Outcome of Renal Transplantation from Very Old Donors

The use of kidneys from elderly donors may permit more transplantations, but it has been associated with poorer outcomes than transplantations performed with kidneys from younger donors.1 According to data from the United Network for Organ Sharing, the rates of graft loss and patient death among recipients of grafts from donors 70 years of age or older are 24% and 21% higher, respectively, than rates among recipients of grafts from donors 60 to 69 years of age.2 We previously reported that the outcomes of transplantations performed with kidneys from donors older than 60 years of age were similar to the outcomes of transplantations performed with kidneys from young donors when the kidneys from the older donors were selected and allocated on the basis of histologic changes observed before implantation.3,4 In this more recent study involving patients referred to the transplantation centers in Padua and Verona, Italy, between 2000 and 2006, we compared the graft outcome among 71 recipients of one or two kidneys from donors 70 years of age or older — with the kidneys having been histologically evaluated before implantation — with the graft outcome among 67 recipients of kidneys from donors 60 to 69 years of age. Patients provided written informed consent to undergo renal transplantation and to participate in the program, which was approved by the institutional review committee at each participating center. Histologic changes in the vessels, glomeruli, tubules, and connective tissue in biopsy specimens obtained from the donor kidneys before transplantation were scored on a scale from 0 (no changes) to 3 (severe changes). When both donor kidneys had a score from 0 to 3, the two kidneys were used for two single transplants. When one kidney had a score from 0 to 3 and the other kidney had a score of 4 or more, and when both kidneys had a score from 4 to 6, the two kidneys were transplanted together into the same recipient. If one kidney had a score from 4 to 6 and the other kidney had a score of 7 or greater, the two kidneys were discarded.3,4 Recorded data were analyzed with the use of SAS software, version 9.1 (SAS Institute), at the Clinical Research Center for Rare Diseases, Aldo and Cele Daccò, Ranica, Italy. Recipients of grafts from donors 70 years of age or older were significantly older, had significantly more HLA mismatches, spent a shorter time on the waiting list, and were more frequently assigned to dual transplantation than recipients of grafts from donors 60 to 69 years of age (78% of patients vs. 28%, P<0.001). Other characteristics in the two groups were similar. Over a median period of 24 months (interquartile range, 15 to 24), five patients in the group receiving transplants from donors 70 years of age or older (7%) and six patients in the group receiving transplants from younger donors (9%) either had disease progression requiring dialysis or died (Figure 1Figure 1 Graft Survival over a 2-Year Period among Recipients of One or Two Kidneys from Donors 70 Years of Age or Older (with Preimplantation Histologic Evaluation of Kidneys) or from Donors 60 to 69 Years of Age.). Outcomes were similar, even after adjustment for prespecified characteristics (type of transplantation, donor sex and creatinine clearance, recipient sex and age, ratio of the donor's body-mass index to that of the recipient, and number of HLA mismatches). Rates of patient survival, graft survival (in an analysis in which data were censored for patients who died), recovery of renal function, proteinuria, and adverse events were also similar. In this study, selection and allocation of kidneys for single or dual transplantation on the basis of biopsy results improved the survival of grafts from very old donors. With this approach, selection criteria might be extended to increase the number of available transplants without increasing the risk of premature graft failure among recipients of kidneys from older donors.