in carefully selected candidate taken in consideration the donor selected criteria the pre transplant assessment for comorbid diseases in particular CVD ,infection ,malignancy ,and to focus on frailty score pre and post transplantations .
References
1-Transplantation • Volume 83, Number 8, April 27,2007
2-Keith DS, Cantarovich M, Paraskevas S, Tchervenkov J. Recipient age and risk of chronic allograft nephropathy in primary deceased donor kidney transplant. Transpl Int 2006;19:649–56. https://doi.org/10.1111/j.1432-2277.2006.00333.
3-Friedman AL, Goker O, Kalish MA, Basadonna GP, Kliger AS, Bia MJ, et al. Renal transplant recipients over aged 60 have diminished immune activity and a low risk of rejection. Int Urol Nephrol 2004;36:451–6. https://doi.org/10.1007/ s11255-004-8685-2
4- Keith DS, Demattos A, Golconda M, Prather J, Norman D. Effect of donor recipient age match on survival after first deceased donor renal transplantation. J Am Soc Nephrol 2004;15:1086–91. https://doi.org/10.1097/01.ASN.0000119572.02053.F2
Ahmed mehlis
3 years ago
It is systemic review
Level 1 evidence
Summery .
This article reviewed RT in elderly of different points 👉
First ..
Compared to younger age groups
1. Survival patient/graft .
2 acute rejection .
3 susceptibility to infection .
4 quality of life .
Second..
Survival on Rt or on regular dialysis in US 🇺🇸 or Europe 🇪🇺
Third
Patient donor pool in elderly
Fourth
Allocation strategies and living doner kidney.
..● (patient Survival) in elderly is more after RT compared to Dx .
Patient Survival in elderly is worse than younger age groups The main causes of death were cardiac (21%), infection
(21%) and malignancy 13%. Elderly patients are
seven times more likely to die with a functioning graft compared with
patients aged 18–29 years
●(Graft survival) (GS) in elderly patients is worse when compared to
younger recipients. Elderly recipients are more likely to receive kidneys
from older donors, which in turn are associated with an increased risk of
graft failure [25]. However, the reduced GS is more likely a reflection of
the increased risk of death with a functioning graft in elderly recipients
since death-censored graft survival (DCGS) is similar, or even better, to
younger patients.
●(Acute rejection:)
Elderly recipients are associated with a reduced risk of AR.
●Infection rates and associated complications
Elderly recipients are at a higher risk of developing infections.
●Quality of life
Transplantation is associated with an improvement in the quality of
life (QOL).
●Outcomes based on donor source
Increased demand for DD renal transplantation has led to longer
waiting periods and this is significant since the annual mortality rate
for all patients on the waiting list varies between 5 and 10% worldwide
but increases greatly in older patients on dialysis . Increased waiting
time on dialysis impacts on both PS and GS.
● Strategies to increase the donor pool and impact on outcomes
1. Use of ECD kidneys
Several studies have reported good results with ECD kidneys
transplanted in elderly RTRs .
Some studies have reported bet-
ter PS with ECD kidneys compared to remaining waitlisted on dialysis.
In the study by Rao et al., elderly recipients aged above 70 years receiv-
ing ECD kidneys had a 25% reduction in overall risk of death compared
with waitlisted candidates
2.Use of donation after circulatory death kidneys and dual kidney
transplants
Another way of expanding the DD pool is the increased use of kid-
neys from donation after circulatory death (DCD) donors. DCD trans-
plantation now accounts for 40% of all DD renal transplant activity in
the UK, although there is marked regional variation.
●Allocation strategies:
In the the Eurotransplant Senior Programme (ESP), RTRs aged
65 years and above are offered kidneys from DDs aged 65 years and
older. Kidneys are allocated locally to unsensitised recipients without
human leucocyte antigen (HLA) matching. 5 year PS and GS were signif-
icantly reduced in the ESP group when compared with recipients aged
60 to 64 years with a donor of any age.
●Use of living donor kidneys:
LD renal transplantation is associated with better PS and GS. Elderly recipients aged 70 years and older had a 57% reduction in mortality following LDtransplant when compared to remaining onthe waiting list.
Balaji Kirushnan
3 years ago
Narrative Review
level of evidence is V
Summary of the article
Elderly are defined age more than 70 years and those between 60 – 69 years in various studies. Overall geriatric care has improved in the last decade and survival rates with comorbidities also seem better in the general population. Elderly patients with ESRD have high mortality and morbidity due to associated cardiovascular disease. Transplantation in the elderly remain a challenge to the nephrologist as careful patient selection is needed to achieve overall outcome
Overall patient survival after transplantation is better while compared to patients waiting on dialysis even at the age of more than 70 years and 60-69 years. There is definite mortality benefit after transplantation, but the relative risk of death is higher in the initial 2 weeks after transplantation due to surgical and infectious complication
It takes longer (mean of 180 days) for the elderly patients to achieve the survival benefit after transplant than younger patients. Careful selection of these patients taking into consideration their comorbidities, frality and cognitive function may improve the outcome. For reasons not clear, the european data reports higher survival than the data from US for elderly transplants and dialysis patients as well, making it difficult to extrapolate the data to the world.
when compared to the younger patients, survival after transplant is poor. Studies have shown mortality rates more in age group more than 70 years than in age group of 60 to 69 years
Graft survival is worse as compared to patients in the younger age group. Elderly patients most likely recieve kidneys from elderly patient which are associated with comorbidities like HTN, diabetes (kidney from ECD).
elderly patients are associated with fewer episodes of acute rejection probably attributed to immunosenescence. They also require a lower dose of the immunosuppressive medications
Elderly patients after renal transplant are known to have more complications of infections and cardiovascular diseases as compared to younger patients
Quality of life was not addressed by many studies, while few studies showed improved quality of life with mental and physical health, many studies did not address this issue
In order to improve the organ donation pool for the elderly recipients, donor with comorbidities with protocol biopsies of the donor kidney was done in many centers. In this way the extended criteria donors were allocated to recipients of elder age in order to increase the pool of organ donation. Few centers used implantation biopsy to allocate kidneys for Dual kidney transplants based on scores of Esker or Remuzzi scores. Other centers in the US, also used KDPI and EPTS scoring for allocation of kidneys with higher KDPI score to elderly donors to optimize the deceased donor renal transplants. However living donor related transplants even in the elderly have the best outcomes, but strategies need to be planned to improve the elderly living donor pool.
Recipient co morbidities increase the immediate post operative complications after transplantation and also the overall mortality at 1 year and 3 years. However the survival rates even after adjusting the presence of co morbidities were seen in few studies
Cognitive impairment and non adhereance to medications remain an area of concern in the elderly with comorbidities, but regular training and role of caregivers can be emphasized to improve the outcomes
Theepa Mariamutu
3 years ago
1- systemic review
2-level 1
3-summary
this systemic review generally analysed studies in elderly concerning outcomes of transplantation in elderly.
1- PS – elderly RTR vs wait-listed on dialysis
-elderly RTR had reduction in mortality and additional survival benefits when compared to dialysis
-time to equal the risk of death is about 125 days and 1.8 years for survival
these data differs form UK and US where dialysis care in UK better than US. UK Study showed no survival benefit for elderly RTR but study in Normay showed elderly still gets survival benefits
2- comparing with young RTR
Patient survival
– higher risk of death vs younger RTR
Graft survival
-worse when compared with younger RTR
-but it can be due to older RTR gets older donor kidneys
-death censoring graft survival – lower compared with young RTR
Acute rejection
-elderly associated with reduced risk of AR
-due to immunoscescence
-but the impact of AR toward Patient survival and graft survival more severe in elderly
Infection rates
-elderly had higher risk of getting infection
-increases linearly RR3.0 to 16.7 over the years
Quality of life
-better health related QOL when compared with remaining dialysis
Outcome based on pre-Tx characteristics
Comorbidities
-mortality increases with comorbodities
-survival benefits reduced from 9.8 years to 6-7.9 years but still better than remaining on dialysis
Frailty
-worse physical function unlikely to get Transplantation but if they gets transplantation still has better survival than remaining dialysis
Cognitive function
– mild cognitive impairment still cab undergo transplantation
– forgetfulness will lead to non adherence to meds and increased risk of missing appointment
Jamila Elamouri
3 years ago
Type of article: Narrative article
As the elderly population increased, more elderly with ESRD and ESRD receiving renal transplantation are increasing worldwide. In the UK about 22% between 60 and 69 years and 8% over 70 years receiving transplantation. In US transplanted elderly represent 18.4% compared with 3.4% in 1990.
Compared with young recipients, older RTRs have lower patient and graft survival. Many factors influence the outcome in these populations, like donor characteristics, immunosuppression regime which is not clearly defined for this category of patients, pre-transplant characteristics such as frailty, cognitive function, and functional status which are not routinely assessed. 3. Overall outcome: 3.1: Comparison of patient survival with patients remaining waitlisted on dialysis:
Although, dialysis outcomes in Europe were improved, and it is better than that in US, overall; the transplantation offers survival benefits after the first 2 weeks, compared to waitlist dialysis patients, in addition to improvement in the quality of life. 3.2: comparison with younger RTRs: 3.2.1: Patients survival:
Elderly recipients are seven times more likely to die with functioning graft than young recipients aged between 18 – 29 years. The main causes of death with functioning graft were cardiac and infection. Overall, causes of death in these recipients are cardiac, infection, and malignancy. 3.2.2: Graft survival:
Graft survival is worse when compared to younger recipients. 3.2.3: Acute Rejection:
There is different relation between acute rejection and the age of the recipient and donor in this category of patients. the AR risk decreases with the increase in the recipient age, which can be, explained by the changes in the immune system related to aging. on the other hand; the AR increases with increasing the donor age, as the kidney from older donors may have a lower regenerative capacity to tissue injury, increasing the immunogenicity. Graft loss after AR was higher compared to younger recipients. 3.2.4: infection rates and associated complications:
Infection is the leading cause of death in the elderly recipients, after cardiac causes. The relative risk (RR) of death due to infection over 24 months increased six-fold in those above 65 years compared to the younger group, independent of the baseline immunosuppression. 3.2.5: Quality of life:
There is a conflict between studies about, Qol in these patients. Some studies show improvement when compared to age- and gender-matched national norms. Others showed a slow recovery in these patients who may be overwhelmed by unexpected comorbidities and medication side effects. Therefore, it is important to clarify expectations of post-transplantation risk and outcome. 4- Outcomes based on donor source 4-1. Waitlist mortality and impact of waiting time on dialysis on patients and graft survival:
Increased waiting time on dialysis affect both graft survival and patient survival. 10 years adjusted GS for DD transplants was 69% for pre-emptive transplants compared to 39% for transplant after 2 years on dialysis. 4.2. strategies to increase the donor pool and impact on outcomes:
Elderly donors’ contribution to kidney donation increased largely recently. Due to age matching criteria, the probability to receive an old LD or an ECD kidney increases with the recipient’s age. 4.2.1. Use of ECD kidneys:
Several studies have reported good results with ECD kidneys transplanted in elderly RTRs. Some studies have reported better PS with ECD kidneys compared to remaining waitlisted on dialysis. Not all studies have shown a survival advantage of ECD kidneys in elderly recipients as compared to waitlisted patients of the same age. 4.2.2: use of donation after circulatory death kidney and dual kidney transplants:
Another way to increase the DD pool in the
The use of kidneys from donation after circulatory death (DCD) donor increased, aiming to increase the DD pool. In the UK (DCD) is higher than donation after brain death (DBD) and elderly RTRs received commonly DCD kidneys from older donors but waited for less for transplantation compared to the UK average. In addition, pre-implantation biopsy to determine marginal kidneys that can be transplanted simultaneously as dual kidney transplantation, and can decrease the waiting time by increasing the DD pool. 4.3. allocation strategies:
In the Eurotransplant Senior Program (ESP) aged 65 years and above are offered kidneys from DDs aged 65 years and older. Kidneys are allocated locally to unsensitised recipients without human leukocyte antigen (HLA) matching. 4.4. Use of living donor kidney
In elderly patients, LD transplantation is associated with an immediate survival advantage in those with comorbidity. Despite this, elderly patients are unlikely to receive LD as they are unwilling to put young donors at risk especially their children. 5. Outcomes based on pre-transplant characteristics
Age per se no more contraindication to kidney transplantation, but careful selection to the recipient and donor kidney needed, in order to avoid death with functional graft. 5.1. comorbidity
Although comorbidity increases mortality risk post-transplantation, elderly recipients still have survival benefits. It significantly predicts survival in elderly recipients but not in those receiving LD kidneys. However, patients with comorbidity still has survival benefit after transplantation as compared with waiting time. CVD even occult in those older than 50 years should be screened for, but the optimal method is not known yet. Screening for infection and malignancy is recommended by most guidelines. Recommended age-appropriate screening for malignancy as that for the general population. 5.2. Frailty
Frailty is different from comorbidity; it is decreased physical function that increases with age, making the elderly more dependent and increasing the risk of death. With the increase in its score, whatever the score used is associated with an increase the mortality post-transplantation. There are no guidelines to indicate a level of frailty at which a patient may be excluded. 5.3. physical function
Functional status can be assessed either subjectively using a certain questionnaire, or objectively using tests of physical performance like gait speed. Lower physical status is associated with increase patient mortality. 5.4. Cognitive function and non-adherence to medication:
Cognitive impairment is not a contraindication to transplantation, but these patients need loge term support after transplantation with regard to medication and follow-up. In conclusion, age is not a contraindication to transplantation, but careful selection and assessment of the patients are critical aspects. LD can be encouraged for the elderly.
AMAL Anan
3 years ago
1- It is a systematic review.
2- level of evidence IB/II.
3- In order to determine post transplantation outcome we must reassess benefits and risks related to elderly renal transplantation.
Comparison between elderly and younger renal transplant:
~ Patient survival:
Elderly recipients have a higher risk of death compared to younger recipients.
The main causes of death were cardiac , infection
and malignancy .
~ Graft survival :
Graft survival in elderly patients is worse when compared to younger recipients. Elderly recipients are more likely to receive kidneys from older donors, which in turn are associated with an increased risk of graft failure .
A potential explanation for the lower risk of graft failure may be that death caused by poor graft function are classified as death with afunctioning graft.
~ Acute rejection:
Elderly recipients are associated with a reduced risk of AR . The effect of age on AR was independent of baseline immunosuppression.
The risk of AR is also dependent on donor age
AR was associated with increased mortality
in those aged above 60 years but not in the younger patients.
>>>Infection rates and associated complications
Elderly recipients are at a higher risk of developing infections. Infections in the elderly are associated with an increased risk ofcomplications.
Infections increase the risk of death censerned to graft failure and this association is higher in elderly RTRs . Both bacterial and viral infections have been reported to be particular problems in elderly recipients. particularly urinary infections, BK viraemia and polyomavirusassociated nephropathy .
>>>Quality of life:
Transplantation is associated with an improvement in the quality of life . greater benefits in mental health and worse physical functioning scores in elderly recipients when compared to younger recipients.
Outcomes based on donor source :
*Waitlist mortality and impact of waiting time on dialysis on patient and graft survival. Increased waiting time on dialysis impacts on both PS and GS. Strategies such as expanded criteria donor
(ECD) and LD transplantation may increase access of elderly patients to transplantation Strategies to increase the donor pool and impact on outcomes
There has been a progressive increase in organs harvested from older donors the likelihood of receiving an old LD or an ECD kidney increases with recipient age Use of ECD kidneys Several studies have reported good results with ECD kidneys transplanted in elderly recipients.
However, the RR of patient death was higher when older ECD kidneys were transplanted in recipients younger than 60 years. ECD kidneys are also associated with an increase in perioperative mortality. Use of donation after circulatory death kidneys and dual kidney
transplants . Another way of expanding the DD pool is the increased use of kidneys from donation after circulatory death (DCD) donors.
Allocation strategies.
In the the Eurotransplant Senior Programme (ESP), RTRs aged 65 years and above are offered kidneys from DDs aged 65 years and older. Kidneys are allocated locally to unsensitised recipients without human leucocyte antigen (HLA) matching. 5 years PS and GS were significantly reduced in the ESP group when compared with recipients aged 60 to 64 years with a donor of any age Use of living donor kidneys LD renal transplantation is associated with better PS and GS . Elderly recipients aged 70 years and older had a 57% reduction in mortality following LD transplant when compared to remaining on
the waiting list LD transplantation is also associated with an immediate survival advantage in patients with comorbidity.
~ Outcomes based on pre-transplant characteristics.
Age is not a contraindication to renal transplantation. However, careful selection of the potential elderly transplant candidate is important due to the increased risk of death with a functioning graft
Comorbidities:
Comorbidity increases the mortality risk after transplantation . Some studies recommended non-invasive stress testing in asymptomatic patients older than 50 years to screen for occult CVD . However, the optimal method
to screen for CVD is not known and there is little evidence to support this recommendation.
Although there is no evidence to asses frailty score for transplant recipients before transplantation, its incidence between 5-9% in people above 65 y and increase to be more than 60% between dialysis patients , which reflects on risk of hospital readmission and increase risk of death independently on age . Post transplant mortality increasing in frail recipients than non frail ones . If Cognitive impairment cause memory impairment in level made patients non-compliant for medication (immunosuppressive medication) will increase risk of graft loss , so early recognition of cognitive function important to keep certain patients on regular appointments for memory prescription .
Professor Ahmed Halawa
Admin
3 years ago
Dear All You have not seen my answer above. It is a systematic review, level 1B. I’m not impressed
Mohammed Sobair
3 years ago
This review article, with level of evidence of V.
It describe transplant outcome in elderly ,which increased dramatically now ,with percent
in UK U22% and 8% of those receiving a renal transplant were aged between 60 and 69
years and above 70 years, respectively AND In the United States , the proportion of
adults aged 65 years and above represent 18.4% of the renal transplant recipients .
Though it’s associated with increased mortality with increasing age, still it’s better than
continuing in hemodialysis.
The study compare outcome in different domain include:
1- Comparison of patient survival with patients remaining waitlisted on dialysis renal
transplantation improves patient survival.
2. Comparison with younger
Patient survival Elderly recipients have a higher risk of death compared to young
. Common cause of death is cardiac disease and infection i.e Death with a functioning
graft was the commonest cause of graft failure in those aged above 65 years accounting
for 61% of graft losses.
Graft survival:
Graft survival in elderly patients is worse when compared to younger recipients. This is
also increased risk of death with a functioning graft. And survival after 5years is similar
or better than young.
3- Acute rejection Elderly recipients are associated with a reduced risk of AR .This due
to immunosenescence.
4- Infection rates and associated complications Elderly recipients are at a higher risk of
developing infections. Both viral and bacterial infection are common.
5- Quality of life:
Transplantation is associated with an improvement in the quality of life.
Paper also discuss strategy to improve donor pool and impact on outcome, which
include:
1-Use of ECD kidneys.
2. Allocation strategies
3- Use of kidney donation after circulatory death kidneys and dual kidney transplant.
4- Use of living donor kidneys.
Outcomes based on pre-transplant characteristics:
Though age is not contraindication, carful patient selection reduce death with function
graft, Assessment of comorbidity, frailty, physical and cognitive function should be
included in the evaluation process.
Nasrin Esfandiar
3 years ago
1. This is a literature review article.
2. Its level of evidence is 5.
3. There is increasing need for kidney transplantation in older patients with ESKD. This literature review article discuss about outcome of elderly patients with kidney transplantation based on donor and recipient characteristics.
First, the overall outcome of elderly patients with kidney transplantation were compared with those remained on dialysis in different studies. Few studies had bias because of comparison of results in UK with USA. Hence, patient survival in elderly patients with kidney transplantation was better comparing those who remained on dialysis.
In comparison with younger recipients, elderly patients showed higher risk of death. With increasing age, patient survival decreased in elderly patients but deaths with functioning graft were increased. The most common reasons for death in this patients were cardiovascular diseases and infections.
Graft survival was lower in elderly patients with kidney transplantation. This can be explained with higher rate of deaths with functioning graft in these patients because in studies based on death- censored graft survival, similar results comparing younger patients were reported.
The more time patients stay with dialysis, the more GS and less Patients survival would be. Hence, some strategies had been used to increase Donor pool. These strategies include ECD and DCD kidneys that performing kidney biopsy help improve the outcome in these kidneys.
Nowadays for allocation, we use indicators such as KDPI and EPTS for deceased donors. Transplantation in elderly patients with kidneys that have higher levels of KDPI compared to patients that stayed on dialysis, had better results. Living donor kidney had better results in almost any age group compared to deceased donor. Compatibilities before transplant had an effect on the outcome in this age group and had heightened the mortality risk. These compatibilities include cardiovascular conditions, malignancy or infections.
For computing the mortality risk in this age group, the Charloson Compatibility Index had been introduced that shows the survival of the patients, especially in elderly patients over 70 years of age.
The older the patients and higher their comorbidity rate, the worse the outcome would be. With an increase in frailty index, we also had an increase in the mortality of patients and no level of frailty would exclude patients in terms of transplantation. Physical activity can be collected by a questionnaire. The older patients and the less their physical activity, the worse their survival rate would be and these patients would benefit from kidney transplantation. Another indicator is Peak Oxygen that would show increased mortality in case if was less than 40 percent. Cognitive function disorders would increase by age that can effect medication adherence and increase the graft loss risk but it wouldn’t be enough to prevent transplantation.
In conclusion, we can say that kidney transplantation in elderly patients is one of the most effective treatments that we should make its outcome better by examining and optimizing the said factors.
Tahani Hadi
3 years ago
Narrative review article that veiw the studies that done on renal transplanted old age group, presented or compared between the risks and benefits and also in compared to younger age group .
Renal transplant recipient (RTR ) especially old age patients should be selected carefully with proper assessment before doing transplantation including clinical assessment, presence of comorbidities and general review of the patient and reveiw all factors that have effect on graft survival and posttransplant outcome.
Regarding overall outcomes both dialysis and transplantation have better outcome in Europe than USA ,but all patients have risk of higher mortality and death in the first 2 weeks post transplant and all have benefits of survival up to 3 years post transplant in compare to those on wait list.
In old age RTR they have higher risk of death than younger patients mainly due to cardiac cause ,infection (bacterial or viral) and malignancy, also graft survival is better in younger patients because old age RTR usually receives kidney from old age donors that will affect on graft function and survival .
Regarding acute rejection studies showed in this article that it was independent of baseline immunosuppression others showed that it’s age dependent.,another point that had been discussed is the infection and it’s complications and risks and most studies approved that rate of death is higher in old age group due to cardiovascular disease then infection, but kidney transplant cause better quality of life and improve general health.
The article review the factors that contribute in kidney transplant outcome:
Donor factors whether living or deceased donor ,age of the donor and HLA match between donor and recipient.
Recipient factors like age ,comorbidities and cognitive and physical function ,all have their effect on transplantation outcome.
Dear All Thank you very much for your contributions.
Nazik Mahmoud
3 years ago
*review article
* level 5 evidence
* In summary the article discuss the benefits versus the risks in transplanting the old patients, the quality of their life it will be better but with high mortality rate ,less graft survival,less episodes of acute rejections but careful assessment should be done in term of physical function, frailty and cognitive function.over all the outcome was good even when using low quality kidneys (expanded criteria donor),the patient should be counselled about the high mortality rate mainly in the first year post transplant.
MICHAEL Farag
3 years ago
· Review article
· Level evidence is 5
Renal transplantation in the elderly
The aim of this review article is to assess the benefits and risks of renal transplantation in elderly RTRs
Outcomes-based on different immunosuppressive regimes are not included in this study
1. Comparison of patient survival with patients remaining waitlisted on dialysis
Transplantation in age group 60-74 has high risk of mortality especially in first 2 weeks so the patient survival is less than compared dialysis patient but this comparison changes with time ; after the first year. The transplantation improves the patient survival compared to dialysis patient
2. Comparison with younger RTRs
a) Patient survival
Elderly recipients have a higher risk of death compared to younger, The main causes of death are cardiac infection and malignancy
b) Graft survival
Graft survival (GS) in elderly patients is worse when compared to younger recipients. However, the reduced GS is more likely a reflection of the increased risk of death with a functioning graft in elderly recipients.
c) Acute rejection
Elderly recipients are associated with a reduced risk of Acute rejection. A lower rate of AR may be due to
changes in the immune system that occur with ageing. Acute rejection has worse outcome on elder age than young recipient.
d) Infection rates and associated complications
elder recipients have high risk to develop infection post transplantation; from other side, infection has poor outcome on this age group.
