© Borgis - Postępy Nauk Medycznych 2/2013, s. 118-123
*Joanna Stępniewska1, Ewa Kwiatkowska1, Marek Myślak1, Barbara Dołęgowska2, Magda Wiśniewska1, Małgorzata Marchelek-Myśliwiec1, Kazimierz Ciechanowski1
Starszy nie znaczy gorszy – wyniki transplantacji nerek u seniorów
Older does not mean worse – the results of kidney transplantation in seniors
1Department of Nephrology, Transplantology and Internal Medicine, Pomeranian Medical University, Szczecin
Head of Department: prof. Kazimierz Ciechanowski, MD, PhD
2Department of Medical Analysis, Pomeranian Medical University, Szczecin
Head of Department: prof. Maria Jastrzębska, MD, PhD
Wstęp. Występowanie przewlekłej choroby nerek wzrasta z wiekiem. Starsi pacjenci coraz częściej kwalifikowani są do dializoterapii oraz do zabiegu przeszczepienia nerki. Charakteryzuje ich specyficzny profil współchorobowości, wpływający na przeżycie graftu i pacjenta.
Materiał i metody. Grupę badaną stanowiło 64 pacjentów w wieku powyżej 65. roku życia (średnio 66,2 ± 2,8) poddanych transplantacji nerki, obserwowanych w czasie 7 lat po zabiegu.
Wyniki. Przeżycie pacjenta w pierwszym roku po transplantacji oceniono na 84,4%, a nerki przeszczepionej na 76,5%. Pierwszoroczne przeżycie pacjentów determinowane przez zgony z czynnym graftem stanowiło 84,4%. Dwuletnie przeżycia pacjentów i przeszczepionych nerek wynosiły odpowiednio: 84,4 i 70,3%. Głównymi przyczynami zgonów były incydenty sercowo-naczyniowe i infekcje.
Wnioski. Przedstawione wyniki potwierdzają skuteczność przeszczepiania nerek u wybranych pacjentów powyżej 65. roku życia w porównaniu do młodszych chorych. Głównym problemem w grupie seniorów pozostaje śmierć z czynnym graftem.
Introduction. The prevalence of chronic kidney disease is rising with advancing age. The elderly patients are qualified to the dialysis treatment and are increasingly being considered to the kidney transplantation. They are characterized by specific co-morbidity profile, that compromise graft and patient outcome.
Material and methods. A group of 64 patients aged over 65 years (mean 66.2+/-2.8) were studied during the seven year period after kidney transplantation.
Results. One-year patient survival was assessed as 84.4% and graft survival 76.5%. The death-censored graft survival in the first year after transplantation was 84.4%. The two- years patient and graft survival were 84.4% and 70.3%, respectively. The main causes of death were cardio-vascular diseases and infections.
Conclusions. Our results confirm that renal transplant must be considered in selected patients older than 65 years as patient and graft survivals are similar to those of younger patients. The leading problem is death-censored graft survival.
Chronic kidney disease become an illness of the elderly. Every year the number of dialyzed patients aged over 65 years increases in Poland and all over the world. It is related to prolonged life expectancy, better medical care and access to replacement therapy. The ageing of the society results in growing morbidity due to civilization diseases, so we have to look forward the rise of the elderly people population ongoing regular dialysis. From the Medicare data, since 80’ in United States patients over 65 years of age accounted for 30% dialyzed ones (1). The Polish renal replacement registry reports 56% patients in this age, who have begun the dialysis in 2007 and 47.5% in the end of this year. It is worth noting, that patients aged over 75 years constituted 15.43% among dialyzed population in Poland in 2007 (2). A high percentage of dialyzed older people is also caused by their low registration to the transplantation waiting list. This phenomenon is based on the opinion about higher risk than benefits from the renal transplantation in the elderly. In 2006 in United States only 6% of elderly people ongoing regular hemodialysis were enrolled to the waiting list and only 0.8% patients after transplantation were older than 65 years of age (1, 3). The first large study describing a group of elderly people after kidney transplantation was carried out in1971 and showed very poor outcome (4, 5). However, the introduction of the new immunosupression strategies with cyclosporine and tacrolimus, the subsequent reduction of steroids, improved the graft and patients survival in this elder recipient group. Currently in qualification to kidney transplantation age itself is not the exclusion criterion, but the general health and so-called “biological age”.
We evaluate the role of kidney transplantation in the menagement of end stage renal failure in patients older than 65 years. We analyzed the kidney recipients from our center transplanted between 1999-2012 year.
