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Excerpt
The older (>60 yrs) renal transplant recipient is an interesting paradox to the transplant surgeon with regards to their assumed decreased ability to mount a clinical immune response. It has been previously reported that older recipients tend to have fewer acute rejection episodes; we questioned if their decrease immune response would lead to increased mortality or graft loss from a clinical infectious challenge, such as a post-transplant gastrointestinal complication requiring surgery. Over a ten year period (1987-1996), our institution performed 1467 renal transplants; 208 recipients were 60 years of age or older. The older recipients did not differ from the younger with respect to proportion of cadaveric vs. living donor grafts, percentage receiving anti-lymphocyte induction immunosuppression, or pre-existing diabetes (DM). They did tend to have more polycystic kidney disease (PKD) (p=0.05 by Chi-Square) and fewer acute rejection episodes (31 vs 44%, p<0.001). Their six month(0.90 vs 0.96) and one year(0.86 vs 0.94) patient survival were less than the younger patients(p=0.002 and p<0.001, log rank of Kaplan-Meier curves). Their death-censored graft survival was not different at two years(.87 vs. .92, p=0.13), but did reach statistical difference by the third year (0.86 vs. 0.90, p=0.02).
The percentage of older patients who did require an operation for a GI complication post-transplant was not different from the younger group. The older patients also had no increase in the percentage with bowel perforations or in their likelihood of having PKD, DM, or anti-lymphocyte induction therapy. The number of GI operations per patient was also the same, i.e., no increase in recurrent operations per patient. Most surprisingly, there was no difference in patient survival at six months, one year, or ten years in the patients who had GI surgical operations. We then focused on the early posttransplant period, less than 90 days, to accentuate the difference in immune response. Of the recipients who did require operations during this period, fewer were older patients(2.9 vs 6.3%, p=0.02). Only one of 13 older patients displayed acute rejection within 90 days of their operation compared to 8 of 37 younger patients(p>0.05). The older patients in this early posttransplant GI surgery group displayed no difference in renal graft loss at one or two years, and did have improved long-term death-censored graft survival(p=0.046, log rank) vs. younger patients. There was no difference in patient death at six months, one year, or ten years in these patient groups.
Renal transplant recipients age 60 years or over do not have an increased incidence of early or late posttransplant GI complications requiring operative intervention. The older patients tend to have less acute rejection episodes, both independent of GI operative intervention and after such complications. The older recipients appear to have a graft and patient survival advantage after GI operative interventions compared to the younger patients.