3. Outcomes based on donor source
Use ECD for elderly people still has the same positive impact of transplantation compared to dialysis patient but this needs proper selection of the recipients who can undergo through ECD to avoid the risk of acute rejection and infection complications in elderly people
4) Outcomes based on pre-transplant characteristics
This has a very important impact on the outcome of kidney transplantation especially in old age group.
Comorbid diseases in crease the risk of mortality after transplantation. The general and physical condition of the recipient; ambulatory patient has better outcome than bed bound or patients with restricted physical activity.
The compliance to medications is very important so we should be sure that the patient will adhere to his post-transplantation medications and this in turn needs persons with proper cognitive function.
Well written.
Re-check for the type of study.
Thank you
Last edited 3 years ago by Ala Ali
Fatima AlTaher
3 years ago
Review article Level of evidence 5 Summary
In many kidney transplantation worldwide ,elderly recipients represent a very few cases , this may be attributed to the special character of this age group as increased prevalence of fraility and other comorbidities as DM , HPN and atherosclerosis as well as increased post operative mortality risk . In their study , Wolfe et al found increased mortality rates among elderly recipients specially during the first two weeks postoperative that became equal between groups after that .(1)
acute rejection rates were lower in elderly recipients may be due to immunescenses and also lower with elderly donors due to decraes immune response to tissue injury that turns the graft more immunogenic .Thus the graft survival was better in elderly due to less acute rejection episodes , in fact many elderly recipient die with functioning graft and the commenst causes for death are CV and infections. (2)
As kidney transplantation offers better quality of live for elder recipients , they can be offered ECD kidneys where the patient survival after ECD transplantation was found better in older recipients than younger ons.(3)
1- Robert A, Wolfe PhD, Valarie B, Ashby MA, Edgar L, Milford MD, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med 1999;341:1725–30
2- Heldal K, Hartmann A, Leivestad T, Svendsen MV, Foss A, Lien B, et al. Clinical outcomes in elderly kidney transplant recipients are related to acute rejection episodes rather than pretransplant comorbidity. Transplantation 2009;87:1045–51. https://doi.org/10.1097/TP.0b013e31819cdddd.
3- Molnar MZ, Streja E, Kovesdy CP, Shah A, Huang E, Bunnapradist S, et al. Age and the associations of living donor and expanded criteria donor kidneys with kidney transplant outcomes. Am J Kidney Dis 2012;59:841–8. https://doi.org/10.1053/j. ajkd.2011.12.014
This is Narrative Review article
Level of evidence 5
It’s aim is to assess the benefits and risks of renal transplantation in elderly RTRs .
Summary
The numbers of transplanted kidney in elderly patients has been increased , in the United Kingdom , the numbers of transplanted reached 22% with age between 60-69 and 8% with age above 70 .
In the United States (US), adults aged 65 years and above received kidney transplant represent 18.4% of the recipients compared to 3.4% in 1990.
Several studies showed increased survival with renal transplant when compared to staying on dialysis with reduction in mortality by 25–78%. even with ECD kidneys , mortality reduced X25%.
For patients older than 70 years, mortality decreased by 41% after renal transplant compared to those maintained on Dialysis .
In spite of improved mortality with transplantation but was associated with an initial increase in mortality compared to remaining In waiting list , in the first 2 weeks which was 2.8 times higher than those remaining on dialysis, then risk of death became equal in both groups at 106 days .
Patients survival in old and young renal recipients :
Old age recipient are in great risk of death compared to younger recipients as showmen by the following studies:
In Karim et al., study following the patients for 4.4 years, the mortality rate in old age group (70-79)was 32% and decreased to 22% for those aged 60–69 years, while 6% for those younger than 50 years.
They found the main causes of death were cardiac causes (21%) then infection (21%) and lastly malignancy (20%) .
In other study by Heldal et al., the 5 year Patient survival for Renal transplant recipients was 56% in recipients with age above 70 years compared to 72% in those recipients aged 60–69 years while reached 91% in those aged between 45 and 54 years .
In the study by Huang et al., 2 years patient survival in recipients age above 80 was73% and was 86% in age 70–79 years compared to recipients aged 60–69 years which was 89% , also compared to the Patient survival for whom on dialysis aged 80–84 years was 44%.
Older patients are 7 times more likely to die with a functioning graft compared with younger patients aged 18–29 years .
Graft survival :
elderly patients has graft survival less than younger recipients , as they are more likely to receive kidneys from older donors, so they are associated with an increased risk of graft failure .
Acute rejection:
Elderly patients with kidney transplants are associated with a reduced risk of Acute rejection , which was 19.7% compared to 28% in those aged 18_29 years old .
This explained by the effect of aging on immune system .
In spite that the effect of acute rejection on Patient and graft survival may be more severe in the elderly transplant patients .
Meier-Kriesche et al., study showed that graft loss associated with acute rejection after 5 years post-transplant in patients aged 65 years or more years is 3 times more than those aged 18–35 years .
Infection rates and associated complications:
The older patients are at a higher risk of developing infections, which increase risk of complications.
Both bacterial and viral infections have been reported to be particular problems in elderly RTRs particularly urinary infections, BK viraemia and polyoma virus associated nephropathy.
Quality of life
there is improvement in the quality of life in elderly patients with renal transplant compared to those still in waiting list on Dialysis.
Outcomes based on pre-transplant characteristics
Age is not a contraindication to renal transplantation but we still in need for careful selection of the potential elderly transplant candidate which is very important to avoid the increased risk of death with a functioning graft.
Rania Mahmoud - Suspended
3 years ago
It is a systematic review , level of evidence 2
Summary
-In the United Kingdom (UK), 22 percent and 8% of people who received a kidney transplant were between the ages of 60 and 69 years and over the age of 70 years.
When compared to dialysis, there was a survival advantage at all ages .Older RTRs have a lower patient and graft survival rate than younger receivers
-The goal of this narrative review is to evaluate the advantages and dangers of renal transplantation in elderly RTRs by looking at (a) overall results as well as outcomes based on donor source and (b) pretransplant features.
-Articles are limited to publications between 2005 and 2018.
-Those who had a transplant lived an average of 5.3 years longer than those who stayed on the waiting list at 65–69 years old, and 3.7 years longer at 70 years and beyond.
Even after adjusted for race and comorbidities, dialysis outcomes in Europe were better than in the US in the late 1990s, with an RR of death that was 33% higher in the US.
-The 5-year DCGS was 89 percent in 301 RTRs over the age of 70, which was equivalent to senior patients aged 60–69 years and control patients aged 45–54 years.
-Survival of the patient when compared to younger RTRs, elderly recipients have a greater chance of death. The leading causes of death were cardiac (21 percent), infection (21 percent), and cancer (20 percent )
– Elderly recipients had a lower risk of AR
-Meier-Kriesche et al. found a progressive decrease in the incidence of AR in the first 6 months after transplantation according to age in a sample > 73,000 RTRs.
-The AR rate was 28% among those aged 18–29 years old, compared to 19.7% for those aged 65 and more.
-Immunosenescence, or changes in the immune system that occur with aging, may explain why there is a reduced rate of AR.
-Infections are more likely to affect elderly receivers.
-The most common cause of death in older RTRs was cardiovascular disease (CVD), which had a death rate of 37 per 1000 patients per year , followed by death from infection, which had a death rate of 16.7 per 1000 patients per year.
-Those over 60 years old had a 10.5 percent death rate compared to 4.4 percent for those between 18 and 65 years old
-Infections raise the likelihood of death-censored graft failure, which is more common in elderly RTRs
-Other studies revealed larger advantages in mental health and lower physical functional grades in senior RTRs as compared to younger recipients
-Transplantation is connected with an improvement in quality of life except for those patients who lost their graft, all subgroups of patients experienced a significant improvement in their QOL 2 years following transplantation
-The annual death rate for all patients on the waiting list fluctuates between 5 and 10% generally, but it rises dramatically in dialysis patients over the age of 65.
-Strategies such as (ECD) and living donor (LD) transplantation may make transplantation more accessible to elderly patients.
-In the first two weeks after transplantation, ECD recipients had a 5-fold higher risk of perioperative mortality than standard therapy recipients (standard criteria donor [SCD] kidneys and remaining on the waiting list
-Due to the increased risk post transplantation, screening for infection and malignancy should also be included in the work-up of older renal transplant candidates. Comorbidity increases the mortality risk following transplantation.
-The recommendation based on this study: Patients with ESRD who are elderly should be evaluated for transplantation.
Last edited 3 years ago by Rania Mahmoud - Suspended
Mujtaba Zuhair
3 years ago
Systematic review , level of evidence 2
this article reviews the outcome of transplantation in the elderly and compare it with dialysis and transplantation in the younger age groups.
Renal transplantation in elderly improves survival when comparing it with dialysis , despite the increased risk of death early after transplantation.
Elderly patient with kidney transplantation had lower patient survival and graft survival when compared with younger age groups , and the most common cause of death is cardiovascular followed by infection.
Acute rejection rate was lower in the elderly , since elderly’s immune system is weaker , a process may referred as immunosenescent. But the effect of acute rejection on graft and patient survival was worse in the elderly, with increased graft loss and increased mortality in older patients who had acute rejection.
The risk of Infection also increased in the elderly and the complication and mortality also increased. The quality of life is improved in the elderly kidney transplant recepients.
Also the study shows increased uses of ECD in the elderly , and better patient survival in the elderly who received ECD kidneys compared with dialysis. Old donor kidneys for old recepients.
Donation after circulatory dearth DCD is increasing the deceased donor pool and the use of kidney biopsy may increase the DD pool furthermore by using dual kidney transplantation.
Thank you all Yes, it is a systematic review, well done.
Amit Sharma
3 years ago
1. What is the type of this study?
It is a review article, a systematic review, involving literature search in multiple databases.
Although the authors, in the introduction of the article, have described this article as a narrative review.
2. What is the level of evidence this study provides?
As this is a systematic review, the level of evidence is level II (as the study includes a number of cohort studies/ registry studies, no direct randomized control trial)
3. In your own words, summarise the outcome of this study!
Kidney transplant has a survival advantage over dialysis. Elderly patients account for 20 to 30% of total renal transplants. This study was done to evaluate the outcomes of kidney transplantation in elderly.
Comparing elderly transplant recipients with those remaining on dialysis, there is a definite advantage in terms of mortality. Even with ECD kidneys, the mortality reduction was 25% in the elderly as compared to remaining on dialysis, although the results were better with standard criteria deceased donor (SCD) kidneys. This reduction in mortality was seen even at age more than 75 years, although there was increased mortality initially due to post-operative complications.
In comparison with younger kidney transplant recipients, elderly patients had lower patient and graft survival but the death censored graft survival were similar. Risk of acute rejection was lower while the risk of infections was higher in the elderly recipients. Infections increased risk of death in elderly by 6 times as compared to younger recipients. Lesser acute rejection was seen in elderly recipients receiving older kidneys as compared to younger recipients receiving older kidneys. Better results in elderly recipients were observed with a live donor kidney, similar to a SCD kidney. Kidney transplant led to markedly improved quality of life in the elderly recipients.
Patients with longer dialysis vintage had poorer outcomes. Donation after cardiac death (DCD) kidneys as well as dual kidney transplant (DKT) have been used in elderly. Old kidney for old patients transplants have decreased patient and graft survival with increased acute rejection rates, although delayed graft function (DGF) and cold ischemia time is reduced. Risk of death one year post transplant is 2 times in elderly than in younger recipients, but it increases to 5 times in elderly with co-morbidities. Similarly, the mortality risk as well as risk of DGF is higher (2 times) in frail patients and those with poor physical function. Cognitive dysfunction needs to be addressed as it has an impact on long-term graft function.
The recommendations for renal transplant in elderly include encouraging patients for transplant, case by case approach with emphasis on frailty and physical function, keep looking for a living donor but ready to choose even an ECD kidney if living donor not available, an informed decision and a comprehensive post-transplant support system.
Last edited 3 years ago by Amit Sharma
Mohamed Essmat
3 years ago
This article is mostly a systematic review of level 2 evidence , as it included more than big cohort study as we as meta analysis too.
This article cited a multiple of dependable studies regarding transplantation of elderly .
In brief transplantation has no limit relatively , transplantation of elderly through proper regimens and selection , care of comorbidities , care of pre and post transplant periods especially early post transplant period the ,post operative 2 weeks , are important for better patient survival .
patient survival is overall better compared to those on dialysis , with increased risk post op., equal to those on dialysis at 244 days and then better after , mortality s more in elderly compared to those young transplant individuals especially those older than 70 , depending on comorbidities and the graft quality .
Graft survival is worse when compared to young , the fact that most of the elderly receive older grafts or deceased or ECD which are still better for survival compared to those on dialysis based on most of the studies done .
Cause of death is mostly due to cardiac causes, infections and malignancy .
Acute rejection is relatively less in elder transplant population than young , due to immunesensce ;variation of immunity with age , But the Acute rejection risks and effects on elderly survival and graft survival as well are higher than that of young population ; meaning that acute rejection usually doesn’t occur in elderly compared to young recipients but when it does it’s more lethal .It’s directly proportional with the age of the donor graft.
Quality of life is better than dialysis
living donor graft is the best
frailty of elderly should always be kept in mind
Number of older ESRD is increasing ,Nearly half of all new patients are older than 65 years and one third are older than 70 years.
Renal transplantation is the best option of treatment proved to increase not only patient survival but also quality of life.
Older patients have lower patient and graft survival than younger patients but still better than patients on dialysis.
pre-emptive transplants have higher graft survival than patients after 2 years on dialysis.
Most common causes of death in elderly patient are cardiovascular ,infections and malignancy.
Donor characteristics greatly affects the outcomes of transplantation and older patients mostly will receive an older deceased donor kidney and less likely to receive a living donor kidneys.
The the optimal immunosuppression combination in elderly patients is unclear as they are naturally immuncompromized changes
in the immune system that occur with ageing referred to as immunosenescence.
Elderly patients have lower risk for acute rejection than younger patients in the first 6 months posttransplantation.
The effect of age on acute rejection was independent of baseline immunosuppression , older patients tend to reject less.
Acute rejection also is affected by the age of doner older Kidneys from older donors may have a lower regenerative capacity to tissue injury increasing immunogenicity.
Death due to infection over 24 months increased six-fold in recipients above the age of 65 years compared to the younger group and this was independent of baseline immunosuppression.
Different bacterial and viral infections have been reported elderly recipients particularly urinary infections, BK viraemia and polyomavirus-associated nephropathy (PVAN) .
•Strategies to increase the donor pool and impact on outcomes
°ECD
Strategies such as expanded criteria donor ECD and LD transplantation may increase access of elderly patients to transplantation and decrease number of patients on waitliste.
Several studies have reported good results with ECD kidneys transplanted in elderly recipients studies have reported better patient survival with ECD kidneys compared to remaining waitlisted on dialysis.
° Donation after circulatory death kidneys and dual kidney transplants
DCD transplantation now accounts for 40% of all DD renal transplant activity in the UK.
DKTs with single kidney transplants in elderly recipients, DKT recipients had a higher rate of venous graft thrombosis but a similar rate of early surgical revisions, signifcantly higher glomerular filtration rate (GFR) at 24 months and a shorter waiting time .
°living donor kidneys
Elderly patients most likely will receive kidneys from older living donors , studies showed that living donor transplantation has better effect in patient and graft survival.
outcomes based on pre-transplant evaluation of patients
comorbid conditions and Chronic diseases increase mortality risk.
frailty: is associated with reduced physiologic function increase dependency and/or death. The prevalence is between 5 and 9% in people aged above 65 years, although this increases to 60% in patients with ESRD on dialysis.
These patients have a 60% DGF and are more liable to rejection risk with using of low doses of MMF. there is no guidelines to indicate the level of frailty at which the patient is considered non-transplantable.
physical function
poor physical function associated with increased mortality.
Bad physical function was associated with higher 3-year mortality and the association was particularly strong in elderly recipients .
cognitive factors
Mild Impairment of cognitive function isn’t contraindication for transplantation but these patients need extra care and help after transplantation
forgetfulness associated with non-intentional non adherence to medications.
Akram Abdullah
3 years ago
It is a narrative review, , level of evidence 5.
1-There is no upper age limit for renal transplantation, successful outcomes have been described even in octogenarians.
2-Survival rate for elderly recipients is better with kidney transplant than patients remain on dialysis or waiting list .
3-Older kidney transplant patients have an improvement of quality of life, increased length of hospitalization & readmission , increased risk of death with a functioning graft (mostly due to cardiovascular disease ,or infection), increased risk of infection & malignancy but fewer acute rejection.
4- Older donor kidneys would be better placed in older recipient.
5- Expanding the diseased donor pool by using grafts from extended criteria donors , donation after circulatory death & dual kidneys from marginal organs , all are reasonable to be used for elderly recipient .
6- Assessment of comorbidity , frailty, physical & cognitive functions should be involved in the evaluation process .
7-Assessment of cardiovascular disease for all elderly recipients.(routine stress test)
8-Eldely recipients should seek a living donor option especially if there is along wait for diseased donor kidney.
Dear All It is a systematic review level IB/II. There is a reward for the 2 colleagues (Nadia Ibrahim and Hamdy Hegazy) who put in an effort and did not go with the flow.
Nadia Ibrahim
3 years ago
· Systematic Review
· Level 1A Summary of the outcome: 1. Patient survival in elderly is improved among elderly aged above 60ys underwent renal transplantation rather than those maintained on dialysis by 5.3 years for those aged 65–69 years and 3.7 for those aged 70 years and above
2. Compared to younger RTRs aged 18 t0 29 years, eldery are more prone to risk of death with a functioning graft
3. Elderly RTRs receive kidneys from older donors resulting in increased chance for graft failure
4. Immunosenescence occurs with aging decreases exposure of elderly RTRs to episodes of acute rejection regardless the baseline immunesuppression received , however , the older the donor the more immunogenic the graft due to lower capacity of regeration after tissue injury
5. Elderly recipients are at a higher risk of developing infections which is considered the second common cause of mortality after CVD. Common infections include urinary infections, BK viraemia and polyomavirusassociated nephropathy (PVAN,
6. Transplantation is associated with a better quality of life including physical functioning, bodily pain, general health, vitality and social functioning when compared with dialysis patients
7. The need for DD as a main source for kiney transplantation among elderly has significantly im=ncreased the waiting list among those patients leading to worse patient survival and graft survival. ECD is now considered away to overcome that problem.
8. Elderly RTRs may benefit from receiving ECD kidney Tx with a positive outcome reported on patient survival compared to those waitlisted on dialysis. However some studies reported that increasing donor age was associated with lower PS in all adult age groups
9. For eldery reciepients receiving kidneys from donation after circulatory death (DCD) donor is a reasonable option,however associated with higher rate of venous graft thrombosis
10. Although elderly patients have a poor chance to receive a kidney from living donor than younger patients, LD renal transplantation is associated with better PS and GS and can improve the general condition in patients with comorbidities.
Age is not a contraindication to renal transplantation yet age-related comorbidities are considered a relative contraindications as it is considered a risk factor of death with a functioning graft. Screening for infection, malignancy and CVD should be included in the work-
Dear Nadia Excellent, it is a systematic review level IB/II. Well done. You read it and analysed it very well. You are the winner of this original textbook (Original in a PDF format – not a pirate copy). Please send me an email to receive your reward.
You need to explain to us first why it is a systematic review to receive your reward.
Dear All
You have not noticed my comments above and followed each other blindly (except Dr Hamdy Hegazy and Dr Nadia Ibrahim)
thank you dear professor, Im honored to explain why it is a systematic review . This article was answering certain target research questions, answers were formulated through searching the literature . relevant researches and studies were selected , reviewed and underwent critical appraisal,. Data were collected, analysed and presented in a comparative form.
MOHAMMED GAFAR medi913911@gmail.com
3 years ago
its a rivew article
level of incidence 5
Kidney transplantation remains the optimal treatment of end stage renal disease. The incidence of end stage renal disease among older population becoming more prevalent and despite old age, these patients are still considered candidates for kidney transplantation and age is not a contraindication.
Kidney transplantation is associated with better quality of life, better survival rate, better cardiovascular outcomes when comparing to dialysis regardless of patient’s age, comorbidities, HLA mismatch and kidney donor profile index.
Elderly recipients have a higher risk of death following surgery compared to younger RTRs. The main causes of death were cardiac, infection and malignancy. Elderly patients are seven times more likely to die with a functioning graft compared with patients aged 18–29 year
Elderly recipients have lower patient and graft survival compared to younger recipients and are more likely to die with a functioning kidney allograft. As a result, death censored graft survival may be similar to or even better than younger patients. One study demonstrated that with every decade increase in the age, death censored graft survival has increased progressively
A study show that incidence of acute rejection early after transplant decrease as the age of recipient increase, this may be due to immunosenescence (changes in immune system with ageing.
While other study reported that acute rejection rate increases with increased age of donor.
a way to increase donor resources is to transplant after circulatory death ( DCD) which now account for 40% of deceased donation.
dual kidney transplant is a good option for elderly transplant , as 2 marginal kidneys increases GFR significantly but may be associated with increased risk of vascular thrombosis .
living donors are good option for elderly and are associated with better patient and graft survival.
Last edited 3 years ago by MOHAMMED GAFAR medi913911@gmail.com
Wessam Moustafa
3 years ago
This is a literature review
Level of evidence is V
Authors of this article ,reviewed studies involving elderly transplant since 2005 to 2018
They were assessing overall outcome after transplantation of elderly population and they concluded that :
* transplantation improves survival of elderly compared to staying on dialysis with 61% reduction in mortality rates
* when compared to younger populations , mortality is higher in elderly with main causes of death including cardiac events , infections and malignancy , with increased rates of death with functioning graft in elderly
*incidence of graft survival was worse in elderly ,but this may be due to increased rates of Death with functioning graft which is common among elderly
* incidence of acute rejections in elderly is lower , due to phenomenon known as immunosenescence,
However this incidence may increase with increasing the donor age .
acute rejections had deleterious effects on graft and patient survival ( particularly I’m elderly)
*Incidence of infections in this age group is higher and is associated with more complications, compared to younger patients
* Quality of life in most of studies improved significantly after transplantation for all age groups
* The longers that a patient stays on dialysis ,the poorer the patient and graft survival after transplantation ( favoring pre emptive tx)
*most of studies concluded that ECD improves survival of elderly populations, compared to remaining on dialysis , some studies didn’t conclude such benefit as in Italy 2012 where outcomes of using ECD was worse than staying on dialysis .
*a way to increase donor resources is to transplant after circulatory death ( DCD) which now account for 40% of deceased donation.
* dual kidney transplant is a good option for elderly tx , as 2 marginal kidneys increases GFR significantly but may be associated with increased risk of vascular thrombosis .
* living donors are good option for elderly and are associated with better patient and graft survival.
Age is not a contraindication for transplantation, but patients should be carefully selected , and assessment should include co morbidities, physical and cognitive functions
The aim of this review is to assess the benefits and risks of renal transplantation in elderly.
The outcome of the study can be summarized in the following points:
Comparing renal transplantation to patients on dialysis waiting list:
Renal transplantation provided a better survival benefit and quality of life to the elderly when compared to those remaining on the dialysis waiting list. However , the relative risk of death was high in the early post transplantation period.
Comparing elderly to the younger renal transplant:
Despite the lower patient and graft survival(as they more likely to receive grafts for older donors).Sill transplantation is a better option than remaining on dialysis. The main causes of death are cardiovascular causes, infections, and malignancy .
Elderly are more likely to die with functioning grafts so the death-censored graft survival (DCGS) is similar, or even better when comparing elderly to younger patients .
On the contrary, the rate of acute rejection was lower in elderly due to immunosenescence giving a room to decrease immunosuppression doses to avoid their deleterious effects, However, the impact of acute rejection episodes was higher on both patient and graft survival when compared to the younger transplanted patients.
