Long-Term Patient and Graft Survival in the Eurotransplant Senior Program: A Single-Center Experience

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When questions of age are discussed in the context of renal transplantation, there are two separate but linked topics: firstly, the influence of donor age on transplant outcome; secondly, the appropriateness or otherwise of offering a transplant to older potential recipients, particularly in the light of the severe donor shortage. One response to the latter problem has been the increased emphasis on living donor transplants for older recipients that has been adopted more recently by some American centers—a reversal of the long-standing consensus that living donation was principally for younger patients. However, the issues are of particular interest in deceased-donor transplantation, where there are a number of conflicting pressures. The increased take-on rate of patients for renal replacement therapy has resulted in large part from acceptance of older patients, and there is increasing evidence that for these patients, as for others, survival of those accepted onto the transplant list is higher if they receive a transplant than if they remain on dialysis (1). Equally, the increased cadaveric donor rate seen in countries such as Spain over the last decade is (in part) the result of a large rise in the donation (and transplantation) of kidneys from older donors. In Spain, 33.9% of cadaveric organ donors are >60 years of age compared with 14% in the UK in 2003. Thus there are more older patients waiting for a kidney, and more older kidneys to allocate.
It has been shown repeatedly that increasing donor age is strongly associated with inferior graft outcome and this has been confirmed in a recent analysis (2). Further confounding issues include the increased comorbidity found in older donors (particularly hypertension, diabetes and mildly impaired renal function at the time of donation), the uncertain interactions between donor age, cold ischemia and HLA matching, and the suggestion that—in terms of the risk of anti-HLA sensitization—HLA matching may be less relevant for older recipients.
Oniscu et al. (1) have recently asked the provocative question: how old is old for transplantation? Their analysis shows that while patients over age 60, and particularly those over 65 years, have equivalent outcomes to younger patients when graft survival is censored for death with a functioning transplant, these groups have a much higher rate of death following transplantation and over 60% of graft failures result from death with a functioning transplant.
How should kidney allocation schemes respond to these issues? In the U.S., UNOS has recently introduced a definition of a “marginal” kidney donor that includes all those over 60 years, and those between 50-60 years who have varying degrees of comorbidity. Kidneys from marginal donors are subject to different allocation rules designed principally to encourage local use, thus limiting the cold ischemia time. Another approach that combines concerns about both older recipients and older donors has been the Eurotransplant Seniors Programme (ESP) that was introduced in 1999. This requires local allocation of kidneys from cadaveric donors over 65 years of age to recipients over 65 years of age. Only unsensitized patients waiting for a first transplant are eligible and no effort is made to achieve HLA matching. The kidney is allocated to the ABO blood-group compatible, crossmatch negative patient who has waited longest. Recipients over 65 are also entitled to receive a kidney allocated through the standard Eurotransplant Kidney Allocation System (EKTAS), which applies to all donors under 65 years of age. Fabrizii et al.
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