PATIENTS AND METHODS
Between 1999-2012 in our center were performed 796 kidney transplantations. The recipients age ranged from 17 to 76 years. The number of patients older than 65 years was 64, what accounted for 8% of patients after transplantation. This group consisted of 43 men and 21 women. The mean age was 66.2+/-2.8 years. The mean age of the donors for this group was 57.3+/-5.5 years. 63 patients underwent first transplantation. Only one female patient was retransplanted. All patients received kidney from deceased donors. The leading causes of end stage renal disease (ESRD) were diabetes mellitus in 21 subjects, chronic glomerulonephritis in 15 subjects, chronic interstitial nephritis in 5 subjects, autosomal dominant polycystic kidney disease in 6 subjects, hypertension in 7 subjects and other ob unknown causes in 10 subjects. All the examined patients were hemodialysed before transplantation. The mean hemodialysis period was 19.2+/-12.1 months. 9 patients had PRA (panel reactive antibodies) over 20%. The mean CIT (cold ischemia time) was 16.5+/-5.4 hours (tab. 1). The observation period was from 21 days to 7 years (tab. 1).
Table 1. Recipients characteristics.
|Patients age||66.2+/-2.8 years|
|Cause of renal failure|
|DM ||21 (32.81%)|
|Panel reactive antibodies over 20% (%)||9 (5.76%)|
|Cold ischaemia time||16.5+/-6.4 hours|
|AZA, CsA, pred||8 (12.50%)|
|MMF, CsA, pred||23 (35.93%)|
|MMF, TAC, pred||25 (39.06%)|
|AZA, TAC, pred||2 (3.12%)|
|RAPA, TAC, pred||2 (3.12%)|
|RAPA, MMF, pred||4 (6.25%)|
|Type of donor || |
|Deceased donor ||64 (100%) |
RAPA – rapamycin; MMF – mycophenolate mofetil;
CsA – cyclosporine; pred – prednisolone; DM – diabetes mellitus;
GN – chronic glomerulonephritis; Interstitial – chronic interstitial nephritis; ADPKD – autosomal dominant polycystic kidney disease;
HA – hypertension
We evaluated the patient and graft 1 and 2-year survival after renal transplantation in 64 subjects. After this time 23 patients moved for the further care to the other transplant centers so the data from that time were assessed on the smaller group of subjects.
During the whole post transplantation follow up 13 of 64 (20%) recipients have died, including 10 patients (15.6%) in the first year after transplantation. The one- and two-years patient survival was 84.4% (54 patients). The dominating cause of death with functioning graft in the first year after transplantation were cardio-vascular diseases in seven subjects. The other were infectious complications in two subjects and colon cancer in one subject. The mortality in later years was also related to cardio-vascular events in two patients and gastrointestinal bleeding in one patient (tab. 2).
Table 2. One-year patient and graft survival with causes of death and graft loss. Two-year patient and graft survival.
|Patient and graft survival||n (%)|
|One-year patient survival||54 (84.4%)|
|One-year graft survival||49 (76.5%)|
|One-year death censored graft survival||54 (84.4%)|
|Causes of death in the first year after transplantation|
|Cardio-vascular complicationts||7 (10.9%)|
|Causes of graft loss in the first year after transplantation|
|Thrombosis of kidney vessels||3 (4.6%)|
|Acute rejection||1 (1.5%)|
|Surgical complications||1 (1.5%)|
|Two-year patient||54 (84.4%)|
|Two-year graft survival||45 (70.3%)|
Among 31 patients who were followed in our center above 2 years post transplant, three returned to haemodialysis due to the graft failure during follow up period up to 7 years.
20 recipients seven years after transplantation had well functioning grafts (eGFR > 60 ml/min). In the same period of observation among the patients below 65 years of age 71 of 732 transplanted patients died, what gives the mortality rate 9.7%. It is two times lower, than in the elder group.
One-year graft survival was 76.5% (46 patients) and death censored 1-year graft survival was 84.4%. Two-year graft survival was 70.3% and no other patients died in the second year.
The lost of the graft in the first year after transplantation concerned 5 subjects and was due to thrombosis of kidney vessels (3 subjects), acute rejection (1 subject) and surgical complications (1 subject).
Analysis of one-year survival within the > 65 age group shows no age – related differences in both patient and graft survival (fig. 1-3).
Fig. 1. Relationship between age and graft function in the first year after kidney transplantation.
1 – subjects with functioning graft, 0 – graft lost, Tx – transplantation of the kidney
Fig. 2. Relationship between age and graft function in the second year after kidney transplantation.
1 – subjects with functioning graft, 0 – graft lost, Tx – transplantation of the kidney
Fig. 3. Relationship between graft survival and recipients age (Kaplan-Meier).
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