Outcomes based on donor source:
Due to limited donor pool, elderly has to wait more on dialysis and this impacts both patients and graft survival. Accordingly a number of strategies were implemented to increase the donor pool like using use of ECD kidneys, donation after circulatory death kidneys and dual kidney transplants, encouraging living donation and implementing better allocation strategies using both the KDPI and EPTS score .
Out comes based on pre-transplantation characteristics:
Advancing age is not a contraindication for renal transplantation but meticulous pre-transplant work up should focus on proper selection of suitable candidates to avoid the increased risk of death with a functioning graft. This can be done through proper assessment for any comorbidities, frailty, functional performance, psychological and cognitive state
Comparison of patient survival with patients remaining waitlisted on
dialysis
1)In older patients, renal transplantation improves patient survival (PS) when compared to those who remain on dialysis waiting lists.
2)Patients aged 60–74 years experienced a 61 percent reduction in death and a four-year increase in expected life years.
Comparison with younger RTRs
A)Patient survival
When compared to younger RTRs, elderly receipients had a greater chance of death.After a median follow-up of 4.4 years, the death rate for those aged 70–79 years was 32 percent, and 22 percent for those aged 60–69 years, according to Karim et al. This compares to 6% for those < 50 years. Cardiovascular disease (21%),malignancy (20 percent ) and infection (11%) were the leading causes of mortality.
B)Graft survival
When compared to younger receivers, elderly individuals have a lower graft survival rate. Elderly patients are more likely to receive kidneys from older donors, which is linked to a higher risk of graft failure. The lower graft survival in the elderly is more a reflection of the increased risk of death with a functioning graft since death censored graft survival is same or even better as compared to younger receipients.
C) Acute rejection
Recipients above the age of 65 have a lower risk of developing AR.The AR rate was 28% among those aged 18–29 years old, compared to 19.7% for those aged 65 and more.Immunosenescence, or changes in the immune system that occur with age, may explain why there is a reduced rate of AR.The risk of AR is also dependent on donor age.With each cohort of rising recipient age, the incidence of AR decreased, while it increased with each decade of increasing donor age. Kidneys from older donors may have a decreased regeneration capability, making them more immunogenic.Acute rejection was linked to a higher risk of death in people over the age of 60, but not in those under the age of 60.
D)Infection rates and associated complications
Infections are more likely to affect elderly receipients.Infections among the elderly are linked to a higher risk of complications.
E)Quality of life
Transplantation was linked to improved health-related QOL and Significantly improved physical performance, bodily pain, overall health, vitality, and social function as compared to Patients on dialysis have a higher mortality rate .
Outcomes based on donor source
A)Waitlist mortality and impact of waiting
Increased duration on dialysis prior to transplantation was related with worse PS in RTRs aged >70 years.
B)Strategies to increase the donor pool and impact on outcomes
Strategies such as extended criteria donor (ECD) and LD transplantation may make transplantation more accessible to elderly individuals.
C)Use of ECD kidneys
When compared to standard criteria donor [SCD]), ECD recipients had a 5-fold higher risk of perioperative mortality in the first two weeks after transplantation.However, After three years, individuals who received an ECD kidney had a 17 percent reduction in death w hen comparing ECD kidney to standard therapy. Because of the elevated risk throughout the perioperative phase, the cumulative risk is higher and Until 3.5 years, survival did not match that of the conventional therapy group after transplantation.
D)Use of donation after circulatory death kidneys and dual kidney
transplants
E) Allocation strategies
RTRs aged
65 years and above are offered kidneys from DDs aged 65 years and
older.Kidneys with a KDPI of b20% will be offered to patients
with an EPTS of 20% or less. Recipients of high KDPI kidneys have increased
short-term but decreased long term mortality risk with a
“break-even point” of 18 months for kidneys with a KDPI of 81–90%.
F)Use of living donor kidneys
If there is a significant wait for a DD kidney, elderly recipients should consider an LD option.
Outcomes based on pre-transplant characteristics
A)Comorbidity
After a transplant, comorbidity raises the risk of death.With waiting times of up to three years, individuals with comorbidities still had a survival benefit from transplantation.non-invasive stress testing to detect occult CVD in asymptomatic patients over the age of 50
age-appropriate screening for malignancy as recommended for the general population should be done.
B)Frailty
Frailty is not the same as disability or comorbidity. It’s linked to decreased physiologic function, which raises a person’s risk of developing increased dependency and/or death..
A commonly
used score is the one based on the phenotypic model of physical
frailty which consists of !ve items: weight loss, weakness, exhaustion,
walking speed and physical activity.Frailty leads to increased risk of post tx mortality,increased length of stay post tx and also impacts graft outcomes.
C)Physical function
assessed by tools such as short form-36 or physical function subscale.Despite the fact that individuals with the worst PF had a lower post-transplant survival rate, transplantation was associated with a survival benefit in every function when compared to dialysis.
D)Cognitive function and non-adherence to medication
Memory and executive function impairments require long-term support after transplantation, including assistance with making clinic visits and methods to help remember medicines.
Recommendations
1)Transplantation should be considered for elderly patients with ESRD.
2) Predictive tools should not be utilised to determine who may and cannot be transplanted on their own.
3)Potential kidney transplant candidates should be carefully evaluated.
4) The evaluation should involve a look at comorbidities, frailty, and functional status and cognitive performance.
5)Renal transplant candidates over the age of 65 should be warned about the higher risk of death in the first year following transplantation compared to dialysis for the rest of his life. This risk is influenced by a number of factors, including comorbidities and the source of the donor.
6)Patients should be informed that the chance of survival takes longer to equalise When compared to younger recipients after renal transplantation.
7)Patients should be urged to accept an LD kidney if DD is not available even if a kidney of inferior quality is used
regarding the level of evidence provided by this article.
I think it is level II a because it has reviewed a lot of cohort studies, registry study (I am not sure, what kind of study it should be), and registry data.
I have reviewed my colleagues answers, I am not sure what are the reasons for opting to level V and level I?
In your own words, summarise the outcome of this study!
This article had conducted a systematic review of many cohort studies in order to assess the overall outcomes of renal transplantation in above 65-year-old recipients.
The above-mentioned intended outcomes included the following:
A/ Comparison of patient survival with patients remaining waitlisted on dialysis:
Patient survival of elderly RTRs has improved when compared to that waitlisted-on dialysis. Wolfe et al. concluded patients aged 60–74 years had a 61% reduction in mortality.
B/Patient survival in comparison with younger RRTs:
Elderly RTR s have higher risk of death compared to younger RTRs.
Karim et al. concluded the mortality rate was 32% for those aged 70–79 years, 22% for those aged 60–69 years and 6% for those below 50 years. The main causes of death were cardiac (21%), infection (21%) and malignancy (20%).
Graft survival in comparison with younger RRTs:
Graft survival (GS) in elderly patients is worse when compared to younger recipients. Elderly recipients are more likely to receive kidneys from older donors, which in turn are associated with an increased risk of graft failure. However, the reduced GS is more likely a reflection of the increased risk of death with a functioning graft in elderly recipients since death-censored graft survival (DCGS) is similar, or even better, to younger patients.
Acute rejection in comparison with younger RRTs:
Elderly recipients are associated with a reduced risk of AR.
Heldal et al. showed recipients above70 years old had an AR rate of 35% at 12 weeks after transplantation compared to 45% in those aged between 45 and 54 years. A lower rate of AR may be due to changes in the immune system.
Infection rates and associated complications in comparison with younger RRTs.
Elderly recipients are at a higher risk of developing infections and increased risk of complications.
The relative risk of death due to infection over 24 months increased six-fold in those above the age of 65 years compared to the younger group and this was independent of baseline immunosuppression.
Both bacterial and viral infections have been reported to be particular problems in elderly RTRs particularly urinary infections, BK viraemia and polyomavirus- associated nephropathy (PVAN).
Quality of life in comparison with younger RRTs:
Quality of life is improved after renal transplantation.
Rebollo et al. showed transplantation was associated with better health-related QOL and significantly better physical functioning, bodily pain, general health, vitality and social functioning when compared with dialysis patients.
QOL has also been assessed before and after transplantation.
Laupacis et al. concluded except for those patients who lost their graft, all subgroups of patients had a marked improvement in their QOL 2 years after transplantation.Qualitative studies such as those by Pinter et al. showed that some elderly RTRs may experience a slow recovery and they may be overwhelmed by un- expected comorbidities and medication side-effects.
It is important to clarify expectations of post-transplantation risks and outcomes.
4. Outcomes based on donor source in comparison with younger RRTs:
4.1. Waitlist mortality and impact of waiting time on dialysis on patient and graft survival
Patient and graft survival are affected by the time on dialysis.
Use of ECD kidneys
Rao et al. concluded elderly recipients aged above 70 years receiving ECD kidneys had a 25% reduction in overall risk of death compared with waitlisted candidates.
Use of donation after circulatory death kidneys and dual kidney transplants A single centre study from Cambridge, UK, with the highest proportion of DCD to dona- tion after brainstem death (DBD) kidney only transplants in the country showed that elderly RTRs received predominantly DCD kidneys from older donors but waited less for transplantation compared to the UK average. Pre-implantation biopsy may also help expand the DD pool by determining which marginal kidneys can be transplanted simultaneously as a dual kidney transplant (DKT). Mendel et al. comparing DKTs with single kidney transplants in elderly recipients, DKT recipients had a higher rate of venous graft thrombosis but a similar rate of early surgical revisions, significantly higher GFR at 24 months and a shorter waiting time. The authors concluded that DKT is a reasonable option in elderly RTRs.
Use of living donor kidneys
LD renal transplantation is associated with better PS and GS.
Outcomes based on pre-transplant characteristics:
Age is not a contraindication to renal transplantation.
careful selection of the potential elderly transplant candidate is important due to the increased risk of death with a functioning graft.
Comorbidities:
Comorbidity increases the mortality risk after transplantation.
Gill et al., the average increase in the life expectancy for RTRs was 9.8 years but this was lower in recipients with comorbid conditions assessed at time of dialysis initiation ranging from 6 to 7.9 years.
Frailty:
Frailty is associated with reduced physiologic function that increases an individual’s vulnerability for developing increased dependency and/or death.
Candidates who become frailer have an increased risk of post-transplant mortality and higher odds of length of stay of 2 weeks or more after renal transplantation.
DGF was seen in 30% of frail patients who presented for a renal transplant as compared to 15% in non-frail recipients.
Physical function:
Reese et al. concluded worse physical function was associated with higher 3-year mor- tality and the association was particularly strong in elderly RTRs.
Cognitive function and non-adherence to medication:
Impaired memory may lead to unintentional non-adherence of IS medications which is associated with an increased risk of graft loss. Those with memory problems will need help to remember prescriptions and clinic appointments.
Dear Hamdy Excellent, it is a systematic review level IB/II. Well done. You read it and analysed it very well. You are the winner of this original textbook (Original in a PDF format – not a pirate copy). Please send me an email to receive your reward.
Dear All
You have not noticed my comments above and followed each other blindly (except Dr Hamdy Hegazy and Dr Nadia Ibrahim)
Dear All
You are just describing Narrative reviews by copying others. Please respond to the questions to the point.
Last edited 3 years ago by Professor Ahmed Halawa
Sherif Yusuf
3 years ago
Review article
Level of evidence 5
In UK 30 % of renal transplant recipients are elderly> 60 years
Renal transplantation improve survival and QOL of the majority of ESRD patients including elderly
Although mortality is higher in elderly compared to young transplant recipient, but it is lower than waitlisted patients on regular hemodialysis this become apparent after 1 year post transplantation
Elderly < 70 years and not > 70 years has higher mortality and higher incidence of graft loss if they receive ECD kidney compared to those who received deceased SCD kidney. Living donor kidney is always preferred, as it is associated with better graft survival, Moreover, ECD kidneys are associated with perioperative complications, delayed graft function, and mortality, despite that elderly are less likely to receive living donor kidney when compared to young.
Receiving kidneys from younger donor is associated with better graft survival, despite that elderly usually receive kidney from older donors.
Although graft survival is lower in elderly when compared to young, this may reflect an increase in risk of death with functioning graft rather than true graft failure since elderly are 7 times more prone to die with functioning graft when compared to young.
Elderly has lower rate of acute rejection episodes than young because of immunosenecense, but the outcome related to acute rejection is more severe (graft loss)
Elderly recipients are at a higher risk of developing infections (viral or bacterial ) which with cardiovascular disease constitute the most common causes of death in renal transplant recipients
Preemptive renal transplantation is associated with better outcomes when compared to those who initiate hemodialysis.
Assessment of comorbidities, frailty (which is assessed using 5 items : weight loss, weakness, exhaustion, walking speed and physical activity) and cognitive impairment is very important since they are associated with poor graft survival and increased mortality.
Weam Elnazer
3 years ago
Narrative Review
weak evidence(level 5)
The goal of this narrative review is to evaluate the advantages and dangers of renal transplantation in elderly RTRs by looking at (a) overall results as well as outcomes depending on donor source and (b) pretransplant features.
The results of other immunosuppressive regimens are not included in this research but are provided in a separate review. These findings are used to make practice recommendations.
a survival advantage across all ages when compared to staying on dialysis.
However, it is important to Reevaluate the advantages and dangers of kidney transplantation in older patients, since age remains a significant role in post-transplantation outcomes.
Older RTRs had a poorer patient and graft survival rate than younger receivers. Furthermore, dialysis survival has increased since the late 1990s. Donor characteristics also impact transplant results, with elderly RTRs having a higher chance of receiving an older deceased donor (DD) kidney and a lower chance of receiving a live donor (LD) kidney.
In older patients with ESRD, pre-transplant parameters such as frailty, functional status, and cognitive function are not regularly examined. Finally, in older RTRs, the best immunosuppressive mix is unknown.
following are some recommendations based on this review:
• Transplantation should be considered for elderly individuals with ESRD.
• Predictive techniques should not be utilized to determine who may and cannot be transplanted on their own.
• A thorough assessment of possible renal transplant candidates should be carried out.
• Comorbidities, frailty, functional status, and cognitive performance should all be assessed throughout the evaluation.
• Renal transplant candidates over the age of 65 should be warned about the higher risk of mortality in the first year following transplantation as compared to dialysis. This risk is influenced by a number of variables, including comorbidities and the source of the donor.
• Patients should be advised that, as compared to younger recipients, the risk of survival following kidney transplantation takes longer to equalize.
• Donating a kidney while you’re still alive should be promoted.
Doaa Elwasly
3 years ago
1-This study is a narrative review study
2-level of evidence is 5
3-To summurise
Patient survival in the elderly transplanted patients is much higher than those patients on dialysis waiting list as demonstrated by multiple studies.
Mortality risk of elderly transplanted patients is increased in the first 2 weeks postransplantation if compared to patients on dialysis but the mortality risk decreases for transplantated patients if compared with dialysis patients on the long term .
Regarding patient survival elderly recepiants has higher mortality risk compared to younger ones ;the former group are 7 times more likely to die with a functioning graft in comparison to young aged recipents. Cardiac diseases, infection and malignancy are the main causes of death.
Graft survival in elderly recepients is less than that for younger recipients could be attributed to receiving kidneys from older donors.
Death -censored graft survival (DCGS) is similar, or could be better, in older recepiants with lower acute rejection rates in the elderly compared to younger patients may be due to immunosenescence .
Infections especially urinary infections, BK viraemia and polyomavirus[1]associated nephropathy (PVAN) were reported in elederly recipents .
RTR patients had a marked improvement in their quality of life especilay 2 years postransplantation
Studies stated that increasing time on dialysis pretransplantation was associated with worse patient survival outcome.
Those receiving an ECD kidney had reduction of overall mortality compared to standard therapy and particularly in those aged above 60 years ,
Studies concluded that DKT is a suitable choice for elderly recepiants.
the Kidney Donor Profile Index (KDPI) score and the Estimated Post-transplant Sur[1]vival Score (EPTS) are recently applied in USA for graft allocation where a low KDPI for a graft is associated with better function and a low EPTS score is associated with a longer patient survival.
Recepiants over 60 years from older than 65 years LD had comparable GS to SCD kidneys and higher GS and PS compared to ECD kidney recepiants.
Screening for certain diseased is crucial in transplant reciepnt evaluation pretransplanting such as
CVD,
infection
malignancy
physical frailty assessment which consists of five items: weight loss, weakness, exhaustion, walking speed and physical activity
physical function
Cognitive function and adherence to medications
Conclusion : Age is not an obstacle for renal transplantation with favourable outcomes just proper pretransplantation assessment is mandatory.
Heba Wagdy
3 years ago
Narrative review
level of evidence V
The number of elderly patients undergoing renal transplantation is increasing in the US
Elderly patients survival after transplant vs elderly patients survival in waitlist on dialysis:
Renal transplant in elderly improves patient survival and decrease mortality rate when compared to elderly patients on dialysis.
relative risk of death is higher during first 2 weeks after transplantation in elderly
one study from UK revealed equal survival rate in elderly receiving transplant and on dialysis
Elderly vs. younger renal transplant recipient: Patient survival:
mortality rate is more in elderly recipients due to cardiac causes, infections & malignancy.
The commonest cause of graft failure in elderly >65 years is death.
Graft survival:
elderly have increased risk of graft failure due to receiving kidneys from older donors
they have higher risk of death with functioning graft
Acute rejection:
A study show that incidence of acute rejection early after transplant decrease as the age of recipient increase, this may be due to immunosenescence (changes in immune system with ageing)
While other study reported that acute rejection rate increases with increased age of donor
Infection rate & associated complications:
Infection is more common in elderly recipients
Relative risk of death from infections in elderly >65 years is 6 times that in younger patients.
Risk of death censored graft failure increase by infection especially in elderly recipients
Particular infections are urinary infection, BK viremia & polyomavirus associated nephropathy
Quality of life:
A study reported that elderly & young patients have marked improvement of quality of life 2 years after transplantation
Some studies showed that elderly are more vulnerable to side effects of medications
Outcomes based on donor source: Waitlist mortality & waiting time:
Rate of death is higher in elderly patients on dialysis.
In deceased donor transplants, 10 year graft survival was higher in pre-empetive transplant than transplant after 2 years of dialysis
Methods to increase donor pool:
Use of extended criteria donor kidneys: A study showed 25% decrease in risk of death in recipients aged >70 years with marginal kidneys compared to similar age group on dialysis
Use of donation after circulatory death decrease the waiting time
Dual kidney transplant is an option in elderly recipients
some studies suggest that older recipients should receive older donor kidneys
Allocation strategies:
Euro transplant senior program: patients >65 years receive kidney from deceased donor >65 years, unsensitized recipient receive kidneys without HLA matching that caused significant decrease in patient and graft 5 year survival
New allocation scheme in the US is based on kidney donor profile index score and estimated post transplant survival score where patients with EPTS <20% recieve kidney with KDPI <20%
A study showed that mortality risk is less in elderly having KDPI >85% than those on dialysis waiting for lower KDPI kidneys
Use of living donor kidneys:
living donor transplant in elderly has lower mortality risk than those in waitlist
Living donor provide better survival in all age groups
Outcomes based on pre transplant characters:
There is a higher risk of death with functioning graft in elderly Comorbidities:
comorbid conditions decrease life expectancy post transplant, mortality rate at one year is 10% in elderly and 10-20% in presence of comorbidities.
Some studies estimate mortality risk and life expectancy according to comorbidities
Frailty:
Decreased physiological functions leading to increased dependency &/or death, occurs in > 60 of patients on dialysis
increases risk of post transplant mortality, prolonged hospital admission and delayed graft function
Assessed by weight loss, weakness, exhaustion, walking speed & physical activity and should be included in assessment of elderly pre transplant.
Physical function:
In elderly transplant recipients poor physical function is associated with increased 3 year mortality and decreased patient survival
It is assessed by questionnaire of physical function subscale and objective tests as gait speed, grip strength, short physical performance battery and peak oxygen uptake
Cognitive function:
Mild cognitive impairment & decreased rememberness may lead to decrease compliance to immunosuppression therapy leading to increased risk of graft loss.
Recommendations:
Elderly patients should be arranged for transplantation with careful evaluation, not only by predictive tools but also with assessment of comorbidities, frailty, functional status and cognitive function
elderly candidates should know the high risk of death in the first year post transplant and to be encouraged to receive lower quality kidneys to decrease waiting time.
Nandita Sugumar
3 years ago
Narrative review.
Level of evidence 5.
Summary of outcomes
Patient survival rate is higher when patients undergo renal transplantation in comparison with remaining on the waitlist while undergoing dialysis regularly. However, the fact remains that the risk of mortality post renal transplantation is higher within the immediate 2 week period. The rate of mortality risk is equalized between the two groups (transplant and dialysis -waitlist groups) only around 100 days.
Elderly recipients have a greater mortality risk in comparison with younger recipients of renal transplant. The most common cause of death in older recipients with death with functioning graft, with the trigger being cardiac disease and infection.
Graft survival is also found to have lower rates among the elderly recipients in comparison with younger recipients. This could be contributed by the fact that elderly recipients receive organs from older donors in comparison with the younger recipients who have a chance of getting younger donors.
Elderly recipients have a reduced risk of acute rejection. This could be because of the changes in the immune system with increasing age of the recipient, this process is known as immunosenescence. The risk of AR is also dependent on the age of the donor.
Although this is the case, if AR occurs in elderly recipients, it can have a more significant and negative impact and could be fatal with graft loss or death, while in younger recipients the impact may not leads to death.
Infection incidence is higher in the elderly group. This also leads to complications such as death censored graft failure, urinary infections, BK viremia, and PVAN or polyomavirus associated nephropathy.
Transplantation increases the quality of life quotient in these patients, with better physical functioning, reduction in bodily pain, increase in general health standard, vitality and social functioning in comparison with remaining on dialysis.
Esmat MD
3 years ago
This study is a narrative review article with lowest level of evidence (level 5) The percentage of old patient with ESKD who receive kidney transplantation is increasing and reach up to 22% of those receiving transplant in some countries with good accessibility. It seems kidney transplantation shows survival advantage over different ages compared being in the waiting list. Even renal transplantation improves patient survival in elderly patients, as many studies have demonstrated may lead to 4-5 extra life years in contrast to those who remained in the waiting list. But some issues should be taken in to consideration and an assessment of benefits and risks for every individual patient should be done. Donors and recipients characteristics may influence the outcome of kidney transplantation. On the other hand, survival in patients on dialysis has improved in many countries in recent years. Elderly recipients have lower patient and graft survival compared to younger recipients and are more likely to die with a functioning kidney allograft. As a result, death censored graft survival may be similar to or even better than younger patients. One study demonstrated that with every decade increase in the age, death censored graft survival has increased progressively. Risk of acute rejection s lower in elderly recipients may be due to lower immune response that is defined as immunosenescense and depends on the recipient’s age as well, but the consequences of acute rejection are worse than in younger recipients. Infection with CVD, are the most causes of death after kidney transplantation and these are more prominent in elderly recipients. Kidney transplantation is associated with improvement in the quality of life in elderly recipients like younger recipients. Increasing time spent on dialysis is associated with worse patient and graft survival outcome. Good results with ECD kidneys transplanted in elderly recipients were reported. Receiving allograft from DCD donors and dual kidney transplantation are other ways to reduce the time spending on dialysis for elderly patients. Overall, new allocation systems utilize KDPI and EPTS, and more effectively match graft life expectancy with patient life expectancy. Living donor kidney transplantation is associated with excellent PS and GS in elderly recipients, although they have less probability of receiving living donor allograft. Although age per se is not a contraindication for kidney transplantation, the elderly transplant candidate’s characteristics such as frailty, comorbidities, life expectancy, physical and mental function should be considered.
A narrative review might not have clarity on the methods used as well as the selection criteria and it has a wider scope than the systematic reviews
Ibrahim Omar
3 years ago
this article is a narrative review, descriping the outcome of renal transplantation in elderly pts.
its level of evidence id 5
summary :
unfortunately, elderly pts with ESRD are increasing in numbers worldwide in paralell with increasing their comorbidities. as renal transplantation is the best option of ttt for ESRD pts, this has created a more greater demand for kidney donors who are already lacking. this article described the outcome of this therapy in those elderly pts.
the conclusion was as folowing :
1- Renal transplantation is still the best ttt for those elderly pts with ESRD and should be offered to them. However, the multiple comorbidities should be taken into a serious consideration and candidates are carefully selected.
