Results of a study reported online in the American Journal of Transplantation show that older patients could be receiving kidneys from older donors (called extended-criteria donors, or ECDs), but instead are unnecessarily waiting longer for kidneys from younger donors.
“Every adult over 65 should be listed by their physicians for ECDs because the sooner they can get a kidney, the better the chance for survival,” says transplant surgeon Dorry L. Segev, M.D., Ph.D., associate professor of surgery at the Johns Hopkins University School of Medicine and the study’s leader. “A 65-year-old does not need a 20-year-old kidney; they just need a kidney that will last as long as they will. While young people might have time to wait for the perfect kidney, older people don’t.”
While older kidneys once were discarded in the belief that they conferred too little benefit, studies over the past decade, including the current one by Johns Hopkins researchers, show they have been widely and successfully transplanted.
By accepting these kidneys, an older person’s chances for survival increase significantly, Segev says. Older kidneys are not expected to last as long as younger kidneys, but older kidney recipients generally have shorter life spans than younger ones and don’t need the organs to last as long, Segev says.
Researchers reviewed 142,907 first-time, deceased-donor kidney registrants reported to the United Network of Organ Sharing, the national organization in charge of organ allocation, between 2003 and 2008. They looked at those who were willing to be listed for ECD kidneys and compared survival rates from time of registration for those willing to receive ECD kidneys and those who were not.
When placed on the waiting list, patients of all ages are given the option of being listed for a standard-criteria donor (SCD) kidney only — basically kidneys from donors under 60 — or consent to accept an ECD kidney if one becomes available first.
Those willing to take the older kidneys were more likely to be transplanted and more likely to be transplanted sooner than those only willing to accept younger kidneys, the study found.
Older adults represent half of dialysis patients in the United States and a growing proportion of the national waiting list. Five-year survival on dialysis for people over 65 is 27 percent. One in 10 patients on waiting lists will die each year before they are transplanted.
Segev says he was struck by the variation in listing practices among transplant centers. Some centers list no older patients for older kidneys, while some list everyone for those organs. “They’re all over the map,” Segev says. Failing to list older patients for ECD kidneys “disenfranchises” them, he says, calling for patients to be better educated about their options.
Segev suspects that “regulatory pressure for good patient outcomes” contributes to the problem. “There is a tendency for some institutions and some surgeons to be too picky, so that those patients who get transplants are guaranteed to do well,” he says. “The regulations cover only those patients who receive transplants. But the harmful effect is you neglect those on the waiting list who instead of being transplanted will die waiting.”
At The Johns Hopkins Hospital, all patients over 65 are listed for ECD kidneys. Segev has grants from the National Institutes of Health’s National Institute on Aging and the American Geriatric Society to look at the issues of older adults considering kidney transplantation.
Other Johns Hopkins researchers on the study include Morgan E. Grams, M.D.; Karl L. Womer M.D.; Richard M. Ugarte, M.D. M.H.S.; Niraj M. Desai M.D.; and Robert A. Montgomery, M.D., Ph.D.
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