© 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).
Powyżej zamieściliśmy fragment artykułu, do którego możesz uzyskać pełny dostęp.
1. Eggers PW: Effect of transplantation on the Medicare end-stage renal disease program. New Engl J Med 1988; 318: 223.
2. Rutkowski B, Lichodziejewska-Niemierko M, Grenda R et al.: Polski rejestr nefrologiczny. Zespół konsultanta krajowego w dziedzinie nefrologii. Raport o stanie leczenia nerkozastępczego w Polsce 2007, Gdańsk 2009.
3. Bethesda MD: US Renal Data System. USRDS 2008 annual data report: atlas of end-stage renal disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases 2008.
4. Delmonico FL, Cosimi AB, Russell PS: Renal transplantation in the older age group. Arch Surg 1975; 110: 1107.
5. Simmons RL, Kjellstrand CM, Buselmeier TJ, Najarian JS: Renal transplantation in high-risk patients. Arch Surg 1971; 103: 290.
6. Rowińska D, Dębska-Ślizień A: Przygotowanie pacjenta z przewlekłą niewydolnością nerek do przeszczepienia nerki. Dializoterapia w praktyce lekarskiej. Gdańsk, MAKmedia 2004; 595-610.
7. Fehrman I, Brattstrom C, Duraj F, Groth CG: Kidney transplantation in patients between 65 and 75years of age. Transplant Proc 1989; 21: 2018.
8. Murie JA, Lauffer G, Gray D et al.: Renal transplantation in the older patient. Transplant Proc 1989; 21: 2024.
9. Tapson JS, Rodger RSC, Mansy H: Renal replacement therapy in patients aged over 60 years. Postgrad Med J 1987; 63: 1071.
10. Fauchald P, Albrechtsen D, Leivestad T: Renal replacement therapy in elderly patients. Transplant Int 1988; 1: 131.
11. Roza AM, Gallagher-Lepatk S, Johnson CP, Adams MB: Renal transplantation in patients more than 65 years old. Transplantation 1989; 48: 689.
12. ERA-EDTA Registry: ERA-EDTA Registry Annual Report 2009. Academic Medical Center, Department of Medical Informatics. Amsterdam, The Netherlands 2011.
13. Wong G, Howard K, Chapman JR et al.: Comparative survival and economic benefits of deceased donor kidney transplantation and dialysis in people with varying ages and co-morbidities. PLoS One 2012; 7(1): e29591.
14. Grams ME, McAdams Demarco MA, Kucirka LM, Segev DL: Recipeint Age and time spent hospitalized in tue year before and after kidney Transplantation. Transplantation 2012.
15. Meier-Kriesche HU, Ojo AO, Hanson JA, Kaplan B: Exponentially increased risk of infectious death in older renal transplant recipients. Kidney Int 2001; 59: 1539-1543.
16. Jordan ML, Novick AC, Steinmuller D: Renal transplantation in the older recipient. J Urol 1985; 134: 243.
17. Howard RJ, Pfaff WW, Salomon D: Kidney transplantation in older patients. Transplant Proc 1989; 21: 2020.
18. Kauffman HM, McBride MA, Cors CS et al.: Early mortality rates in older kidney recipients with comorbid risk factors. Transplantation 2007; 83: 404-410.
19. Meier-Kriesche HU, Ojo A, Hanson J, Cibrik D et al.: Increased immunosuppressive vulnerability in elderly renal transplant recipients. Transplantation 2000; 69: 885-889.
20. Kuypers DR: Immunotherapy in elderly transplant recipients: a guide to clinically significant drug interactions. Drugs Aging 2009; 26(9): 715-737.
21. Chuang P, Parikh CR, Langone A: Urinary tract infections after real transplantation: a retrospective review at two US transplant centers. Clin Transplant 2005; 19: 230-235.
22. Trouillhet I, Benito N, Cervera C et al.: Influence of age in renal transplant infections: cases and controls study. Transplantation 2005; 80: 989-992.
23. Westlie L, Umen A, Nestrud S, Kjellstrand CM: Mortality, morbidity, and life satisfaction in the very old dialysis patient. Trans Amer Soc Artif Intern Organs 1984; 30: 21.
24. Husebye DG, Westlie L, Styrvoky TJ, Kjellstrand CM: Psychological, social, and somatic prognostic indicators in old patients undergoing long-term dialysis. Arch Intern Med 1987; 147: 1921.
25. Apostolou T, Hutchison AJ, Boulton AJ et al.: Quality of life in CAPD, transplant, and chronic renal failure patients with diabetes. Ren Fail 2007; 29: 189-197.
26. Rebollo P, Ortega F, Baltar JM et al.: Health related quality of life (HRQOL) of kidney transplanted patients: variables that influence it. Clin Transplant 2000; 14: 199-207.
27. Humar A, Denny R, Matas AJ, Najarian JS: Graft and quality of life outcomes in oder recipiens of a kidney transplant. Exp Clin Transplant 2003; 1(2): 69-72.
28. Rao PS, Merion RM, Ashby VB et al.: Renal transplantation in elderly patients oder than 70 years of age: results from the Scientific Registry of Transplant Recipients. Transplantation 2007; 83(8): 1069-1074.
29. Stallone G, Infante B, Gesualdo L: Older donors and oder recipiens in kidney Transplantation J Nephrol 2010; 23 (Suppl. 15): s98-103.
30. Pedroso S, Martins L, Fonseca I: Real Transplantation in patients oder 60 years of age: a single center experience. Transplant Proc; 38(6): 1885-1889.
31 Saxena R, Yu X, Arenas J: Renal Transplantation in the elderly. Int Urol Nephrol 2009; 41(1):195-210.
32. Debska-Slizien A, Jankowska MM, Wołyniec W et al.: A single Center experience of real Transplantation in elderly patients: a paired – kidney analysis. Transplantation 2007; 83(9): 1188-1192.