2- patient and graft survival are lower in those elderly pts, if compared to these of young pts.
3- patient survival for transplanted elderly pts is lower in the 1st year, if compared to remaining on hemodialysis. after the 1st year, the survival will be better for transplanted pts.
4- optimum immunosuppression in transplanted elderly pts is still unclear as the risk benefit ratio is different than in other pts.
This is review article with level of evidence 5. Many conclusion could be drawn from this extensive review. The increase in life expectancy in the developed countries was associated with increase comorbidities including DMII, hypertension, vascular diseases and coronary artery disease. With the increase in vascular related diseases, the incidence of chronic kidney diseases and end stage renal diseases are becoming more and more prevalent and problematic especially with the increase in economic burden related to health care system. The improvement in renal medical care and developments in renal replacement therapies does not improve the overall survival as expected.
Kidney transplantation remains the optimal treatment of end stage renal disease. The incidence of end stage renal disease among older population becoming more prevalent and despite old age, these patients are still considered candidates for kidney transplantation and age is not a contraindication. Kidney transplantation is associated with better quality of life, better survival rate, better cardiovascular outcomes when comparing to dialysis regardless of patient’s age, comorbidities, HLA mismatch and kidney donor profile index.
In UK, around 30% of all kidney transplantation is done in the age group older than 60 years. In USA 18.4% of kidney recipients are 65 years and older. This statistics opened the door for more kidney transplantation in this elderly age group especially that most encountered patients with ESRD are elderly with estimation of 38% of CKD population in USA aged more than 65 years.
This review article was designed to study the outcomes of kidney transplantation in elderly recipients, in terms of patients survival, graft survival comparing to younger kidney recipients and taking in consideration kidney donor source.
Transplantation was associated with an initial increase in mortality in the first few weeks following transplantation with an increase relative risk of death 2-4 times comparing to patients on dialysis, which became equal in both groups at around 100 days and the likelihood of survival equalized at 8 months. It took longer for those aged between 60 and 74 years to reach these points.
Elderly recipients have a higher risk of death following surgery compared to younger RTRs. The main causes of death were cardiac, infection and malignancy. Elderly patients are seven times more likely to die with a functioning graft compared with patients aged 18–29 years.
Graft survival in elderly patients is worse when compared to younger recipients because older patients are getting more kidneys from EDC or from old donors from SDC.
Elderly recipients are associated with a reduced risk of AR and this was independent of baseline immunosuppression. Lower rate of AR is attributed to immunosenescence.
Elderly recipients are at a higher risk of developing infections. There was a linear increase in death due to infection in the waitlisted group which was increasing with age group more than 65 years.
Quality of life Transplantation is associated with an improvement in the quality of life in terms of social, psychological and physical activities.
Increased waiting time on dialysis impacts on both PS and GS, GS for DD transplants was much more higher for pre-emptive transplants compared to for transplant after 2 years on dialysis.
Use of ECD kidneys Several studies have reported good results with ECD kidneys transplanted in elderly RTRs. Some studies showed that elderly recipients aged above 70 years receiving ECD kidneys had reduction in overall risk of death compared with waitlisted candidates.
Use of living donor kidneys LD renal transplantation is associated with better PS and GS in all group ages including patients above 65 years.
Ahmed Faisal
3 years ago
1. It is a narrative review
2. Level of evidence 5
—————————————————————–
3. Summary
OUTCOME of KIDNEY TRANSPLANTATION in the ELDERLY
(I) OVERALL OUTCOME
● In comparison to those on dialysis (waitlisted for transplantation) —–> Patient survival (PS)
. Improvement of PS.
. Reduction of mortality rate, however some authors reported that there is increase of mortality rate initially after transplantation especially the first two weeks.
. Equal survival rate becomes clear after average 8 months (244 days). The duration differs according to the age, which is longer with older patients.
. Increase of expected extra life years (by 5.3 years for younger than 70 and 3.7 for above 70 years)
————
● In comparison to younger renal transplant recipient (RTR):
☆ Patient survival:
. Death risk in higher in elderly
. Mortality rate is increased with increased age
. Death with a functioning graft is about 7 fold increase in elderly and considered as the main cause of graft loss in above 65 years.
. Cardiac disease and infection are the principle causes of death.
☆ Graft survival (GS)
. GS is more worsen in elderly (they received older donor Kidneys)
. Higher risk of graft failure.
. Some authors reported that death-censored graft survival (DCGS) is that same among ages from younger than 50 to older than 65 years.
☆ Acute rejection (AR)
. AR is lower with older age of recipients, while it is higher with older age of donors.
. AR ,as a cause of graft failure, is more incident in elderly by about 3 folds and leads to high mortality rate in this age group.
☆ Infection
. Elderly renal recipients have a more incidences of infection which is considered the second cause of death in this group (linear association) regardless the immunosuppressive agents used.
. UTI , BK virus and polyomavirus-associated nephropathy (PVAN) are the common infections.
☆ Quality of life (QOL)
. Better QOL is evident with transplantation physically, mentally and socially.
————————————————————
(II) OUTCOME based on DONOR SOURCE
☆ TIME on DIALYSIS
. The longer duration on dialysis, the more worse rate of patient survival, so living donor and extended criteria donor (ECD) transplantation are helpful in decreasing time on waiting list for transplantation.
. Pre-emptive kidney transplantation has a better outcomes for graft survival than transplantation after dialysis for 2 years.
—————-
☆ Extended criteria Donor (ECD)
. One of the resources to enlarge the pool of donor to shorten the waiting list for transplantation.
. Kidneys of ECD has a greater PS and lower risk of death than those on dialysis.
. PS is decreased with older donor age.
. ECD kidneys from older than 70 years has a lower rates of PS and GS than these from younger age (50-69 years).
Surprisingly, transplant of older ECD Kidneys into younger recipients ( Eurotransplant Senior Programme (ESP)
65-year or older recipients received DD kidneys of 65-year or older regardless the matching of HLA.
°(ESP recipients have a lower rate if PS and GS than younger recipients (60-64) from any age groups)
• US ——>
Kidney Donor Profile Index (KDPI) score and the Estimated Post-transplant Survival Score (EPTS)
LOW score of KDPI —–> better graft function
LOW score of EPTS —–> better patient survival
——————–
☆ LIVING DONOR KIDNEYS (LD)
. It has a higher rate of PS and GS.
. There is more than 50 % decease in mortality rate in 70-year recipients from LD than those waiting on dialysis.
. It has a better outcomes than ECD.
. Elderly recipients account of small percentage of recipients of LD kidney transplantation.
————————————————————
(III) OUTCOMES based on PRE-TRANSPLANT CHARACTERISTICS
. Elderly candidates for transplantation (regardless of age) should be meticulously selected and assessed according to many factors such as the comorbidites, physical activity and cognitive functions.
☆ Comorbidity
. Comorbidity is associated with high mortality rate and low life expectancy after transplantation. Therefore, screening for cardiovascular diseases, malignancy and infection is recommended before transplantation.
. Charlson Comorbidity Index is a prediction method for determining mortality risk and life expectancy after transplantation.
☆ Frailty
. Frailty means reduction of physiological functions and increasing of dependency.
. Frailty score depends on 5 parameters; physical activity, walking speed, exhaustion, weight loss and weakness.
. High score is predictive of high risk of DGF and mortality rate.
☆ Physical functions (functional status)
. It is evaluated by either by questionnaire of the patient or objective assessment by grip strength, gait speed, short physical performance battery (SPPB) or peak oxygen uptake ( VO²).
. Deceased physical activity is linked to low percentage of patient survival and high mortality rate.
☆ Cognitive functions
. Impairment of cognitive functions, mainly memory, is connected to non-adherence of immunosuppressive and therefore graft loss.
• Transplantation for elderly ESRD patients is a better option than dialysis in terms of longer patient survival and better quality of life, in spite of the higher risk of mortality in the transplantation, particularly in the first year of transplantation which relay on comorbidites of recipients and donor Kidneys.
• Living donor transplantation has a better outcomes than deceased donor transplantation. However, if LD is not accessible, transplantation of kidneys with extended criteria has a better outcomes than dialysis.
• Meticulous evaluation of potential elderly recipients before transplantation is an essential step to predict the outcome.
You have not seen my answer above. It is a systematic review, level 1B. I’m not impressed
Dalia Ali
3 years ago
Review article
Evidence 5
Renal Transplantion in elderly
Renal Transplantation improve the long term survival and quality of life of most patients including older patient but still There is significant
Comorbidities
Screening Tool may help to identify Suitable candidate for transplantation using data from french national registry (REIN)
The following point system are
●Male (1 point)
●Age 75 to 80 years (2 points)
●Age 80 to 85 years (5 points)
●Age >85 years (9 points)
●Diabetes (2 points)
●Intermittent hemodialysis (2 points)
●Peripheral vascular disease, stage III to IV (5 points)
●Congestive heart failure, stage I to II (2 points)
●Congestive heart failure, stage III to IV (4 points)
●Arrhythmia (2 points)
●Chronic respiratory disease (2 points)
●Active malignancy (5 points)
●Severe behavioral disorder (6 points)
●Cardiovascular disease (1 point)
●Decreased mobility (needs assistance for transfers) (4 points)
●Totally dependent (9 points)
●Body mass index (BMI) 21 to 25 (1 point)
patients with a score of 0 to 6 points, the probability of being alive within three years was approximately 70 percent.(1)
Out come
1-Patients survival
higher risk of death in elderly recipients.
The main causes of death are
1-infection.
2-cardiovascular disease
3-malignancy
death with functioning graft account for majority of graft loss in older candidate
2 -Graft survival
because Elderly recipients are more likely to receive kidney from older donors So this will lead to high risk of graft loss
3-acute rejection
Older renal transplant recipients were less likely than younger recipients to have Biopsy-proven acute rejection
Prevention of rejection is generally easier in older patients due to natural immunosenescence allowing reduced dosage of immunosuppressant medication.
Immunosuppressant dose reduction in older renal transplant recipients has been associated with improved recipient and graft survival, reduction in cardiovascular risk, reduced drug side effects and cost savings
However, if they do experience acute rejection, this episode is more likely to compromise graft- and or patient survival
4 -infection and cardiovascular disease
Most infections occur in the first six months post transplant and are related to the degree of immunosuppression. A greater degree of immunosuppression results in an increased risk of infectious complications in all patients (young and old). However, as previously mentioned, immunocompetence decreases with age; as a result, older individuals are more susceptible to infectious complications at lower levels of immunosuppressive therapy. Agents associated with the highest infection risk are high-dose glucocorticoids and anti lymphocyte antibodies used in the induction immunosuppressive regimen.
– Even in the absence of immunosuppression, older subjects have an increased risk of cardiovascular disease and an increased risk of cardiovascular-related death. In addition, some risk factors for heart disease, such as hypertension and diabetes mellitus, may be exacerbated or induced by immunosuppressive medications.
5-Donors sources
out comes with kidney from older living donors are acceptable and better than DD.
A living-donor kidney is preferred, if it is available. Among all recipients, including older adults, living-donor kidneys are associated with better patient and graft survival compared with deceased-donor kidneys. The use of a living-donor kidney allows for preemptive transplantation before the candidate needs to start dialysis. Among most patients, preemptive transplantation is associated with superior outcomes compared with transplantation after initiation of dialysis.
because older candidates wait more time on waiting list so we need to increase donors pool to include
1-ECD
2-DD ((DCD donation after circulatory death,DBD donation after brain death))
Reference
1-Update Oct 2021.
Mahmud Islam
3 years ago
as a narrative review, it has level evidence of five
summary:
the ratio as the outcomes is different among countries. Transplanting patients over 75 years is not performed in some countries. speaking in general, transplanting is better and favorable to staying on dialysis. A transplant from extending criteria donors is still better than maintaining dialysis. Successful transplant especially in the elderly is dependent on many factors. recipients should be evaluated in the aspect of comorbidities cognitive function and fragility. frail patients were found to have less favorable results. either transplanted from deceased of living, elder or young, recipients had better outcome compared to dialysis. in terms of quality of life, the same observations are seen. a living donor is better than a deceased donor. patients with accompanying comorbidities had a worse prognosis. the dual transplant was associated with venous thrombosis. elderly should be evaluated for transplant when eligible and thorough evaluation, pretransplant is essential for better outcomes.
You have not seen my answer above. It is a systematic review, level 1B. I’m not impressed
Assafi Mohammed
3 years ago
Type of this study:
Systematic Review ( as it reviewed articles published between 2005 and 2018).
Level of evidence :
Level 1a
Summary:
The study aimed at assessing the benefits and risks of renal transplant in elderly RTRs by assessing overall outcomes and outcomes based on donor source and pre-transplant characteristics.
Renal transplantation improves patient survival (PS) in elderly patients when compared to those remaining waitlisted on dialysis.One of the reviewed articles (Wolfe et al)stated that the transplantation was associated with an initial increase in mortality and risk of death in the first 2 weeks with 2.8 times as high as those remaining waitlisted on dialysis. Another reviewed article(Gill et al) showed that the expected extra life years is much higher in RTRs than those waitlisted on dialysis . Study by (Wolfe et al) may be explained by the good and perfect services given to dialysis patients in the study area (UK) as dialysis services and outcomes are known to be better than in USA.
The systemic review evidenced that the Elderly recipients have a higher risk of death compared to younger and the main causes of death were cardiac (21%), infection (21%) and malignancy (20%){Karim et al}. Overall patient survival for elderly RTRs above the age of 70 was less than PS for those in 60-69 years and death with a functioning graft was common in those above 65 (Huang et al).
The followings are worse among elderly RTRs in comparison with younger recipients;Patient Survival(PS) Graft survival (GS),Infection rates. While elderly RTRs are associated with a reduced rate of acute rejection (Meier-Kriesche et al). Death-censored graft survival (DCGS) in elderly RTRs is similar, or even better, to younger patients (Heldal et al).
Increased waiting time on dialysis impacts on both PS and GS(Meier- Kriesche et al) and strategies such as expanded criteria donor (ECD) and LD transplantation may increase access of elderly patients to transplantation (https://doi.org/10.2215/CJN.03490410.Not) all studies have shown a survival advantage of ECD kidneys in older recipients compared to patients of similar age remaining waitlisted and this could be due to better survival rates for patients on the waiting list because of optimum dialysis services and patient care in some study areas as explained earlier, adding to that some studies assess the impact of ECD kidneys in different recipient age groups.
Strategies to increase the donor pool and impact on outcomes are:
use of ECD kidneys.
Use of donation after circulatory death kidneys and dual kidney transplants.
Allocation strategies.
Use of living donor kidneys.
Age is not a contraindication to renal transplantation. However, careful selection of the potential elderly transplant candidate is important due to the increased risk of death with a functioning graft.Assessment of comorbidity, frailty, physical and cognitive function should be included in the evaluation process.
Based on data analysis and review this systematic review article recommended the followings:
Elderly patients with ESRD should be considered for transplantation.
Predictive tools should not be used on their own to decide who can
and cannot be transplanted.
A careful evaluation of potential renal transplant candidates should be
undertaken.
Evaluation should include assessment of comorbidities, frailty, functional status and cognitive function.
Elderly renal transplant candidates should be counselled about the increased risk of death in the first year after transplantation compared to staying on dialysis. This risk is dependent on various factors including comorbidities and donor source.
Patients should be informed that it takes longer for the risk of survival to equalise after renal transplantation when compared to younger recipients.
Living kidney donation should be encouraged.
If a LD kidney is not available,patients should be encouraged to accept
a lower quality kidney to reduce the waiting time on dialysis.
1.1. It is a review article
2. level of evidence 5
3. Summary for outcomes of renal transplantation in the elderly:
Renal transplantation improved patient survival in the elderly when compared to those remaining waitlisted on dialysis but there is an increase in mortality within the first 2 weeks and became equal in both groups in 106 days and the likelihood of survival equalized at 244days according to Wolfe et al study. A study from the UK did not show elderly patient survival not improved with renal transplantation.
Elderly recipients have a higher risk of death compared to the younger renal transplanted recipient. They are more commonly died with functioning grafts. the most common causes of death cardiac disease, infections, and malignancy in Karim et al study.
The graft survival is reduced in elderly patients in comparison to the younger renal transplanted recipient because they received a donation from an older patient that is associated with graft failure.
In the study by Molnar et al, the resulting death–censored graft failure risk was reduced which is explained by deaths caused by poor graft function are classified as death with functioning graft.
Elderly recipients are associated with reducing the risk of acute rejection that due to change of immune system with aging(immunosenescence)but it increases with the increase of donor age. They have a high risk of infection and its complications.
Elderly recipients have better physical function, social functioning, and general health.
Increasing time on dialysis before transplant is associated with poor patient and graft survival but some studies showed better patient survival with extended criteria kidney compare to remaining on dialysis.
The deceased donation can be expanded by using kidneys from donation after circulatory or brain death in elderly patients. Living donor transplant recipient has better patient survival than deceased donor transplant recipient.
Elderly patients need proper assessment for cognitive function, frailty, comorbidities, and physical functions for renal transplantation.
Ban Mezher
3 years ago
Narrative review article
Level 5
In the last 2 decades the elderly patients with ESRD have improved survival on dialysis, but still renal transplantation is the treatment of choice even in old age patients. But some aspects should be considered during evaluating these patients, as co morbidities( which is common in elderly), mental health, physical activity, frailty & social performance.
several studies show that both patients & graft survival are better compared to dialysis patients. Although in early post transplantation period the patient & graft loss are high but after first year of transplantation both patient & graft failure & acute rejection rate are lower.
All types of kidney donor are better in outcome including deceased standard donor, ECD, DCD and live donor ( show immediate graft advantage even in patients with co morbidities.
Huda Al-Taee
3 years ago
review article
level of evidence 5
in this article the author described the risks and the benefit of transplanting elderly patients and he described the outcome of transplanting such age group of patients.
the number of elderly patients with ESRD is increasing worldwide. studies showed survival benefit of transplanting such patients compared to dialysis. elderly patients should be evaluated thoroughly to assess the risks and the benefit of transplantation & to obtain a suitable balance between the risks and the benefits.
transplanted elderly patients have lower survival benefit as compared to younger patients.
overall outcomes:
compared to dialysis patients, there will an improval in the rate of survival.
compared to younger recipients: patient survival is lower in elderly. main cause of death is cv disease, infection,malignancy. graft survival: worse in elderly.
acute rejection: the risk is lower in elderly, donor age have an effect on acute rejection risk
infection rates and associated complications: elderly have high rate of infection, both bacterial and viral infections have been reported especially UTI, BK virus
quality of life: transplantation improves quality of life.
outcomes based on donor source:
waitlist mortality and dialysis waitting effect on patient and graft survival: increased mortality noticed on long time on listing or on dialysis. strategies such as ECD or LD may increase access of these elderly patients to transplantation.
strategies to increase donor pool: a. EDC: controversy about survival benefit on survival. b. DCD: studies showed that using such donor will lead to decrease waitlisting time.
allocation strategies: Eurotransplant senior offer elderly patients a kidney from a donor with the same age. for the non sensitized patients organ offered without HLA matching so acute rejection rate is high and patient and graft survival are low.USallocation uses KDPI & EPTS scores to increase allograft survival. new US allocation uses DCD & DBD and will match patient & graft survival.
use of live donors: will increase survival compared to DD.
outcomes based on pre-transplant characteristics:
comorbidities: increase mortality risk.
frailty: increase patient dependency and death, rejection risk to to the use of low doses of MMF. there is no guidelines to indicate the level of frailty at which the patient is considered non-transplantable.
physical function: poor physical function associated with increased mortality.
cognitive factors: forgetfulness associated with non-intentional non adherence to medications.
You have not seen my answer above. It is a systematic review, level 1B. I’m not impressed
Asmaa Khudhur
3 years ago
This is Narrative Review article
Level of evidence 5
The aim of this review is to assess the bene!ts and risks of renal transplantation in elderly RTRs by assessing (a) overall outcomes and outcomes based on (b) donor source and (c) pre- transplant characteristics.
Overall outcomes
Comparison of patient survival with patients remaining waitlisted on dialysis
Renal transplantation improves patient survival (PS) in elderly patients when compared to those remaining waitlisted on dialysis
Transplantation was associated with an initial increase in mortality with a relative risk (RR) of death in the !rst 2 weeks which was 2.8 times as high as those remaining waitlisted on dialysis.
Comparison with younger RTRs
Patient survival
Elderly recipients have a higher risk of death compared to younger RTRs
Elderly patients are seven times more likely to die with a functioning graft compared with patients aged 18–29 years
Graft survival
Graft survival (GS) in elderly patients is worse when compared to younger recipients. Elderly recipients are more likely to receive kidneys from older donors, which in turn are associated with an increased risk of graft failure
Acute rejection
Elderly recipients are associated with a reduced risk of AR
A lower rate of AR may be due to changes in the immune system that occur with ageing referred to as immunosenescence , The risk of AR is also dependent on donor age.
the frequency of AR declined with every cohort of increasing recipient age and it increased with every decade of increasing donor age. Kidneys from older donors may have a lower regenerative capacity to tissue injury in- creasing immunogenicity.
The impact of AR on PS and GS may be more severe in the elderly RTR.
Infection rates and associated complications
Elderly recipients are at a higher risk of developing infections. Infections in the elderly are associated with an increased risk of com- plications.
Both bacterial and viral infections have been reported to be particular problems in elderly RTRs particularly urinary infections, BK viraemia and polyomavirus- associated nephropathy (PVAN)
Quality of life
Transplantation is associated with an improvement in the quality of life (QOL)
Outcomes based on donor source
Waitlist mortality and impact of waiting time on dialysis on patient and graft survival:
Increased waiting time on dialysis impacts on both PS and GS.
Strategies such as expanded criteria donor (ECD) and LD transplantation may increase access of elderly patients to transplantation .
Outcomes based on pre-transplant characteristics
Age is not a contraindication to renal transplantation. However, careful selection of the potential elderly transplant candidate is important due to the increased risk of death with a functioning graft. Guidelines include age-related comorbidities as relative contraindications and some use a minimum post-transplantation life expectancy between two and 5years as a contraindication to waitlisting .Assessment of comorbidity, frailty, physical and cognitive function should be in- cluded in the evaluation process.
The narrative review article (as this article) take publications from limited period of time (in this article from 2005 to 2018) while in systematic review it is more comprehensive and take articles through extended period of time .
Narrative literature review articles are publications that describe and discuss the state of the science of a specific topic or theme from a theoretical and contextual point of view. … Systematic literature review articles are considered original work because they are conducted using rigorous methodological approaches.
This study is a narrative review. It takes a less formal approach compared with systemic reviews because narrative reviews do not present the more rigorous aspects that are seen in systemic reviews such as search terms, reporting methodology, database used, and inclusion and exclusion criteria. The given review does present a certain level of methods used but it isn’t as comprehensive and detailed as in every stage involved as would be the case with systemic reviews.
You have not seen my answer above. It is a systematic review, level 1B. I’m not impressed
Riham Marzouk
3 years ago
Narrative Review , level of evidence 5
It discuss the benefit versus the risks of renal transplantation in old age recipient , taking the into consideration donor source and donor criteria.
Renal transplantation is safe procedure can be done in elder patient but after good selection of them depends on their comorbidities and the donor source also.
The candidate should be assessed well as regard comorbidities, cognitive function, psychological status, his adherence to medications.
Of course, his quality of life will be better after transplantation than being on dialysis, but he should know that there is increased risk of death with functioning graft especially early after transplantation more than being stay on dialysis.
The old candidate has low immunological response , so the percent of cellular rejection is lower than younger age candidate who have stronger immune system.
Donors may be live or deceased , and complications of deceased donor should be clarified and explained to the patient especially if old age donor.
What is the type of this study?
Systemic review.
What is the level of evidence this study provides?
Level 1
In your own words, summarise the outcome of this study!
