Older candidates for kidney transplantation: Who to refer and what to expect?

Abstract

The number of older end-stage renal disease patients being referred for kidney transplantation continues to increase. This rise is occurring alongside the continually increasing prevalence of older end-stage renal disease patients. Although older kidney transplant recipients have decreased patient and graft survival compared to younger patients, transplantation in this patient population is pursued due to the survival advantage that it confers over remaining on the deceased donor waiting list. The upper limit of age and the extent of comorbidity and frailty at which transplantation ceases to be advantageous is not known. Transplant physicians are therefore faced with the challenge of determining who among older patients are appropriate candidates for kidney transplantation. This is usually achieved by means of an organ systems-based medical evaluation with particular focus given to cardiovascular health. More recently, global measures of health such as functional status and frailty are increasingly being recognized as potential tools in risk stratifying kidney transplant candidates. For those candidates who are deemed eligible, living donor transplantation should be pursued. This may mean accepting a kidney from an older living donor. In the absence of any living donor, the choice to accept lesser quality kidneys should be made while taking into account the organ shortage and expected waiting times on the deceased donor list. Appropriate counseling of patients should be a cornerstone in the evaluation process and includes a discussion regarding expected outcomes, expected waiting times in the setting of the new Kidney Allocation System, benefits of living donor transplantation and the acceptance of lesser quality kidneys.

Keywords: Kidney transplant outcomes, Frailty, Elderly, Expanded criteria donor, Quality of life

Core tip: Transplant physicians must be well-versed in the intricacies of evaluating older kidney transplant candidates. This includes the appropriate selection of candidates which can be challenging due to the extent of comorbidity and frailty in this patient population. For patients who are deemed appropriate for transplant, physicians must be able to counsel them regarding expected outcomes and explain the expected benefit that transplantation confers over remaining on the deceased donor waiting list. Living donor kidney transplantation, even from older donors, should be encouraged. If no living donor is available, the rationale for accepting lesser quality kidneys should be discussed.