Renal transplantation is safe and effective in carefully selected elderly kidney transplant recipients .The donor source and waiting time on dialysis are important determinants of post transplant outcomes. The pre transplant assessment should take into account the presence of co-morbidities , frailty ,physical and cognitive function .
Overall outcomes;
1-Comparison of patient survival with patients remaining waitlisted on dialysis.
Most of studies showed better patient survival in kidney transplanted elderly recipient when compared to those remaining on dialysis .
2- Comparison with younger RTRs.
A-Patient survival.
Elderly recipients have a higher risk of death compared to younger RTRs.
B- Graft survival.
Graft survival (GS) in elderly patients is worse when compared to younger recipients.
C- Acute rejection.
Elderly recipients are associated with a reduced risk of AR.
D- Infection rates and associated complications.
Elderly recipients are at a higher risk of developing infections.
E- Quality of life .
Transplantation is associated with an improvement in the quality of life .
Outcomes based on donor source;
1-Waitlist mortality and impact of waiting time on dialysis on patient and graft survival.
Increased demand for DD renal transplantation has led to longer waiting periods and this is significant since the annual mortality rate for all patients on the waiting list varies between 5 and 10% worldwide but increases greatly in older patients on dialysis .
2-Strategies to increase the donor pool and impact on outcomes.
There has been a progressive increase in organs harvested from older donors .
3-Use of ECD kidneys.
Several studies have reported good results with ECD kidneys transplanted in elderly RTRs. Older recipients benefit from accepting a lower quality organ early after ESRD.
4-Use of donation after circulatory death kidneys and dual kidney transplants.
DKT is a reasonable option in elderly RTRs.
5-Allocation strategies.
In the Euro transplant Senior Programmed (ESP), RTRs aged 65 years and above are offered kidneys from DDs aged 65 years and older. Kidneys are allocated locally to unsensitized recipients without human leukocyte antigen (HLA) matching.
Benefit of high KDPI kidneys was greatest in recipients older than50 years and in those centers with a waiting time longer than 33 months.
A new scheme introduced in the UK will allocate all kidneys from both DBD and DCD donors and will more effectively match graft life expectancy with patient life expectancy.
6-Use of living donor kidneys .
LD renal transplantation is associated with better PS and GS.
Outcomes based on pre-transplant characteristics;
1-Comorbidities.
Co morbidity increases the mortality risk after transplantation.
2-Frailty.
Frailty is distinct from disability and co morbidity. It is associated with reduced physiologic function that increases an individual’s vulnerability for developing increased dependency and/or death.
3-Physical function .
Functional status can be assessed by measurements relying on patient’s self-report of ability to perform a certain task. Although patients with the worse PF had a worse post transplantation survival, transplantation was associated with survival benefit when compared to dialysis in every function quartile. Objective tests of physical performance include gait speed, grip strength or the short physical performance battery.
4-Cognitive function and non-adherence to medication.
Cognitive impairment does not necessarily preclude transplantation but it is important to recognize.
1.Systematic review
2.Level of evidence : 1B
3.summarize the outcomes of this study
Review article
Level of evidence 5
In UK 30 % of renal transplant recipients are elderly> 60 years
Renal transplantation leads to survival and QOL improvement of the majority of ESRD patients including elderly.
Mortality is higher in elderly compared to young transplant recipient, but it is lower than waitlisted patients on regular HD, which become apparent after 1 year post-Tx.
Elderly less than 70 years and not more than 70 years has higher mortality and higher incidence of graft loss if they receive ECD kidney compared to those who received deceased SCD kidney. LD kidney is always preferred, as it is associated with better graft survival. ECD kidneys are associated with perioperative complications, DGF, and mortality, despite that elderly are less likely to receive living donor kidney when compared to young.
Receiving kidneys from younger donor is associated with better graft survival.
Graft survival is lower in elderly compared to young, and this may reflect increase in risk of death with functioning graft rather than true graft failure since elderly are 7 fold more likely to die with functioning graft when compared to young.
Elderly has lower rate of acute rejection episodes than young because of immunosenecense, but the outcome related to acute rejection is more severe.
Elderly recipients are at a higher risk of developing infection which with cardiovascular disease include most common causes of death in renal transplant recipients
Pre-emptive renal transplantation is associated with better outcomes compared to those who on hemodialysis.
Assessment of co-morbidities, frailty and cognitive impairment is very important since they are associated with poor graft survival and high mortality.
Renal transplantation is safe in the elderly, and is increasingly being done in transplant centers. There are certain factors that influence patient survival and graft survival, but overall patient survival is better in the eldelry recipients than being on the waiting list for a tranplant and continuing on dialysis.
Patient survival also depends on co- morbidites present in the recipient, the donor organ [ECD versus LD] type and age of the donor. Infection rates are lower than in younger recipients irrespective of immunosuppression and this is related to immunosenescence in the elderly.
Renal transplant is safe and has good effect on elderly recipients, but these recipients too have to be carefully selected and prepared.
systematic review article with good evidence from pool of registry studies and cohort studies from different centers , level 1B,11 of evidence
aim of this review to assess the risk and benefit of kidney transplantation in elderly patients by assessing for over all outcome , patient and graft survival in association with many factors like comorbid diseases , donor source criteria quality of life , fragility, physical function , cognitive function. type of immunosuppression medication not included as part of assessment in this systematic review .
in summary
this review study comparing elderly patients receiving RT with those waitlisted on dialysis and shows overall survival advantage in the RT group over those on dialysis with reduced mortality rate in the range of 25-78% , in pool of RT from EDC the mortality rate was lower by 25% only ,also survival rate in better in RTS from LD as compared to DD , EDC . For those older than 70 years, renal transplantation reduced mortality by 41% compared to remaining Waiting list in which the mortality was higher 33%(1) ,but some studies shows higher death in elderly RT with RR of 2.8 in the initial two weeks post RT this can be explained by the surgical complication pre-transplant ,associated comorbid diseases ,and higher infection rate
-comparing outcomes in elderly patients receiving renal transplantation with younger RTRs ,both PS and GS worse in older patients due to complications related to age
and pre transplant comorbidity.GS at 8–10 years was
31–32% in the elderly compared to 55–60% in younger RTRs(3)The main causes of death were cardiac (21%), infection(21%) and malignancy (20%)(4).
-Acute rejection rate
the rate of acute rejection is lower in the old recipients compared to younger transplant recipient in one study the AR rate was 28% in those aged 18–
29 years compared to 19.7% in those aged 65 years and older. The effect
of age on AR was independent of baseline immunosuppression (3) ,this can be explained by low immune response in elderly patient also the AR rate can be influenced by donor age due to increased immunogenicity with ischemic hypo perfusion injuries the acute rejection can impact both PS and GS in old recipients with increased graft loss and mortality .
-Outcome based on donor source
LD source associated with better PS , GS outcome compared to DD especially for elderly recipients with pre-transplant comorbid , the mortality rate reduced by 57% in recipient from living donor, however old recipient get less access to LD compared to young recipients ,older LD may be more available, and have been shown to be similar outcome to younger LDs
old recipient transplant from ECD kidneys require longer time to equal survival.
However, elderly patients receiving an ECD kidney within 2 years of starting dialysis
had better survival than those waiting years longer
and it is better than staying on dialysis.
-Infection rate and comorbid conditions were higher in old RT recipient that contribute to higher morbidity and mortality, Elderly recipients have increased risk of
immunosuppression-related complications and mortality.
-Quality of life , improved post transplant in old recipients with better physical and social activity and good health
-Cognitive function and non-adherence to medication more in elderly that put them at risk of rejection
-Frailty associated with increasing risk of early hospital
readmission and a 2.17-fold higher risk of death,
recommendation from this review that can contribute to change our practice
Chronological age is not a barrier to transplantation, and there is currently no age
limit for access to transplantation .
renal transplantation for elderly patient safe and promising in term of over all patient and graft survival in carefully selected candidate taken in consideration the donor selected criteria the pre transplant assessment for comorbid diseases in particular CVD ,infection ,malignancy ,and to focus on frailty score pre and post transplantations .
References
1-Transplantation • Volume 83, Number 8, April 27,2007
2-Keith DS, Cantarovich M, Paraskevas S, Tchervenkov J. Recipient age and risk of chronic allograft nephropathy in primary deceased donor kidney transplant. Transpl Int 2006;19:649–56. https://doi.org/10.1111/j.1432-2277.2006.00333.
3-Friedman AL, Goker O, Kalish MA, Basadonna GP, Kliger AS, Bia MJ, et al. Renal transplant recipients over aged 60 have diminished immune activity and a low risk of rejection. Int Urol Nephrol 2004;36:451–6. https://doi.org/10.1007/ s11255-004-8685-2
4- Keith DS, Demattos A, Golconda M, Prather J, Norman D. Effect of donor recipient age match on survival after first deceased donor renal transplantation. J Am Soc Nephrol 2004;15:1086–91. https://doi.org/10.1097/01.ASN.0000119572.02053.F2
It is systemic review
Level 1 evidence
Summery .
This article reviewed RT in elderly of different points 👉
First ..
Compared to younger age groups
1. Survival patient/graft .
2 acute rejection .
3 susceptibility to infection .
4 quality of life .
Second..
Survival on Rt or on regular dialysis in US 🇺🇸 or Europe 🇪🇺
Third
Patient donor pool in elderly
Fourth
Allocation strategies and living doner kidney.
..● (patient Survival) in elderly is more after RT compared to Dx .
Patient Survival in elderly is worse than younger age groups The main causes of death were cardiac (21%), infection
(21%) and malignancy 13%. Elderly patients are
seven times more likely to die with a functioning graft compared with
patients aged 18–29 years
●(Graft survival) (GS) in elderly patients is worse when compared to
younger recipients. Elderly recipients are more likely to receive kidneys
from older donors, which in turn are associated with an increased risk of
graft failure [25]. However, the reduced GS is more likely a reflection of
the increased risk of death with a functioning graft in elderly recipients
since death-censored graft survival (DCGS) is similar, or even better, to
younger patients.
●(Acute rejection:)
Elderly recipients are associated with a reduced risk of AR.
●Infection rates and associated complications
Elderly recipients are at a higher risk of developing infections.
●Quality of life
Transplantation is associated with an improvement in the quality of
life (QOL).
●Outcomes based on donor source
Increased demand for DD renal transplantation has led to longer
waiting periods and this is significant since the annual mortality rate
for all patients on the waiting list varies between 5 and 10% worldwide
but increases greatly in older patients on dialysis . Increased waiting
time on dialysis impacts on both PS and GS.
● Strategies to increase the donor pool and impact on outcomes
1. Use of ECD kidneys
Several studies have reported good results with ECD kidneys
transplanted in elderly RTRs .
Some studies have reported bet-
ter PS with ECD kidneys compared to remaining waitlisted on dialysis.
In the study by Rao et al., elderly recipients aged above 70 years receiv-
ing ECD kidneys had a 25% reduction in overall risk of death compared
with waitlisted candidates
2.Use of donation after circulatory death kidneys and dual kidney
transplants
Another way of expanding the DD pool is the increased use of kid-
neys from donation after circulatory death (DCD) donors. DCD trans-
plantation now accounts for 40% of all DD renal transplant activity in
the UK, although there is marked regional variation.
●Allocation strategies:
In the the Eurotransplant Senior Programme (ESP), RTRs aged
65 years and above are offered kidneys from DDs aged 65 years and
older. Kidneys are allocated locally to unsensitised recipients without
human leucocyte antigen (HLA) matching. 5 year PS and GS were signif-
icantly reduced in the ESP group when compared with recipients aged
60 to 64 years with a donor of any age.
●Use of living donor kidneys:
LD renal transplantation is associated with better PS and GS. Elderly recipients aged 70 years and older had a 57% reduction in mortality following LDtransplant when compared to remaining onthe waiting list.
Elderly are defined age more than 70 years and those between 60 – 69 years in various studies. Overall geriatric care has improved in the last decade and survival rates with comorbidities also seem better in the general population. Elderly patients with ESRD have high mortality and morbidity due to associated cardiovascular disease. Transplantation in the elderly remain a challenge to the nephrologist as careful patient selection is needed to achieve overall outcome
1- systemic review
2-level 1
3-summary
this systemic review generally analysed studies in elderly concerning outcomes of transplantation in elderly.
1- PS – elderly RTR vs wait-listed on dialysis
-elderly RTR had reduction in mortality and additional survival benefits when compared to dialysis
-time to equal the risk of death is about 125 days and 1.8 years for survival
these data differs form UK and US where dialysis care in UK better than US. UK Study showed no survival benefit for elderly RTR but study in Normay showed elderly still gets survival benefits
2- comparing with young RTR
Patient survival
– higher risk of death vs younger RTR
Graft survival
-worse when compared with younger RTR
-but it can be due to older RTR gets older donor kidneys
-death censoring graft survival – lower compared with young RTR
Acute rejection
-elderly associated with reduced risk of AR
-due to immunoscescence
-but the impact of AR toward Patient survival and graft survival more severe in elderly
Infection rates
-elderly had higher risk of getting infection
-increases linearly RR3.0 to 16.7 over the years
Quality of life
-better health related QOL when compared with remaining dialysis
Outcome based on pre-Tx characteristics
Comorbidities
-mortality increases with comorbodities
-survival benefits reduced from 9.8 years to 6-7.9 years but still better than remaining on dialysis
Frailty
-worse physical function unlikely to get Transplantation but if they gets transplantation still has better survival than remaining dialysis
Cognitive function
– mild cognitive impairment still cab undergo transplantation
– forgetfulness will lead to non adherence to meds and increased risk of missing appointment
Type of article: Narrative article
As the elderly population increased, more elderly with ESRD and ESRD receiving renal transplantation are increasing worldwide. In the UK about 22% between 60 and 69 years and 8% over 70 years receiving transplantation. In US transplanted elderly represent 18.4% compared with 3.4% in 1990.
Compared with young recipients, older RTRs have lower patient and graft survival. Many factors influence the outcome in these populations, like donor characteristics, immunosuppression regime which is not clearly defined for this category of patients, pre-transplant characteristics such as frailty, cognitive function, and functional status which are not routinely assessed.
3. Overall outcome:
3.1: Comparison of patient survival with patients remaining waitlisted on dialysis:
Although, dialysis outcomes in Europe were improved, and it is better than that in US, overall; the transplantation offers survival benefits after the first 2 weeks, compared to waitlist dialysis patients, in addition to improvement in the quality of life.
3.2: comparison with younger RTRs:
3.2.1: Patients survival:
Elderly recipients are seven times more likely to die with functioning graft than young recipients aged between 18 – 29 years. The main causes of death with functioning graft were cardiac and infection. Overall, causes of death in these recipients are cardiac, infection, and malignancy.
3.2.2: Graft survival:
Graft survival is worse when compared to younger recipients.
3.2.3: Acute Rejection:
There is different relation between acute rejection and the age of the recipient and donor in this category of patients. the AR risk decreases with the increase in the recipient age, which can be, explained by the changes in the immune system related to aging. on the other hand; the AR increases with increasing the donor age, as the kidney from older donors may have a lower regenerative capacity to tissue injury, increasing the immunogenicity. Graft loss after AR was higher compared to younger recipients.
3.2.4: infection rates and associated complications:
Infection is the leading cause of death in the elderly recipients, after cardiac causes. The relative risk (RR) of death due to infection over 24 months increased six-fold in those above 65 years compared to the younger group, independent of the baseline immunosuppression.
3.2.5: Quality of life:
There is a conflict between studies about, Qol in these patients. Some studies show improvement when compared to age- and gender-matched national norms. Others showed a slow recovery in these patients who may be overwhelmed by unexpected comorbidities and medication side effects. Therefore, it is important to clarify expectations of post-transplantation risk and outcome.
4- Outcomes based on donor source
4-1. Waitlist mortality and impact of waiting time on dialysis on patients and graft survival:
Increased waiting time on dialysis affect both graft survival and patient survival. 10 years adjusted GS for DD transplants was 69% for pre-emptive transplants compared to 39% for transplant after 2 years on dialysis.
4.2. strategies to increase the donor pool and impact on outcomes:
Elderly donors’ contribution to kidney donation increased largely recently. Due to age matching criteria, the probability to receive an old LD or an ECD kidney increases with the recipient’s age.
4.2.1. Use of ECD kidneys:
Several studies have reported good results with ECD kidneys transplanted in elderly RTRs. Some studies have reported better PS with ECD kidneys compared to remaining waitlisted on dialysis. Not all studies have shown a survival advantage of ECD kidneys in elderly recipients as compared to waitlisted patients of the same age.
4.2.2: use of donation after circulatory death kidney and dual kidney transplants:
Another way to increase the DD pool in the
The use of kidneys from donation after circulatory death (DCD) donor increased, aiming to increase the DD pool. In the UK (DCD) is higher than donation after brain death (DBD) and elderly RTRs received commonly DCD kidneys from older donors but waited for less for transplantation compared to the UK average. In addition, pre-implantation biopsy to determine marginal kidneys that can be transplanted simultaneously as dual kidney transplantation, and can decrease the waiting time by increasing the DD pool.
4.3. allocation strategies:
In the Eurotransplant Senior Program (ESP) aged 65 years and above are offered kidneys from DDs aged 65 years and older. Kidneys are allocated locally to unsensitised recipients without human leukocyte antigen (HLA) matching.
4.4. Use of living donor kidney
In elderly patients, LD transplantation is associated with an immediate survival advantage in those with comorbidity. Despite this, elderly patients are unlikely to receive LD as they are unwilling to put young donors at risk especially their children.
5. Outcomes based on pre-transplant characteristics
Age per se no more contraindication to kidney transplantation, but careful selection to the recipient and donor kidney needed, in order to avoid death with functional graft.
5.1. comorbidity
Although comorbidity increases mortality risk post-transplantation, elderly recipients still have survival benefits. It significantly predicts survival in elderly recipients but not in those receiving LD kidneys. However, patients with comorbidity still has survival benefit after transplantation as compared with waiting time. CVD even occult in those older than 50 years should be screened for, but the optimal method is not known yet. Screening for infection and malignancy is recommended by most guidelines. Recommended age-appropriate screening for malignancy as that for the general population.
5.2. Frailty
Frailty is different from comorbidity; it is decreased physical function that increases with age, making the elderly more dependent and increasing the risk of death. With the increase in its score, whatever the score used is associated with an increase the mortality post-transplantation. There are no guidelines to indicate a level of frailty at which a patient may be excluded.
5.3. physical function
Functional status can be assessed either subjectively using a certain questionnaire, or objectively using tests of physical performance like gait speed. Lower physical status is associated with increase patient mortality.
5.4. Cognitive function and non-adherence to medication:
Cognitive impairment is not a contraindication to transplantation, but these patients need loge term support after transplantation with regard to medication and follow-up.
In conclusion, age is not a contraindication to transplantation, but careful selection and assessment of the patients are critical aspects. LD can be encouraged for the elderly.
1- It is a systematic review.
2- level of evidence IB/II.
3- In order to determine post transplantation outcome we must reassess benefits and risks related to elderly renal transplantation.
Comparison between elderly and younger renal transplant:
~ Patient survival:
Elderly recipients have a higher risk of death compared to younger recipients.
The main causes of death were cardiac , infection
and malignancy .
~ Graft survival :
Graft survival in elderly patients is worse when compared to younger recipients. Elderly recipients are more likely to receive kidneys from older donors, which in turn are associated with an increased risk of graft failure .
A potential explanation for the lower risk of graft failure may be that death caused by poor graft function are classified as death with afunctioning graft.
~ Acute rejection:
Elderly recipients are associated with a reduced risk of AR . The effect of age on AR was independent of baseline immunosuppression.
The risk of AR is also dependent on donor age
AR was associated with increased mortality
in those aged above 60 years but not in the younger patients.
>>>Infection rates and associated complications
Elderly recipients are at a higher risk of developing infections. Infections in the elderly are associated with an increased risk ofcomplications.
Infections increase the risk of death censerned to graft failure and this association is higher in elderly RTRs . Both bacterial and viral infections have been reported to be particular problems in elderly recipients. particularly urinary infections, BK viraemia and polyomavirusassociated nephropathy .
>>>Quality of life:
Transplantation is associated with an improvement in the quality of life . greater benefits in mental health and worse physical functioning scores in elderly recipients when compared to younger recipients.
Outcomes based on donor source :
*Waitlist mortality and impact of waiting time on dialysis on patient and graft survival. Increased waiting time on dialysis impacts on both PS and GS. Strategies such as expanded criteria donor
(ECD) and LD transplantation may increase access of elderly patients to transplantation Strategies to increase the donor pool and impact on outcomes
There has been a progressive increase in organs harvested from older donors the likelihood of receiving an old LD or an ECD kidney increases with recipient age Use of ECD kidneys Several studies have reported good results with ECD kidneys transplanted in elderly recipients.
However, the RR of patient death was higher when older ECD kidneys were transplanted in recipients younger than 60 years. ECD kidneys are also associated with an increase in perioperative mortality. Use of donation after circulatory death kidneys and dual kidney
transplants . Another way of expanding the DD pool is the increased use of kidneys from donation after circulatory death (DCD) donors.
Allocation strategies.
In the the Eurotransplant Senior Programme (ESP), RTRs aged 65 years and above are offered kidneys from DDs aged 65 years and older. Kidneys are allocated locally to unsensitised recipients without human leucocyte antigen (HLA) matching. 5 years PS and GS were significantly reduced in the ESP group when compared with recipients aged 60 to 64 years with a donor of any age Use of living donor kidneys LD renal transplantation is associated with better PS and GS . Elderly recipients aged 70 years and older had a 57% reduction in mortality following LD transplant when compared to remaining on
the waiting list LD transplantation is also associated with an immediate survival advantage in patients with comorbidity.
~ Outcomes based on pre-transplant characteristics.
Age is not a contraindication to renal transplantation. However, careful selection of the potential elderly transplant candidate is important due to the increased risk of death with a functioning graft
Comorbidities:
Comorbidity increases the mortality risk after transplantation . Some studies recommended non-invasive stress testing in asymptomatic patients older than 50 years to screen for occult CVD . However, the optimal method
to screen for CVD is not known and there is little evidence to support this recommendation.
Although there is no evidence to asses frailty score for transplant recipients before transplantation, its incidence between 5-9% in people above 65 y and increase to be more than 60% between dialysis patients , which reflects on risk of hospital readmission and increase risk of death independently on age . Post transplant mortality increasing in frail recipients than non frail ones . If Cognitive impairment cause memory impairment in level made patients non-compliant for medication (immunosuppressive medication) will increase risk of graft loss , so early recognition of cognitive function important to keep certain patients on regular appointments for memory prescription .
Dear All
You have not seen my answer above. It is a systematic review, level 1B. I’m not impressed
This review article, with level of evidence of V.
It describe transplant outcome in elderly ,which increased dramatically now ,with percent
in UK U22% and 8% of those receiving a renal transplant were aged between 60 and 69
years and above 70 years, respectively AND In the United States , the proportion of
adults aged 65 years and above represent 18.4% of the renal transplant recipients .
Though it’s associated with increased mortality with increasing age, still it’s better than
continuing in hemodialysis.
The study compare outcome in different domain include:
1- Comparison of patient survival with patients remaining waitlisted on dialysis renal
transplantation improves patient survival.
2. Comparison with younger
Patient survival Elderly recipients have a higher risk of death compared to young
. Common cause of death is cardiac disease and infection i.e Death with a functioning
graft was the commonest cause of graft failure in those aged above 65 years accounting
for 61% of graft losses.
Graft survival:
Graft survival in elderly patients is worse when compared to younger recipients. This is
also increased risk of death with a functioning graft. And survival after 5years is similar
or better than young.
3- Acute rejection Elderly recipients are associated with a reduced risk of AR .This due
to immunosenescence.
4- Infection rates and associated complications Elderly recipients are at a higher risk of
developing infections. Both viral and bacterial infection are common.
5- Quality of life:
Transplantation is associated with an improvement in the quality of life.
Paper also discuss strategy to improve donor pool and impact on outcome, which
include:
1-Use of ECD kidneys.
2. Allocation strategies
3- Use of kidney donation after circulatory death kidneys and dual kidney transplant.
4- Use of living donor kidneys.
Outcomes based on pre-transplant characteristics:
Though age is not contraindication, carful patient selection reduce death with function
graft, Assessment of comorbidity, frailty, physical and cognitive function should be
included in the evaluation process.
1. This is a literature review article.
2. Its level of evidence is 5.
3. There is increasing need for kidney transplantation in older patients with ESKD. This literature review article discuss about outcome of elderly patients with kidney transplantation based on donor and recipient characteristics.
First, the overall outcome of elderly patients with kidney transplantation were compared with those remained on dialysis in different studies. Few studies had bias because of comparison of results in UK with USA. Hence, patient survival in elderly patients with kidney transplantation was better comparing those who remained on dialysis.
In comparison with younger recipients, elderly patients showed higher risk of death. With increasing age, patient survival decreased in elderly patients but deaths with functioning graft were increased. The most common reasons for death in this patients were cardiovascular diseases and infections.
Graft survival was lower in elderly patients with kidney transplantation. This can be explained with higher rate of deaths with functioning graft in these patients because in studies based on death- censored graft survival, similar results comparing younger patients were reported.
The more time patients stay with dialysis, the more GS and less Patients survival would be. Hence, some strategies had been used to increase Donor pool. These strategies include ECD and DCD kidneys that performing kidney biopsy help improve the outcome in these kidneys.
Nowadays for allocation, we use indicators such as KDPI and EPTS for deceased donors. Transplantation in elderly patients with kidneys that have higher levels of KDPI compared to patients that stayed on dialysis, had better results. Living donor kidney had better results in almost any age group compared to deceased donor. Compatibilities before transplant had an effect on the outcome in this age group and had heightened the mortality risk. These compatibilities include cardiovascular conditions, malignancy or infections.
For computing the mortality risk in this age group, the Charloson Compatibility Index had been introduced that shows the survival of the patients, especially in elderly patients over 70 years of age.
The older the patients and higher their comorbidity rate, the worse the outcome would be. With an increase in frailty index, we also had an increase in the mortality of patients and no level of frailty would exclude patients in terms of transplantation. Physical activity can be collected by a questionnaire. The older patients and the less their physical activity, the worse their survival rate would be and these patients would benefit from kidney transplantation. Another indicator is Peak Oxygen that would show increased mortality in case if was less than 40 percent. Cognitive function disorders would increase by age that can effect medication adherence and increase the graft loss risk but it wouldn’t be enough to prevent transplantation.
In conclusion, we can say that kidney transplantation in elderly patients is one of the most effective treatments that we should make its outcome better by examining and optimizing the said factors.
Narrative review article that veiw the studies that done on renal transplanted old age group, presented or compared between the risks and benefits and also in compared to younger age group .
Renal transplant recipient (RTR ) especially old age patients should be selected carefully with proper assessment before doing transplantation including clinical assessment, presence of comorbidities and general review of the patient and reveiw all factors that have effect on graft survival and posttransplant outcome.
Regarding overall outcomes both dialysis and transplantation have better outcome in Europe than USA ,but all patients have risk of higher mortality and death in the first 2 weeks post transplant and all have benefits of survival up to 3 years post transplant in compare to those on wait list.
In old age RTR they have higher risk of death than younger patients mainly due to cardiac cause ,infection (bacterial or viral) and malignancy, also graft survival is better in younger patients because old age RTR usually receives kidney from old age donors that will affect on graft function and survival .
Regarding acute rejection studies showed in this article that it was independent of baseline immunosuppression others showed that it’s age dependent.,another point that had been discussed is the infection and it’s complications and risks and most studies approved that rate of death is higher in old age group due to cardiovascular disease then infection, but kidney transplant cause better quality of life and improve general health.
The article review the factors that contribute in kidney transplant outcome:
Donor factors whether living or deceased donor ,age of the donor and HLA match between donor and recipient.
Recipient factors like age ,comorbidities and cognitive and physical function ,all have their effect on transplantation outcome.
Dear All
Thank you very much for your contributions.
*review article
* level 5 evidence
* In summary the article discuss the benefits versus the risks in transplanting the old patients, the quality of their life it will be better but with high mortality rate ,less graft survival,less episodes of acute rejections but careful assessment should be done in term of physical function, frailty and cognitive function.over all the outcome was good even when using low quality kidneys (expanded criteria donor),the patient should be counselled about the high mortality rate mainly in the first year post transplant.
· Review article
· Level evidence is 5
Renal transplantation in the elderly
The aim of this review article is to assess the benefits and risks of renal transplantation in elderly RTRs
Outcomes-based on different immunosuppressive regimes are not included in this study
1. Comparison of patient survival with patients remaining waitlisted on dialysis
Transplantation in age group 60-74 has high risk of mortality especially in first 2 weeks so the patient survival is less than compared dialysis patient but this comparison changes with time ; after the first year. The transplantation improves the patient survival compared to dialysis patient
2. Comparison with younger RTRs
a) Patient survival
Elderly recipients have a higher risk of death compared to younger, The main causes of death are cardiac infection and malignancy
b) Graft survival
Graft survival (GS) in elderly patients is worse when compared to younger recipients. However, the reduced GS is more likely a reflection of the increased risk of death with a functioning graft in elderly recipients.
c) Acute rejection
Elderly recipients are associated with a reduced risk of Acute rejection. A lower rate of AR may be due to
changes in the immune system that occur with ageing. Acute rejection has worse outcome on elder age than young recipient.
d) Infection rates and associated complications
elder recipients have high risk to develop infection post transplantation; from other side, infection has poor outcome on this age group.
3. Outcomes based on donor source
Use ECD for elderly people still has the same positive impact of transplantation compared to dialysis patient but this needs proper selection of the recipients who can undergo through ECD to avoid the risk of acute rejection and infection complications in elderly people
4) Outcomes based on pre-transplant characteristics
This has a very important impact on the outcome of kidney transplantation especially in old age group.
Comorbid diseases in crease the risk of mortality after transplantation. The general and physical condition of the recipient; ambulatory patient has better outcome than bed bound or patients with restricted physical activity.
The compliance to medications is very important so we should be sure that the patient will adhere to his post-transplantation medications and this in turn needs persons with proper cognitive function.
Well written.
Re-check for the type of study.
Thank you
Review article
Level of evidence 5
Summary
In many kidney transplantation worldwide ,elderly recipients represent a very few cases , this may be attributed to the special character of this age group as increased prevalence of fraility and other comorbidities as DM , HPN and atherosclerosis as well as increased post operative mortality risk . In their study , Wolfe et al found increased mortality rates among elderly recipients specially during the first two weeks postoperative that became equal between groups after that .(1)
acute rejection rates were lower in elderly recipients may be due to immunescenses and also lower with elderly donors due to decraes immune response to tissue injury that turns the graft more immunogenic .Thus the graft survival was better in elderly due to less acute rejection episodes , in fact many elderly recipient die with functioning graft and the commenst causes for death are CV and infections. (2)
As kidney transplantation offers better quality of live for elder recipients , they can be offered ECD kidneys where the patient survival after ECD transplantation was found better in older recipients than younger ons.(3)
1- Robert A, Wolfe PhD, Valarie B, Ashby MA, Edgar L, Milford MD, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med 1999;341:1725–30
2- Heldal K, Hartmann A, Leivestad T, Svendsen MV, Foss A, Lien B, et al. Clinical outcomes in elderly kidney transplant recipients are related to acute rejection episodes rather than pretransplant comorbidity. Transplantation 2009;87:1045–51. https://doi.org/10.1097/TP.0b013e31819cdddd.
3- Molnar MZ, Streja E, Kovesdy CP, Shah A, Huang E, Bunnapradist S, et al. Age and the associations of living donor and expanded criteria donor kidneys with kidney transplant outcomes. Am J Kidney Dis 2012;59:841–8. https://doi.org/10.1053/j. ajkd.2011.12.014
This is Narrative Review article
Level of evidence 5
It’s aim is to assess the benefits and risks of renal transplantation in elderly RTRs .
Summary
The numbers of transplanted kidney in elderly patients has been increased , in the United Kingdom , the numbers of transplanted reached 22% with age between 60-69 and 8% with age above 70 .
In the United States (US), adults aged 65 years and above received kidney transplant represent 18.4% of the recipients compared to 3.4% in 1990.
Several studies showed increased survival with renal transplant when compared to staying on dialysis with reduction in mortality by 25–78%. even with ECD kidneys , mortality reduced X25%.
For patients older than 70 years, mortality decreased by 41% after renal transplant compared to those maintained on Dialysis .
In spite of improved mortality with transplantation but was associated with an initial increase in mortality compared to remaining In waiting list , in the first 2 weeks which was 2.8 times higher than those remaining on dialysis, then risk of death became equal in both groups at 106 days .
Patients survival in old and young renal recipients :
Old age recipient are in great risk of death compared to younger recipients as showmen by the following studies:
In Karim et al., study following the patients for 4.4 years, the mortality rate in old age group (70-79)was 32% and decreased to 22% for those aged 60–69 years, while 6% for those younger than 50 years.
They found the main causes of death were cardiac causes (21%) then infection (21%) and lastly malignancy (20%) .
In other study by Heldal et al., the 5 year Patient survival for Renal transplant recipients was 56% in recipients with age above 70 years compared to 72% in those recipients aged 60–69 years while reached 91% in those aged between 45 and 54 years .
In the study by Huang et al., 2 years patient survival in recipients age above 80 was73% and was 86% in age 70–79 years compared to recipients aged 60–69 years which was 89% , also compared to the Patient survival for whom on dialysis aged 80–84 years was 44%.
Older patients are 7 times more likely to die with a functioning graft compared with younger patients aged 18–29 years .
Graft survival :
elderly patients has graft survival less than younger recipients , as they are more likely to receive kidneys from older donors, so they are associated with an increased risk of graft failure .
Acute rejection:
Elderly patients with kidney transplants are associated with a reduced risk of Acute rejection , which was 19.7% compared to 28% in those aged 18_29 years old .
This explained by the effect of aging on immune system .
In spite that the effect of acute rejection on Patient and graft survival may be more severe in the elderly transplant patients .
Meier-Kriesche et al., study showed that graft loss associated with acute rejection after 5 years post-transplant in patients aged 65 years or more years is 3 times more than those aged 18–35 years .
Infection rates and associated complications:
The older patients are at a higher risk of developing infections, which increase risk of complications.
Both bacterial and viral infections have been reported to be particular problems in elderly RTRs particularly urinary infections, BK viraemia and polyoma virus associated nephropathy.
Quality of life
there is improvement in the quality of life in elderly patients with renal transplant compared to those still in waiting list on Dialysis.
Outcomes based on pre-transplant characteristics
Age is not a contraindication to renal transplantation but we still in need for careful selection of the potential elderly transplant candidate which is very important to avoid the increased risk of death with a functioning graft.
It is a systematic review , level of evidence 2
Summary
-In the United Kingdom (UK), 22 percent and 8% of people who received a kidney transplant were between the ages of 60 and 69 years and over the age of 70 years.
When compared to dialysis, there was a survival advantage at all ages .Older RTRs have a lower patient and graft survival rate than younger receivers
-The goal of this narrative review is to evaluate the advantages and dangers of renal transplantation in elderly RTRs by looking at (a) overall results as well as outcomes based on donor source and (b) pretransplant features.
-Articles are limited to publications between 2005 and 2018.
-Those who had a transplant lived an average of 5.3 years longer than those who stayed on the waiting list at 65–69 years old, and 3.7 years longer at 70 years and beyond.
Even after adjusted for race and comorbidities, dialysis outcomes in Europe were better than in the US in the late 1990s, with an RR of death that was 33% higher in the US.
-The 5-year DCGS was 89 percent in 301 RTRs over the age of 70, which was equivalent to senior patients aged 60–69 years and control patients aged 45–54 years.
-Survival of the patient when compared to younger RTRs, elderly recipients have a greater chance of death. The leading causes of death were cardiac (21 percent), infection (21 percent), and cancer (20 percent )
– Elderly recipients had a lower risk of AR
-Meier-Kriesche et al. found a progressive decrease in the incidence of AR in the first 6 months after transplantation according to age in a sample > 73,000 RTRs.
-The AR rate was 28% among those aged 18–29 years old, compared to 19.7% for those aged 65 and more.
-Immunosenescence, or changes in the immune system that occur with aging, may explain why there is a reduced rate of AR.
-Infections are more likely to affect elderly receivers.
-The most common cause of death in older RTRs was cardiovascular disease (CVD), which had a death rate of 37 per 1000 patients per year , followed by death from infection, which had a death rate of 16.7 per 1000 patients per year.
-Those over 60 years old had a 10.5 percent death rate compared to 4.4 percent for those between 18 and 65 years old
-Infections raise the likelihood of death-censored graft failure, which is more common in elderly RTRs
-Other studies revealed larger advantages in mental health and lower physical functional grades in senior RTRs as compared to younger recipients
-Transplantation is connected with an improvement in quality of life except for those patients who lost their graft, all subgroups of patients experienced a significant improvement in their QOL 2 years following transplantation
-The annual death rate for all patients on the waiting list fluctuates between 5 and 10% generally, but it rises dramatically in dialysis patients over the age of 65.
-Strategies such as (ECD) and living donor (LD) transplantation may make transplantation more accessible to elderly patients.
-In the first two weeks after transplantation, ECD recipients had a 5-fold higher risk of perioperative mortality than standard therapy recipients (standard criteria donor [SCD] kidneys and remaining on the waiting list
-Due to the increased risk post transplantation, screening for infection and malignancy should also be included in the work-up of older renal transplant candidates. Comorbidity increases the mortality risk following transplantation.
-The recommendation based on this study: Patients with ESRD who are elderly should be evaluated for transplantation.
Systematic review , level of evidence 2
this article reviews the outcome of transplantation in the elderly and compare it with dialysis and transplantation in the younger age groups.
Renal transplantation in elderly improves survival when comparing it with dialysis , despite the increased risk of death early after transplantation.
Elderly patient with kidney transplantation had lower patient survival and graft survival when compared with younger age groups , and the most common cause of death is cardiovascular followed by infection.
Acute rejection rate was lower in the elderly , since elderly’s immune system is weaker , a process may referred as immunosenescent. But the effect of acute rejection on graft and patient survival was worse in the elderly, with increased graft loss and increased mortality in older patients who had acute rejection.
The risk of Infection also increased in the elderly and the complication and mortality also increased. The quality of life is improved in the elderly kidney transplant recepients.
Also the study shows increased uses of ECD in the elderly , and better patient survival in the elderly who received ECD kidneys compared with dialysis. Old donor kidneys for old recepients.
Donation after circulatory dearth DCD is increasing the deceased donor pool and the use of kidney biopsy may increase the DD pool furthermore by using dual kidney transplantation.
Thank you all
Yes, it is a systematic review, well done.
1. What is the type of this study?
It is a review article, a systematic review, involving literature search in multiple databases.
Although the authors, in the introduction of the article, have described this article as a narrative review.
2. What is the level of evidence this study provides?
As this is a systematic review, the level of evidence is level II (as the study includes a number of cohort studies/ registry studies, no direct randomized control trial)
3. In your own words, summarise the outcome of this study!
Kidney transplant has a survival advantage over dialysis. Elderly patients account for 20 to 30% of total renal transplants. This study was done to evaluate the outcomes of kidney transplantation in elderly.
Comparing elderly transplant recipients with those remaining on dialysis, there is a definite advantage in terms of mortality. Even with ECD kidneys, the mortality reduction was 25% in the elderly as compared to remaining on dialysis, although the results were better with standard criteria deceased donor (SCD) kidneys. This reduction in mortality was seen even at age more than 75 years, although there was increased mortality initially due to post-operative complications.
In comparison with younger kidney transplant recipients, elderly patients had lower patient and graft survival but the death censored graft survival were similar. Risk of acute rejection was lower while the risk of infections was higher in the elderly recipients. Infections increased risk of death in elderly by 6 times as compared to younger recipients. Lesser acute rejection was seen in elderly recipients receiving older kidneys as compared to younger recipients receiving older kidneys. Better results in elderly recipients were observed with a live donor kidney, similar to a SCD kidney. Kidney transplant led to markedly improved quality of life in the elderly recipients.
Patients with longer dialysis vintage had poorer outcomes. Donation after cardiac death (DCD) kidneys as well as dual kidney transplant (DKT) have been used in elderly. Old kidney for old patients transplants have decreased patient and graft survival with increased acute rejection rates, although delayed graft function (DGF) and cold ischemia time is reduced. Risk of death one year post transplant is 2 times in elderly than in younger recipients, but it increases to 5 times in elderly with co-morbidities. Similarly, the mortality risk as well as risk of DGF is higher (2 times) in frail patients and those with poor physical function. Cognitive dysfunction needs to be addressed as it has an impact on long-term graft function.
The recommendations for renal transplant in elderly include encouraging patients for transplant, case by case approach with emphasis on frailty and physical function, keep looking for a living donor but ready to choose even an ECD kidney if living donor not available, an informed decision and a comprehensive post-transplant support system.
This article is mostly a systematic review of level 2 evidence , as it included more than big cohort study as we as meta analysis too.
This article cited a multiple of dependable studies regarding transplantation of elderly .
In brief transplantation has no limit relatively , transplantation of elderly through proper regimens and selection , care of comorbidities , care of pre and post transplant periods especially early post transplant period the ,post operative 2 weeks , are important for better patient survival .
patient survival is overall better compared to those on dialysis , with increased risk post op., equal to those on dialysis at 244 days and then better after , mortality s more in elderly compared to those young transplant individuals especially those older than 70 , depending on comorbidities and the graft quality .
Graft survival is worse when compared to young , the fact that most of the elderly receive older grafts or deceased or ECD which are still better for survival compared to those on dialysis based on most of the studies done .
Cause of death is mostly due to cardiac causes, infections and malignancy .
Acute rejection is relatively less in elder transplant population than young , due to immunesensce ;variation of immunity with age , But the Acute rejection risks and effects on elderly survival and graft survival as well are higher than that of young population ; meaning that acute rejection usually doesn’t occur in elderly compared to young recipients but when it does it’s more lethal .It’s directly proportional with the age of the donor graft.
Quality of life is better than dialysis
living donor graft is the best
frailty of elderly should always be kept in mind
Thanks, Mohamed
thank you prof.
It’s a narrative review .
Level of evidence 5 .
Summary;
Number of older ESRD is increasing ,Nearly half of all new patients are older than 65 years and one third are older than 70 years.
Renal transplantation is the best option of treatment proved to increase not only patient survival but also quality of life.
Older patients have lower patient and graft survival than younger patients but still better than patients on dialysis.
pre-emptive transplants have higher graft survival than patients after 2 years on dialysis.
Most common causes of death in elderly patient are cardiovascular ,infections and malignancy.
Donor characteristics greatly affects the outcomes of transplantation and older patients mostly will receive an older deceased donor kidney and less likely to receive a living donor kidneys.
The the optimal immunosuppression combination in elderly patients is unclear as they are naturally immuncompromized changes
in the immune system that occur with ageing referred to as immunosenescence.
Elderly patients have lower risk for acute rejection than younger patients in the first 6 months posttransplantation.
The effect of age on acute rejection was independent of baseline immunosuppression , older patients tend to reject less.
Acute rejection also is affected by the age of doner older Kidneys from older donors may have a lower regenerative capacity to tissue injury increasing immunogenicity.
Death due to infection over 24 months increased six-fold in recipients above the age of 65 years compared to the younger group and this was independent of baseline immunosuppression.
Different bacterial and viral infections have been reported elderly recipients particularly urinary infections, BK viraemia and polyomavirus-associated nephropathy (PVAN) .
•Strategies to increase the donor pool and impact on outcomes
°ECD
Strategies such as expanded criteria donor ECD and LD transplantation may increase access of elderly patients to transplantation and decrease number of patients on waitliste.
Several studies have reported good results with ECD kidneys transplanted in elderly recipients studies have reported better patient survival with ECD kidneys compared to remaining waitlisted on dialysis.
° Donation after circulatory death kidneys and dual kidney transplants
DCD transplantation now accounts for 40% of all DD renal transplant activity in the UK.
DKTs with single kidney transplants in elderly recipients, DKT recipients had a higher rate of venous graft thrombosis but a similar rate of early surgical revisions, signifcantly higher glomerular filtration rate (GFR) at 24 months and a shorter waiting time .
°living donor kidneys
Elderly patients most likely will receive kidneys from older living donors , studies showed that living donor transplantation has better effect in patient and graft survival.
outcomes based on pre-transplant evaluation of patients
comorbid conditions and Chronic diseases increase mortality risk.
frailty: is associated with reduced physiologic function increase dependency and/or death. The prevalence is between 5 and 9% in people aged above 65 years, although this increases to 60% in patients with ESRD on dialysis.
These patients have a 60% DGF and are more liable to rejection risk with using of low doses of MMF. there is no guidelines to indicate the level of frailty at which the patient is considered non-transplantable.
physical function
poor physical function associated with increased mortality.
Bad physical function was associated with higher 3-year mortality and the association was particularly strong in elderly recipients .
cognitive factors
Mild Impairment of cognitive function isn’t contraindication for transplantation but these patients need extra care and help after transplantation
forgetfulness associated with non-intentional non adherence to medications.
It is a narrative review, , level of evidence 5.
1-There is no upper age limit for renal transplantation, successful outcomes have been described even in octogenarians.
2-Survival rate for elderly recipients is better with kidney transplant than patients remain on dialysis or waiting list .
3-Older kidney transplant patients have an improvement of quality of life, increased length of hospitalization & readmission , increased risk of death with a functioning graft (mostly due to cardiovascular disease ,or infection), increased risk of infection & malignancy but fewer acute rejection.
4- Older donor kidneys would be better placed in older recipient.
5- Expanding the diseased donor pool by using grafts from extended criteria donors , donation after circulatory death & dual kidneys from marginal organs , all are reasonable to be used for elderly recipient .
6- Assessment of comorbidity , frailty, physical & cognitive functions should be involved in the evaluation process .
7-Assessment of cardiovascular disease for all elderly recipients.(routine stress test)
8-Eldely recipients should seek a living donor option especially if there is along wait for diseased donor kidney.
Dear All
It is a systematic review level IB/II. There is a reward for the 2 colleagues (Nadia Ibrahim and Hamdy Hegazy) who put in an effort and did not go with the flow.
· Systematic Review
· Level 1A
Summary of the outcome:
1. Patient survival in elderly is improved among elderly aged above 60ys underwent renal transplantation rather than those maintained on dialysis by 5.3 years for those aged 65–69 years and 3.7 for those aged 70 years and above
2. Compared to younger RTRs aged 18 t0 29 years, eldery are more prone to risk of death with a functioning graft
3. Elderly RTRs receive kidneys from older donors resulting in increased chance for graft failure
4. Immunosenescence occurs with aging decreases exposure of elderly RTRs to episodes of acute rejection regardless the baseline immunesuppression received , however , the older the donor the more immunogenic the graft due to lower capacity of regeration after tissue injury
5. Elderly recipients are at a higher risk of developing infections which is considered the second common cause of mortality after CVD. Common infections include urinary infections, BK viraemia and polyomavirusassociated nephropathy (PVAN,
6. Transplantation is associated with a better quality of life including physical functioning, bodily pain, general health, vitality and social functioning when compared with dialysis patients
7. The need for DD as a main source for kiney transplantation among elderly has significantly im=ncreased the waiting list among those patients leading to worse patient survival and graft survival. ECD is now considered away to overcome that problem.
8. Elderly RTRs may benefit from receiving ECD kidney Tx with a positive outcome reported on patient survival compared to those waitlisted on dialysis. However some studies reported that increasing donor age was associated with lower PS in all adult age groups
9. For eldery reciepients receiving kidneys from donation after circulatory death (DCD) donor is a reasonable option,however associated with higher rate of venous graft thrombosis
10. Although elderly patients have a poor chance to receive a kidney from living donor than younger patients, LD renal transplantation is associated with better PS and GS and can improve the general condition in patients with comorbidities.
Age is not a contraindication to renal transplantation yet age-related comorbidities are considered a relative contraindications as it is considered a risk factor of death with a functioning graft. Screening for infection, malignancy and CVD should be included in the work-
Dear Nadia
Excellent, it is a systematic review level IB/II. Well done. You read it and analysed it very well. You are the winner of this original textbook (Original in a PDF format – not a pirate copy).
Please send me an email to receive your reward.
You need to explain to us first why it is a systematic review to receive your reward.
Dear All
You have not noticed my comments above and followed each other blindly (except Dr Hamdy Hegazy and Dr Nadia Ibrahim)
thank you dear professor, Im honored
to explain why it is a systematic review . This article was answering certain target research questions, answers were formulated through searching the literature . relevant researches and studies were selected , reviewed and underwent critical appraisal,. Data were collected, analysed and presented in a comparative form.
its a rivew article
level of incidence 5
Kidney transplantation remains the optimal treatment of end stage renal disease. The incidence of end stage renal disease among older population becoming more prevalent and despite old age, these patients are still considered candidates for kidney transplantation and age is not a contraindication.
Kidney transplantation is associated with better quality of life, better survival rate, better cardiovascular outcomes when comparing to dialysis regardless of patient’s age, comorbidities, HLA mismatch and kidney donor profile index.
Elderly recipients have a higher risk of death following surgery compared to younger RTRs. The main causes of death were cardiac, infection and malignancy. Elderly patients are seven times more likely to die with a functioning graft compared with patients aged 18–29 year
Elderly recipients have lower patient and graft survival compared to younger recipients and are more likely to die with a functioning kidney allograft. As a result, death censored graft survival may be similar to or even better than younger patients. One study demonstrated that with every decade increase in the age, death censored graft survival has increased progressively
A study show that incidence of acute rejection early after transplant decrease as the age of recipient increase, this may be due to immunosenescence (changes in immune system with ageing.
While other study reported that acute rejection rate increases with increased age of donor.
a way to increase donor resources is to transplant after circulatory death ( DCD) which now account for 40% of deceased donation.
dual kidney transplant is a good option for elderly transplant , as 2 marginal kidneys increases GFR significantly but may be associated with increased risk of vascular thrombosis .
living donors are good option for elderly and are associated with better patient and graft survival.
This is a literature review
Level of evidence is V
Authors of this article ,reviewed studies involving elderly transplant since 2005 to 2018
They were assessing overall outcome after transplantation of elderly population and they concluded that :
* transplantation improves survival of elderly compared to staying on dialysis with 61% reduction in mortality rates
* when compared to younger populations , mortality is higher in elderly with main causes of death including cardiac events , infections and malignancy , with increased rates of death with functioning graft in elderly
*incidence of graft survival was worse in elderly ,but this may be due to increased rates of Death with functioning graft which is common among elderly
* incidence of acute rejections in elderly is lower , due to phenomenon known as immunosenescence,
However this incidence may increase with increasing the donor age .
acute rejections had deleterious effects on graft and patient survival ( particularly I’m elderly)
*Incidence of infections in this age group is higher and is associated with more complications, compared to younger patients
* Quality of life in most of studies improved significantly after transplantation for all age groups
* The longers that a patient stays on dialysis ,the poorer the patient and graft survival after transplantation ( favoring pre emptive tx)
*most of studies concluded that ECD improves survival of elderly populations, compared to remaining on dialysis , some studies didn’t conclude such benefit as in Italy 2012 where outcomes of using ECD was worse than staying on dialysis .
*a way to increase donor resources is to transplant after circulatory death ( DCD) which now account for 40% of deceased donation.
* dual kidney transplant is a good option for elderly tx , as 2 marginal kidneys increases GFR significantly but may be associated with increased risk of vascular thrombosis .
* living donors are good option for elderly and are associated with better patient and graft survival.
Age is not a contraindication for transplantation, but patients should be carefully selected , and assessment should include co morbidities, physical and cognitive functions
Systematic Review
This article is a narrative review article
Level of evidence: Level 5
The aim of this review is to assess the benefits and risks of renal transplantation in elderly.
The outcome of the study can be summarized in the following points:
Comparing renal transplantation to patients on dialysis waiting list:
Renal transplantation provided a better survival benefit and quality of life to the elderly when compared to those remaining on the dialysis waiting list. However , the relative risk of death was high in the early post transplantation period.
Comparing elderly to the younger renal transplant:
Despite the lower patient and graft survival(as they more likely to receive grafts for older donors).Sill transplantation is a better option than remaining on dialysis. The main causes of death are cardiovascular causes, infections, and malignancy .
Elderly are more likely to die with functioning grafts so the death-censored graft survival (DCGS) is similar, or even better when comparing elderly to younger patients .
On the contrary, the rate of acute rejection was lower in elderly due to immunosenescence giving a room to decrease immunosuppression doses to avoid their deleterious effects, However, the impact of acute rejection episodes was higher on both patient and graft survival when compared to the younger transplanted patients.
Outcomes based on donor source:
Due to limited donor pool, elderly has to wait more on dialysis and this impacts both patients and graft survival. Accordingly a number of strategies were implemented to increase the donor pool like using use of ECD kidneys, donation after circulatory death kidneys and dual kidney transplants, encouraging living donation and implementing better allocation strategies using both the KDPI and EPTS score .
Out comes based on pre-transplantation characteristics:
Advancing age is not a contraindication for renal transplantation but meticulous pre-transplant work up should focus on proper selection of suitable candidates to avoid the increased risk of death with a functioning graft. This can be done through proper assessment for any comorbidities, frailty, functional performance, psychological and cognitive state
its a systematic review with level 5 evidence
Comparison of patient survival with patients remaining waitlisted on
dialysis
1)In older patients, renal transplantation improves patient survival (PS) when compared to those who remain on dialysis waiting lists.
2)Patients aged 60–74 years experienced a 61 percent reduction in death and a four-year increase in expected life years.
Comparison with younger RTRs
A)Patient survival
When compared to younger RTRs, elderly receipients had a greater chance of death.After a median follow-up of 4.4 years, the death rate for those aged 70–79 years was 32 percent, and 22 percent for those aged 60–69 years, according to Karim et al. This compares to 6% for those < 50 years. Cardiovascular disease (21%),malignancy (20 percent ) and infection (11%) were the leading causes of mortality.
B)Graft survival
When compared to younger receivers, elderly individuals have a lower graft survival rate. Elderly patients are more likely to receive kidneys from older donors, which is linked to a higher risk of graft failure. The lower graft survival in the elderly is more a reflection of the increased risk of death with a functioning graft since death censored graft survival is same or even better as compared to younger receipients.
C) Acute rejection
Recipients above the age of 65 have a lower risk of developing AR.The AR rate was 28% among those aged 18–29 years old, compared to 19.7% for those aged 65 and more.Immunosenescence, or changes in the immune system that occur with age, may explain why there is a reduced rate of AR.The risk of AR is also dependent on donor age.With each cohort of rising recipient age, the incidence of AR decreased, while it increased with each decade of increasing donor age. Kidneys from older donors may have a decreased regeneration capability, making them more immunogenic.Acute rejection was linked to a higher risk of death in people over the age of 60, but not in those under the age of 60.
D)Infection rates and associated complications
Infections are more likely to affect elderly receipients.Infections among the elderly are linked to a higher risk of complications.
E)Quality of life
Transplantation was linked to improved health-related QOL and Significantly improved physical performance, bodily pain, overall health, vitality, and social function as compared to Patients on dialysis have a higher mortality rate .
Outcomes based on donor source
A)Waitlist mortality and impact of waiting
Increased duration on dialysis prior to transplantation was related with worse PS in RTRs aged >70 years.
B)Strategies to increase the donor pool and impact on outcomes
Strategies such as extended criteria donor (ECD) and LD transplantation may make transplantation more accessible to elderly individuals.
C)Use of ECD kidneys
When compared to standard criteria donor [SCD]), ECD recipients had a 5-fold higher risk of perioperative mortality in the first two weeks after transplantation.However, After three years, individuals who received an ECD kidney had a 17 percent reduction in death w hen comparing ECD kidney to standard therapy. Because of the elevated risk throughout the perioperative phase, the cumulative risk is higher and Until 3.5 years, survival did not match that of the conventional therapy group after transplantation.
D)Use of donation after circulatory death kidneys and dual kidney
transplants
E) Allocation strategies
RTRs aged
65 years and above are offered kidneys from DDs aged 65 years and
older.Kidneys with a KDPI of b20% will be offered to patients
with an EPTS of 20% or less. Recipients of high KDPI kidneys have increased
short-term but decreased long term mortality risk with a
“break-even point” of 18 months for kidneys with a KDPI of 81–90%.
F)Use of living donor kidneys
If there is a significant wait for a DD kidney, elderly recipients should consider an LD option.
Outcomes based on pre-transplant characteristics
A)Comorbidity
After a transplant, comorbidity raises the risk of death.With waiting times of up to three years, individuals with comorbidities still had a survival benefit from transplantation.non-invasive stress testing to detect occult CVD in asymptomatic patients over the age of 50
age-appropriate screening for malignancy as recommended for the general population should be done.
B)Frailty
Frailty is not the same as disability or comorbidity. It’s linked to decreased physiologic function, which raises a person’s risk of developing increased dependency and/or death..
A commonly
used score is the one based on the phenotypic model of physical
frailty which consists of !ve items: weight loss, weakness, exhaustion,
walking speed and physical activity.Frailty leads to increased risk of post tx mortality,increased length of stay post tx and also impacts graft outcomes.
C)Physical function
assessed by tools such as short form-36 or physical function subscale.Despite the fact that individuals with the worst PF had a lower post-transplant survival rate, transplantation was associated with a survival benefit in every function when compared to dialysis.
D)Cognitive function and non-adherence to medication
Memory and executive function impairments require long-term support after transplantation, including assistance with making clinic visits and methods to help remember medicines.
Recommendations
1)Transplantation should be considered for elderly patients with ESRD.
2) Predictive tools should not be utilised to determine who may and cannot be transplanted on their own.
3)Potential kidney transplant candidates should be carefully evaluated.
4) The evaluation should involve a look at comorbidities, frailty, and functional status and cognitive performance.
5)Renal transplant candidates over the age of 65 should be warned about the higher risk of death in the first year following transplantation compared to dialysis for the rest of his life. This risk is influenced by a number of factors, including comorbidities and the source of the donor.
6)Patients should be informed that the chance of survival takes longer to equalise When compared to younger recipients after renal transplantation.
7)Patients should be urged to accept an LD kidney if DD is not available even if a kidney of inferior quality is used
Do you think the systematic review is level 5 evidence?
Systematic review
according to the attached table by Rossella Ferrari 2015, it seems to be systematic review article.
Narrative review
Main features:
Describes and appraises published articles, but the methods used to select the articles may not be described.
Uses/applications:
General debates, appraisal of previous studies and the current lack of knowledge.
Rationales for future research.
Speculate on new types of interventions available.
Limitations:
The assumption and the planning are not often known.
Selection and evaluation biases not known.
Not reproducible.
Systematic review
Main Features:
The query is well defined (review questions, secondary questions, and/or subgroup analysis).
Clearly defined criteria for the selection of articles from the literature.
Explicit methods of extraction and synthesis of the data.
Comprehensive research to find all relevant studies.
Application of standards for the critical appraisal of the studies quality.
Uses/applications:
Identify, assess and synthesize the literature gathered in response to specific query.
Collect what is known about a topic and identify the basis of that knowledge.
Comprehensive report with explicit processes so that rational, assumptions and methods are open to examination by external organizations.
Limitations:
The scope is limited by the defined query, search terms, and selection criteria.
Usually reader needs to reformulate the alternative question that have not been answered by the main query.
regarding the level of evidence provided by this article.
I think it is level II a because it has reviewed a lot of cohort studies, registry study (I am not sure, what kind of study it should be), and registry data.
I have reviewed my colleagues answers, I am not sure what are the reasons for opting to level V and level I?
This article had conducted a systematic review of many cohort studies in order to assess the overall outcomes of renal transplantation in above 65-year-old recipients.
The above-mentioned intended outcomes included the following:
A/ Comparison of patient survival with patients remaining waitlisted on dialysis:
Patient survival of elderly RTRs has improved when compared to that waitlisted-on dialysis. Wolfe et al. concluded patients aged 60–74 years had a 61% reduction in mortality.
B/Patient survival in comparison with younger RRTs:
Elderly RTR s have higher risk of death compared to younger RTRs.
Karim et al. concluded the mortality rate was 32% for those aged 70–79 years, 22% for those aged 60–69 years and 6% for those below 50 years. The main causes of death were cardiac (21%), infection (21%) and malignancy (20%).
Graft survival in comparison with younger RRTs:
Graft survival (GS) in elderly patients is worse when compared to younger recipients. Elderly recipients are more likely to receive kidneys from older donors, which in turn are associated with an increased risk of graft failure. However, the reduced GS is more likely a reflection of the increased risk of death with a functioning graft in elderly recipients since death-censored graft survival (DCGS) is similar, or even better, to younger patients.
Acute rejection in comparison with younger RRTs:
Elderly recipients are associated with a reduced risk of AR.
Heldal et al. showed recipients above70 years old had an AR rate of 35% at 12 weeks after transplantation compared to 45% in those aged between 45 and 54 years. A lower rate of AR may be due to changes in the immune system.
Infection rates and associated complications in comparison with younger RRTs.
Elderly recipients are at a higher risk of developing infections and increased risk of complications.
The relative risk of death due to infection over 24 months increased six-fold in those above the age of 65 years compared to the younger group and this was independent of baseline immunosuppression.
Both bacterial and viral infections have been reported to be particular problems in elderly RTRs particularly urinary infections, BK viraemia and polyomavirus- associated nephropathy (PVAN).
Quality of life in comparison with younger RRTs:
Quality of life is improved after renal transplantation.
Rebollo et al. showed transplantation was associated with better health-related QOL and significantly better physical functioning, bodily pain, general health, vitality and social functioning when compared with dialysis patients.
QOL has also been assessed before and after transplantation.
Laupacis et al. concluded except for those patients who lost their graft, all subgroups of patients had a marked improvement in their QOL 2 years after transplantation.Qualitative studies such as those by Pinter et al. showed that some elderly RTRs may experience a slow recovery and they may be overwhelmed by un- expected comorbidities and medication side-effects.
It is important to clarify expectations of post-transplantation risks and outcomes.
4. Outcomes based on donor source in comparison with younger RRTs:
4.1. Waitlist mortality and impact of waiting time on dialysis on patient and graft survival
Patient and graft survival are affected by the time on dialysis.
Use of ECD kidneys
Rao et al. concluded elderly recipients aged above 70 years receiving ECD kidneys had a 25% reduction in overall risk of death compared with waitlisted candidates.
Use of donation after circulatory death kidneys and dual kidney transplants
A single centre study from Cambridge, UK, with the highest proportion of DCD to dona- tion after brainstem death (DBD) kidney only transplants in the country showed that elderly RTRs received predominantly DCD kidneys from older donors but waited less for transplantation compared to the UK average.
Pre-implantation biopsy may also help expand the DD pool by determining which marginal kidneys can be transplanted simultaneously as a dual kidney transplant (DKT).
Mendel et al. comparing DKTs with single kidney transplants in elderly recipients, DKT recipients had a higher rate of venous graft thrombosis but a similar rate of early surgical revisions, significantly higher GFR at 24 months and a shorter waiting time.
The authors concluded that DKT is a reasonable option in elderly RTRs.
Use of living donor kidneys
LD renal transplantation is associated with better PS and GS.
Outcomes based on pre-transplant characteristics:
Age is not a contraindication to renal transplantation.
careful selection of the potential elderly transplant candidate is important due to the increased risk of death with a functioning graft.
Comorbidities:
Comorbidity increases the mortality risk after transplantation.
Gill et al., the average increase in the life expectancy for RTRs was 9.8 years but this was lower in recipients with comorbid conditions assessed at time of dialysis initiation ranging from 6 to 7.9 years.
Frailty:
Frailty is associated with reduced physiologic function that increases an individual’s vulnerability for developing increased dependency and/or death.
Candidates who become frailer have an increased risk of post-transplant mortality and higher odds of length of stay of 2 weeks or more after renal transplantation.
DGF was seen in 30% of frail patients who presented for a renal transplant as compared to 15% in non-frail recipients.
Physical function:
Reese et al. concluded worse physical function was associated with higher 3-year mor- tality and the association was particularly strong in elderly RTRs.
Cognitive function and non-adherence to medication:
Impaired memory may lead to unintentional non-adherence of IS medications which is associated with an increased risk of graft loss. Those with memory problems will need help to remember prescriptions and clinic appointments.
Dear Hamdy
Excellent, it is a systematic review level IB/II. Well done. You read it and analysed it very well. You are the winner of this original textbook (Original in a PDF format – not a pirate copy).
Please send me an email to receive your reward.
Dear All
You have not noticed my comments above and followed each other blindly (except Dr Hamdy Hegazy and Dr Nadia Ibrahim)
Dear All
You are just describing Narrative reviews by copying others. Please respond to the questions to the point.
Review article
Level of evidence 5
In UK 30 % of renal transplant recipients are elderly> 60 years
Renal transplantation improve survival and QOL of the majority of ESRD patients including elderly
Although mortality is higher in elderly compared to young transplant recipient, but it is lower than waitlisted patients on regular hemodialysis this become apparent after 1 year post transplantation
Elderly < 70 years and not > 70 years has higher mortality and higher incidence of graft loss if they receive ECD kidney compared to those who received deceased SCD kidney. Living donor kidney is always preferred, as it is associated with better graft survival, Moreover, ECD kidneys are associated with perioperative complications, delayed graft function, and mortality, despite that elderly are less likely to receive living donor kidney when compared to young.
Receiving kidneys from younger donor is associated with better graft survival, despite that elderly usually receive kidney from older donors.
Although graft survival is lower in elderly when compared to young, this may reflect an increase in risk of death with functioning graft rather than true graft failure since elderly are 7 times more prone to die with functioning graft when compared to young.
Elderly has lower rate of acute rejection episodes than young because of immunosenecense, but the outcome related to acute rejection is more severe (graft loss)
Elderly recipients are at a higher risk of developing infections (viral or bacterial ) which with cardiovascular disease constitute the most common causes of death in renal transplant recipients
Preemptive renal transplantation is associated with better outcomes when compared to those who initiate hemodialysis.
Assessment of comorbidities, frailty (which is assessed using 5 items : weight loss, weakness, exhaustion, walking speed and physical activity) and cognitive impairment is very important since they are associated with poor graft survival and increased mortality.
Narrative Review
weak evidence(level 5)
The goal of this narrative review is to evaluate the advantages and dangers of renal transplantation in elderly RTRs by looking at (a) overall results as well as outcomes depending on donor source and (b) pretransplant features.
The results of other immunosuppressive regimens are not included in this research but are provided in a separate review. These findings are used to make practice recommendations.
a survival advantage across all ages when compared to staying on dialysis.
However, it is important to Reevaluate the advantages and dangers of kidney transplantation in older patients, since age remains a significant role in post-transplantation outcomes.
Older RTRs had a poorer patient and graft survival rate than younger receivers. Furthermore, dialysis survival has increased since the late 1990s. Donor characteristics also impact transplant results, with elderly RTRs having a higher chance of receiving an older deceased donor (DD) kidney and a lower chance of receiving a live donor (LD) kidney.
In older patients with ESRD, pre-transplant parameters such as frailty, functional status, and cognitive function are not regularly examined. Finally, in older RTRs, the best immunosuppressive mix is unknown.
following are some recommendations based on this review:
• Transplantation should be considered for elderly individuals with ESRD.
• Predictive techniques should not be utilized to determine who may and cannot be transplanted on their own.
• A thorough assessment of possible renal transplant candidates should be carried out.
• Comorbidities, frailty, functional status, and cognitive performance should all be assessed throughout the evaluation.
• Renal transplant candidates over the age of 65 should be warned about the higher risk of mortality in the first year following transplantation as compared to dialysis. This risk is influenced by a number of variables, including comorbidities and the source of the donor.
• Patients should be advised that, as compared to younger recipients, the risk of survival following kidney transplantation takes longer to equalize.
• Donating a kidney while you’re still alive should be promoted.
1-This study is a narrative review study
2-level of evidence is 5
3-To summurise
Patient survival in the elderly transplanted patients is much higher than those patients on dialysis waiting list as demonstrated by multiple studies.
Mortality risk of elderly transplanted patients is increased in the first 2 weeks postransplantation if compared to patients on dialysis but the mortality risk decreases for transplantated patients if compared with dialysis patients on the long term .
Regarding patient survival elderly recepiants has higher mortality risk compared to younger ones ;the former group are 7 times more likely to die with a functioning graft in comparison to young aged recipents. Cardiac diseases, infection and malignancy are the main causes of death.
Graft survival in elderly recepients is less than that for younger recipients could be attributed to receiving kidneys from older donors.
Death -censored graft survival (DCGS) is similar, or could be better, in older recepiants with lower acute rejection rates in the elderly compared to younger patients may be due to immunosenescence .
Infections especially urinary infections, BK viraemia and polyomavirus[1]associated nephropathy (PVAN) were reported in elederly recipents .
RTR patients had a marked improvement in their quality of life especilay 2 years postransplantation
Studies stated that increasing time on dialysis pretransplantation was associated with worse patient survival outcome.
Those receiving an ECD kidney had reduction of overall mortality compared to standard therapy and particularly in those aged above 60 years ,
Studies concluded that DKT is a suitable choice for elderly recepiants.
the Kidney Donor Profile Index (KDPI) score and the Estimated Post-transplant Sur[1]vival Score (EPTS) are recently applied in USA for graft allocation where a low KDPI for a graft is associated with better function and a low EPTS score is associated with a longer patient survival.
Recepiants over 60 years from older than 65 years LD had comparable GS to SCD kidneys and higher GS and PS compared to ECD kidney recepiants.
Screening for certain diseased is crucial in transplant reciepnt evaluation pretransplanting such as
CVD,
infection
malignancy
physical frailty assessment which consists of five items: weight loss, weakness, exhaustion, walking speed and physical activity
physical function
Cognitive function and adherence to medications
Conclusion : Age is not an obstacle for renal transplantation with favourable outcomes just proper pretransplantation assessment is mandatory.
Narrative review
level of evidence V
The number of elderly patients undergoing renal transplantation is increasing in the US
Elderly patients survival after transplant vs elderly patients survival in waitlist on dialysis:
Renal transplant in elderly improves patient survival and decrease mortality rate when compared to elderly patients on dialysis.
relative risk of death is higher during first 2 weeks after transplantation in elderly
one study from UK revealed equal survival rate in elderly receiving transplant and on dialysis
Elderly vs. younger renal transplant recipient:
Patient survival:
Graft survival:
Acute rejection:
Infection rate & associated complications:
Quality of life:
Outcomes based on donor source:
Waitlist mortality & waiting time:
Methods to increase donor pool:
Allocation strategies:
Use of living donor kidneys:
Outcomes based on pre transplant characters:
There is a higher risk of death with functioning graft in elderly
Comorbidities:
Frailty:
Physical function:
Cognitive function:
Recommendations:
Narrative review.
Level of evidence 5.
Summary of outcomes
Patient survival rate is higher when patients undergo renal transplantation in comparison with remaining on the waitlist while undergoing dialysis regularly. However, the fact remains that the risk of mortality post renal transplantation is higher within the immediate 2 week period. The rate of mortality risk is equalized between the two groups (transplant and dialysis -waitlist groups) only around 100 days.
Elderly recipients have a greater mortality risk in comparison with younger recipients of renal transplant. The most common cause of death in older recipients with death with functioning graft, with the trigger being cardiac disease and infection.
Graft survival is also found to have lower rates among the elderly recipients in comparison with younger recipients. This could be contributed by the fact that elderly recipients receive organs from older donors in comparison with the younger recipients who have a chance of getting younger donors.
Elderly recipients have a reduced risk of acute rejection. This could be because of the changes in the immune system with increasing age of the recipient, this process is known as immunosenescence. The risk of AR is also dependent on the age of the donor.
Although this is the case, if AR occurs in elderly recipients, it can have a more significant and negative impact and could be fatal with graft loss or death, while in younger recipients the impact may not leads to death.
Infection incidence is higher in the elderly group. This also leads to complications such as death censored graft failure, urinary infections, BK viremia, and PVAN or polyomavirus associated nephropathy.
Transplantation increases the quality of life quotient in these patients, with better physical functioning, reduction in bodily pain, increase in general health standard, vitality and social functioning in comparison with remaining on dialysis.
This study is a narrative review article with lowest level of evidence (level 5)
The percentage of old patient with ESKD who receive kidney transplantation is increasing and reach up to 22% of those receiving transplant in some countries with good accessibility.
It seems kidney transplantation shows survival advantage over different ages compared being in the waiting list. Even renal transplantation improves patient survival in elderly patients, as many studies have demonstrated may lead to 4-5 extra life years in contrast to those who remained in the waiting list. But some issues should be taken in to consideration and an assessment of benefits and risks for every individual patient should be done. Donors and recipients characteristics may influence the outcome of kidney transplantation. On the other hand, survival in patients on dialysis has improved in many countries in recent years.
Elderly recipients have lower patient and graft survival compared to younger recipients and are more likely to die with a functioning kidney allograft. As a result, death censored graft survival may be similar to or even better than younger patients. One study demonstrated that with every decade increase in the age, death censored graft survival has increased progressively.
Risk of acute rejection s lower in elderly recipients may be due to lower immune response that is defined as immunosenescense and depends on the recipient’s age as well, but the consequences of acute rejection are worse than in younger recipients. Infection with CVD, are the most causes of death after kidney transplantation and these are more prominent in elderly recipients.
Kidney transplantation is associated with improvement in the quality of life in elderly recipients like younger recipients.
Increasing time spent on dialysis is associated with worse patient and graft survival outcome.
Good results with ECD kidneys transplanted in elderly recipients were reported. Receiving allograft from DCD donors and dual kidney transplantation are other ways to reduce the time spending on dialysis for elderly patients.
Overall, new allocation systems utilize KDPI and EPTS, and more effectively match graft life expectancy with patient life expectancy.
Living donor kidney transplantation is associated with excellent PS and GS in elderly recipients, although they have less probability of receiving living donor allograft.
Although age per se is not a contraindication for kidney transplantation, the elderly transplant candidate’s characteristics such as frailty, comorbidities, life expectancy, physical and mental function should be considered.
Dear All
Do you think that this article is a systematic review?
Yes.
Systematic review:
It has a well defined question, with well defined criteria for selection of articles from literature.
A narrative review might not have clarity on the methods used as well as the selection criteria and it has a wider scope than the systematic reviews
unfortunately, elderly pts with ESRD are increasing in numbers worldwide in paralell with increasing their comorbidities. as renal transplantation is the best option of ttt for ESRD pts, this has created a more greater demand for kidney donors who are already lacking. this article described the outcome of this therapy in those elderly pts.
the conclusion was as folowing :
1- Renal transplantation is still the best ttt for those elderly pts with ESRD and should be offered to them. However, the multiple comorbidities should be taken into a serious consideration and candidates are carefully selected.
2- patient and graft survival are lower in those elderly pts, if compared to these of young pts.
3- patient survival for transplanted elderly pts is lower in the 1st year, if compared to remaining on hemodialysis. after the 1st year, the survival will be better for transplanted pts.
4- optimum immunosuppression in transplanted elderly pts is still unclear as the risk benefit ratio is different than in other pts.
You have not seen my answer above. It is a systematic review, level 1B. I’m not impressed
sorry sir
This is review article with level of evidence 5. Many conclusion could be drawn from this extensive review.
The increase in life expectancy in the developed countries was associated with increase comorbidities including DMII, hypertension, vascular diseases and coronary artery disease. With the increase in vascular related diseases, the incidence of chronic kidney diseases and end stage renal diseases are becoming more and more prevalent and problematic especially with the increase in economic burden related to health care system. The improvement in renal medical care and developments in renal replacement therapies does not improve the overall survival as expected.
Kidney transplantation remains the optimal treatment of end stage renal disease. The incidence of end stage renal disease among older population becoming more prevalent and despite old age, these patients are still considered candidates for kidney transplantation and age is not a contraindication. Kidney transplantation is associated with better quality of life, better survival rate, better cardiovascular outcomes when comparing to dialysis regardless of patient’s age, comorbidities, HLA mismatch and kidney donor profile index.
In UK, around 30% of all kidney transplantation is done in the age group older than 60 years. In USA 18.4% of kidney recipients are 65 years and older. This statistics opened the door for more kidney transplantation in this elderly age group especially that most encountered patients with ESRD are elderly with estimation of 38% of CKD population in USA aged more than 65 years.
This review article was designed to study the outcomes of kidney transplantation in elderly recipients, in terms of patients survival, graft survival comparing to younger kidney recipients and taking in consideration kidney donor source.
Transplantation was associated with an initial increase in mortality in the first few weeks following transplantation with an increase relative risk of death 2-4 times comparing to patients on dialysis, which became equal in both groups at around 100 days and the likelihood of survival equalized at 8 months. It took longer for those aged between 60 and 74 years to reach these points.
Elderly recipients have a higher risk of death following surgery compared to younger RTRs. The main causes of death were cardiac, infection and malignancy. Elderly patients are seven times more likely to die with a functioning graft compared with patients aged 18–29 years.
Graft survival in elderly patients is worse when compared to younger recipients because older patients are getting more kidneys from EDC or from old donors from SDC.
Elderly recipients are associated with a reduced risk of AR and this was independent of baseline immunosuppression. Lower rate of AR is attributed to immunosenescence.
Elderly recipients are at a higher risk of developing infections. There was a linear increase in death due to infection in the waitlisted group which was increasing with age group more than 65 years.
Quality of life Transplantation is associated with an improvement in the quality of life in terms of social, psychological and physical activities.
Increased waiting time on dialysis impacts on both PS and GS, GS for DD transplants was much more higher for pre-emptive transplants compared to for transplant after 2 years on dialysis.
Use of ECD kidneys Several studies have reported good results with ECD kidneys transplanted in elderly RTRs. Some studies showed that elderly recipients aged above 70 years receiving ECD kidneys had reduction in overall risk of death compared with waitlisted candidates.
Use of living donor kidneys LD renal transplantation is associated with better PS and GS in all group ages including patients above 65 years.
1. It is a narrative review
2. Level of evidence 5
—————————————————————–
3. Summary
OUTCOME of KIDNEY TRANSPLANTATION in the ELDERLY
(I) OVERALL OUTCOME
● In comparison to those on dialysis (waitlisted for transplantation) —–> Patient survival (PS)
. Improvement of PS.
. Reduction of mortality rate, however some authors reported that there is increase of mortality rate initially after transplantation especially the first two weeks.
. Equal survival rate becomes clear after average 8 months (244 days). The duration differs according to the age, which is longer with older patients.
. Increase of expected extra life years (by 5.3 years for younger than 70 and 3.7 for above 70 years)
————
● In comparison to younger renal transplant recipient (RTR):
☆ Patient survival:
. Death risk in higher in elderly
. Mortality rate is increased with increased age
. Death with a functioning graft is about 7 fold increase in elderly and considered as the main cause of graft loss in above 65 years.
. Cardiac disease and infection are the principle causes of death.
☆ Graft survival (GS)
. GS is more worsen in elderly (they received older donor Kidneys)
. Higher risk of graft failure.
. Some authors reported that death-censored graft survival (DCGS) is that same among ages from younger than 50 to older than 65 years.
☆ Acute rejection (AR)
. AR is lower with older age of recipients, while it is higher with older age of donors.
. AR ,as a cause of graft failure, is more incident in elderly by about 3 folds and leads to high mortality rate in this age group.
☆ Infection
. Elderly renal recipients have a more incidences of infection which is considered the second cause of death in this group (linear association) regardless the immunosuppressive agents used.
. UTI , BK virus and polyomavirus-associated nephropathy (PVAN) are the common infections.
☆ Quality of life (QOL)
. Better QOL is evident with transplantation physically, mentally and socially.
————————————————————
(II) OUTCOME based on DONOR SOURCE
☆ TIME on DIALYSIS
. The longer duration on dialysis, the more worse rate of patient survival, so living donor and extended criteria donor (ECD) transplantation are helpful in decreasing time on waiting list for transplantation.
. Pre-emptive kidney transplantation has a better outcomes for graft survival than transplantation after dialysis for 2 years.
—————-
☆ Extended criteria Donor (ECD)
. One of the resources to enlarge the pool of donor to shorten the waiting list for transplantation.
. Kidneys of ECD has a greater PS and lower risk of death than those on dialysis.
. PS is decreased with older donor age.
. ECD kidneys from older than 70 years has a lower rates of PS and GS than these from younger age (50-69 years).
Surprisingly, transplant of older ECD Kidneys into younger recipients ( Eurotransplant Senior Programme (ESP)
65-year or older recipients received DD kidneys of 65-year or older regardless the matching of HLA.
°(ESP recipients have a lower rate if PS and GS than younger recipients (60-64) from any age groups)
• US ——>
Kidney Donor Profile Index (KDPI) score and the Estimated Post-transplant Survival Score (EPTS)
LOW score of KDPI —–> better graft function
LOW score of EPTS —–> better patient survival
——————–
☆ LIVING DONOR KIDNEYS (LD)
. It has a higher rate of PS and GS.
. There is more than 50 % decease in mortality rate in 70-year recipients from LD than those waiting on dialysis.
. It has a better outcomes than ECD.
. Elderly recipients account of small percentage of recipients of LD kidney transplantation.
————————————————————
(III) OUTCOMES based on PRE-TRANSPLANT CHARACTERISTICS
. Elderly candidates for transplantation (regardless of age) should be meticulously selected and assessed according to many factors such as the comorbidites, physical activity and cognitive functions.
☆ Comorbidity
. Comorbidity is associated with high mortality rate and low life expectancy after transplantation. Therefore, screening for cardiovascular diseases, malignancy and infection is recommended before transplantation.
. Charlson Comorbidity Index is a prediction method for determining mortality risk and life expectancy after transplantation.
☆ Frailty
. Frailty means reduction of physiological functions and increasing of dependency.
. Frailty score depends on 5 parameters; physical activity, walking speed, exhaustion, weight loss and weakness.
. High score is predictive of high risk of DGF and mortality rate.
☆ Physical functions (functional status)
. It is evaluated by either by questionnaire of the patient or objective assessment by grip strength, gait speed, short physical performance battery (SPPB) or peak oxygen uptake ( VO²).
. Deceased physical activity is linked to low percentage of patient survival and high mortality rate.
☆ Cognitive functions
. Impairment of cognitive functions, mainly memory, is connected to non-adherence of immunosuppressive and therefore graft loss.
• Transplantation for elderly ESRD patients is a better option than dialysis in terms of longer patient survival and better quality of life, in spite of the higher risk of mortality in the transplantation, particularly in the first year of transplantation which relay on comorbidites of recipients and donor Kidneys.
• Living donor transplantation has a better outcomes than deceased donor transplantation. However, if LD is not accessible, transplantation of kidneys with extended criteria has a better outcomes than dialysis.
• Meticulous evaluation of potential elderly recipients before transplantation is an essential step to predict the outcome.
You have not seen my answer above. It is a systematic review, level 1B. I’m not impressed
Review article
Evidence 5
Renal Transplantion in elderly
Renal Transplantation improve the long term survival and quality of life of most patients including older patient but still There is significant
Comorbidities
Screening Tool may help to identify Suitable candidate for transplantation using data from french national registry (REIN)
The following point system are
●Male (1 point)
●Age 75 to 80 years (2 points)
●Age 80 to 85 years (5 points)
●Age >85 years (9 points)
●Diabetes (2 points)
●Intermittent hemodialysis (2 points)
●Peripheral vascular disease, stage III to IV (5 points)
●Congestive heart failure, stage I to II (2 points)
●Congestive heart failure, stage III to IV (4 points)
●Arrhythmia (2 points)
●Chronic respiratory disease (2 points)
●Active malignancy (5 points)
●Severe behavioral disorder (6 points)
●Cardiovascular disease (1 point)
●Decreased mobility (needs assistance for transfers) (4 points)
●Totally dependent (9 points)
●Body mass index (BMI) 21 to 25 (1 point)
patients with a score of 0 to 6 points, the probability of being alive within three years was approximately 70 percent.(1)
Out come
1-Patients survival
higher risk of death in elderly recipients.
The main causes of death are
1-infection.
2-cardiovascular disease
3-malignancy
death with functioning graft account for majority of graft loss in older candidate
2 -Graft survival
because Elderly recipients are more likely to receive kidney from older donors So this will lead to high risk of graft loss
3-acute rejection
Older renal transplant recipients were less likely than younger recipients to have Biopsy-proven acute rejection
Prevention of rejection is generally easier in older patients due to natural immunosenescence allowing reduced dosage of immunosuppressant medication.
Immunosuppressant dose reduction in older renal transplant recipients has been associated with improved recipient and graft survival, reduction in cardiovascular risk, reduced drug side effects and cost savings
However, if they do experience acute rejection, this episode is more likely to compromise graft- and or patient survival
4 -infection and cardiovascular disease
Most infections occur in the first six months post transplant and are related to the degree of immunosuppression. A greater degree of immunosuppression results in an increased risk of infectious complications in all patients (young and old). However, as previously mentioned, immunocompetence decreases with age; as a result, older individuals are more susceptible to infectious complications at lower levels of immunosuppressive therapy. Agents associated with the highest infection risk are high-dose glucocorticoids and anti lymphocyte antibodies used in the induction immunosuppressive regimen.
– Even in the absence of immunosuppression, older subjects have an increased risk of cardiovascular disease and an increased risk of cardiovascular-related death. In addition, some risk factors for heart disease, such as hypertension and diabetes mellitus, may be exacerbated or induced by immunosuppressive medications.
5-Donors sources
out comes with kidney from older living donors are acceptable and better than DD.
A living-donor kidney is preferred, if it is available. Among all recipients, including older adults, living-donor kidneys are associated with better patient and graft survival compared with deceased-donor kidneys. The use of a living-donor kidney allows for preemptive transplantation before the candidate needs to start dialysis. Among most patients, preemptive transplantation is associated with superior outcomes compared with transplantation after initiation of dialysis.
because older candidates wait more time on waiting list so we need to increase donors pool to include
1-ECD
2-DD ((DCD donation after circulatory death,DBD donation after brain death))
Reference
1-Update Oct 2021.
as a narrative review, it has level evidence of five
summary:
the ratio as the outcomes is different among countries. Transplanting patients over 75 years is not performed in some countries. speaking in general, transplanting is better and favorable to staying on dialysis. A transplant from extending criteria donors is still better than maintaining dialysis. Successful transplant especially in the elderly is dependent on many factors. recipients should be evaluated in the aspect of comorbidities cognitive function and fragility. frail patients were found to have less favorable results. either transplanted from deceased of living, elder or young, recipients had better outcome compared to dialysis. in terms of quality of life, the same observations are seen. a living donor is better than a deceased donor. patients with accompanying comorbidities had a worse prognosis. the dual transplant was associated with venous thrombosis. elderly should be evaluated for transplant when eligible and thorough evaluation, pretransplant is essential for better outcomes.
You have not seen my answer above. It is a systematic review, level 1B. I’m not impressed
Type of this study:
Systematic Review ( as it reviewed articles published between 2005 and 2018).
Level of evidence :
Level 1a
Summary:
The study aimed at assessing the benefits and risks of renal transplant in elderly RTRs by assessing overall outcomes and outcomes based on donor source and pre-transplant characteristics.
Renal transplantation improves patient survival (PS) in elderly patients when compared to those remaining waitlisted on dialysis.One of the reviewed articles (Wolfe et al)stated that the transplantation was associated with an initial increase in mortality and risk of death in the first 2 weeks with 2.8 times as high as those remaining waitlisted on dialysis. Another reviewed article(Gill et al) showed that the expected extra life years is much higher in RTRs than those waitlisted on dialysis . Study by (Wolfe et al) may be explained by the good and perfect services given to dialysis patients in the study area (UK) as dialysis services and outcomes
are known to be better than in USA.
The systemic review evidenced that the Elderly recipients have a higher risk of death compared to younger and the main causes of death were cardiac (21%), infection (21%) and malignancy (20%){Karim et al}. Overall patient survival for elderly RTRs above the age of 70 was less than PS for those in 60-69 years and death with a functioning graft was common in those above 65 (Huang et al).
The followings are worse among elderly RTRs in comparison with younger recipients;Patient Survival(PS) Graft survival (GS),Infection rates. While elderly RTRs are associated with a reduced rate of acute rejection (Meier-Kriesche et al). Death-censored graft survival (DCGS) in elderly RTRs is similar, or even better, to younger patients (Heldal et al).
Increased waiting time on dialysis impacts on both PS and GS(Meier- Kriesche et al) and strategies such as expanded criteria donor (ECD) and LD transplantation may increase access of elderly patients to transplantation (https://doi.org/10.2215/CJN.03490410.Not) all studies have shown a survival advantage of ECD kidneys in older recipients compared to patients of similar age remaining waitlisted and this could be due to better survival rates for patients on the waiting list because of optimum dialysis services and patient care in some study areas as explained earlier, adding to that some studies assess the impact of ECD kidneys in different recipient age groups.
Strategies to increase the donor pool and impact on outcomes are:
Age is not a contraindication to renal transplantation. However, careful selection of the potential elderly transplant candidate is important due to the increased risk of death with a functioning graft.Assessment of comorbidity, frailty, physical and cognitive function should be included in the evaluation process.
Based on data analysis and review this systematic review article recommended the followings:
Well done
Please contact me for your reward
1.1. It is a review article
2. level of evidence 5
3. Summary for outcomes of renal transplantation in the elderly:
Renal transplantation improved patient survival in the elderly when compared to those remaining waitlisted on dialysis but there is an increase in mortality within the first 2 weeks and became equal in both groups in 106 days and the likelihood of survival equalized at 244days according to Wolfe et al study. A study from the UK did not show elderly patient survival not improved with renal transplantation.
Elderly recipients have a higher risk of death compared to the younger renal transplanted recipient. They are more commonly died with functioning grafts. the most common causes of death cardiac disease, infections, and malignancy in Karim et al study.
The graft survival is reduced in elderly patients in comparison to the younger renal transplanted recipient because they received a donation from an older patient that is associated with graft failure.
In the study by Molnar et al, the resulting death–censored graft failure risk was reduced which is explained by deaths caused by poor graft function are classified as death with functioning graft.
Elderly recipients are associated with reducing the risk of acute rejection that due to change of immune system with aging(immunosenescence)but it increases with the increase of donor age. They have a high risk of infection and its complications.
Elderly recipients have better physical function, social functioning, and general health.
Increasing time on dialysis before transplant is associated with poor patient and graft survival but some studies showed better patient survival with extended criteria kidney compare to remaining on dialysis.
The deceased donation can be expanded by using kidneys from donation after circulatory or brain death in elderly patients. Living donor transplant recipient has better patient survival than deceased donor transplant recipient.
Elderly patients need proper assessment for cognitive function, frailty, comorbidities, and physical functions for renal transplantation.
several studies show that both patients & graft survival are better compared to dialysis patients. Although in early post transplantation period the patient & graft loss are high but after first year of transplantation both patient & graft failure & acute rejection rate are lower.
All types of kidney donor are better in outcome including deceased standard donor, ECD, DCD and live donor ( show immediate graft advantage even in patients with co morbidities.
review article
level of evidence 5
in this article the author described the risks and the benefit of transplanting elderly patients and he described the outcome of transplanting such age group of patients.
the number of elderly patients with ESRD is increasing worldwide. studies showed survival benefit of transplanting such patients compared to dialysis. elderly patients should be evaluated thoroughly to assess the risks and the benefit of transplantation & to obtain a suitable balance between the risks and the benefits.
transplanted elderly patients have lower survival benefit as compared to younger patients.
overall outcomes:
outcomes based on donor source:
outcomes based on pre-transplant characteristics:
You have not seen my answer above. It is a systematic review, level 1B. I’m not impressed
This is Narrative Review article
Level of evidence 5
The aim of this review is to assess the bene!ts and risks of renal transplantation in elderly RTRs by assessing (a) overall outcomes and outcomes based on (b) donor source and (c) pre- transplant characteristics.
Overall outcomes
Comparison of patient survival with patients remaining waitlisted on dialysis
Renal transplantation improves patient survival (PS) in elderly patients when compared to those remaining waitlisted on dialysis
Transplantation was associated with an initial increase in mortality with a relative risk (RR) of death in the !rst 2 weeks which was 2.8 times as high as those remaining waitlisted on dialysis.
Comparison with younger RTRs
Patient survival
Elderly recipients have a higher risk of death compared to younger RTRs
Elderly patients are seven times more likely to die with a functioning graft compared with patients aged 18–29 years
Graft survival
Graft survival (GS) in elderly patients is worse when compared to younger recipients. Elderly recipients are more likely to receive kidneys from older donors, which in turn are associated with an increased risk of graft failure
Acute rejection
Elderly recipients are associated with a reduced risk of AR
A lower rate of AR may be due to changes in the immune system that occur with ageing referred to as immunosenescence , The risk of AR is also dependent on donor age.
the frequency of AR declined with every cohort of increasing recipient age and it increased with every decade of increasing donor age. Kidneys from older donors may have a lower regenerative capacity to tissue injury in- creasing immunogenicity.
The impact of AR on PS and GS may be more severe in the elderly RTR.
Infection rates and associated complications
Elderly recipients are at a higher risk of developing infections. Infections in the elderly are associated with an increased risk of com- plications.
Both bacterial and viral infections have been reported to be particular problems in elderly RTRs particularly urinary infections, BK viraemia and polyomavirus- associated nephropathy (PVAN)
Quality of life
Transplantation is associated with an improvement in the quality of life (QOL)
Outcomes based on donor source
Waitlist mortality and impact of waiting time on dialysis on patient and graft survival:
Increased waiting time on dialysis impacts on both PS and GS.
Strategies such as expanded criteria donor (ECD) and LD transplantation may increase access of elderly patients to transplantation .
Outcomes based on pre-transplant characteristics
Age is not a contraindication to renal transplantation. However, careful selection of the potential elderly transplant candidate is important due to the increased risk of death with a functioning graft. Guidelines include age-related comorbidities as relative contraindications and some use a minimum post-transplantation life expectancy between two and 5years as a contraindication to waitlisting .Assessment of comorbidity, frailty, physical and cognitive function should be in- cluded in the evaluation process.
Thanks, Asmaa
Do you think it is a systematic review rather than a narritive review?
The narrative review article (as this article) take publications from limited period of time (in this article from 2005 to 2018) while in systematic review it is more comprehensive and take articles through extended period of time .
Narrative literature review articles are publications that describe and discuss the state of the science of a specific topic or theme from a theoretical and contextual point of view. … Systematic literature review articles are considered original work because they are conducted using rigorous methodological approaches.
Thank you, Asmaa
Do you think the time factor should determine the type of the review or the research question?
You have not seen my answer above. It is a systematic review, level 1B. I’m not impressed
This study is a narrative review. It takes a less formal approach compared with systemic reviews because narrative reviews do not present the more rigorous aspects that are seen in systemic reviews such as search terms, reporting methodology, database used, and inclusion and exclusion criteria. The given review does present a certain level of methods used but it isn’t as comprehensive and detailed as in every stage involved as would be the case with systemic reviews.
You have not seen my answer above. It is a systematic review, level 1B. I’m not impressed
Narrative Review , level of evidence 5
It discuss the benefit versus the risks of renal transplantation in old age recipient , taking the into consideration donor source and donor criteria.
Renal transplantation is safe procedure can be done in elder patient but after good selection of them depends on their comorbidities and the donor source also.
The candidate should be assessed well as regard comorbidities, cognitive function, psychological status, his adherence to medications.
Of course, his quality of life will be better after transplantation than being on dialysis, but he should know that there is increased risk of death with functioning graft especially early after transplantation more than being stay on dialysis.
The old candidate has low immunological response , so the percent of cellular rejection is lower than younger age candidate who have stronger immune system.
Donors may be live or deceased , and complications of deceased donor should be clarified and explained to the patient especially if old age donor.
You have not seen my answer above. It is a systematic review, level 1B. I’m not impressed
Dear All
I’m waiting for your replies