The older living kidney donor: Part of the solution to the organ shortage

BACKGROUND: Strategies to increase kidney transplantation are urgently needed. METHODS: We studied all (n = 73,073) first kidney-only transplant recipients in the United States between 1995 and 2003 to determine the incidence and outcomes of living donor transplantation as a function of donor age. Because 90% of living donors were <55 years, we defined older living donors as > or =55 years. Factors associated with transplantation from older living donors and the association of living donor age with allograft function and survival were determined. RESULTS: Recipients of older age, female gender, white race, and preemptive transplants had higher odds of older living donor transplantation. Older living donor transplantation was more likely from spousal donors rather than blood relatives, and more likely when a husband was the donor. The glomerular filtration rate (GFR) one year after transplantation decreased with increasing donor age (P < 0.001). Graft survival from living donors > or =55 years was 85% and 76% at three and five years (compared to 89% and 82% with living donors <55 years, and 82% and 73% with deceased donors <55 years). In a multivariate model, the risk of graft loss with living donors 55-64 years was similar to that with deceased donors <55 years, while recipients from living donors 65-69 years (HR = 1.3, 95% CI: 1.1-1.7) and >70 years (HR = 1.7, 95% CI: 1.1-2.6) had a higher relative risk of graft loss. CONCLUSIONS: Outcomes are excellent with living donors <65 years. Expanded use of older living donors may help meet the demand for transplantation.     

The advanced age deceased kidney donor: current outcomes and future opportunities

BaCKGROUND: Due to the aging general population, deceased donors > or =55 years will form an increasingly larger proportion of the deceased kidney donor pool. METHODS: Using data from the United States Renal Data System, we determined the change in graft survival between 1996 and 2000 among 32,557 recipients of donors aged <55 years and > or =55 years in univariate and multivariate survival analyses. We identified donor risk factors for graft loss that might influence the decision to accept or reject donors <55 and > or =55 years. The initial glomerular filtration rate established 6 months after transplantation (initial GFR), and the stability of GFR in the first post-transplant year (GFR at 12 months post-transplantation-GFR at six months post-transplantation) were compared between recipients of donors <55 and > or =55 years and the association of these factors with graft survival was determined. RESULTS: In 2000, one-year graft survival in donors > or =55 years was 86.7%. Between 1996 and 1999 the projected graft half life improved from 11.4 to 14.5 years for recipients of donors <55 years (P < 0.01); however, there was no improvement for recipients of donors > or =55 years (8.2 to 9.2 year, P= 0.46). Among donor factors studied, only cold ischemic time >24 hours identified recipients of donors > or =55 years at risk for graft loss. Compared to recipients of donors <55 years, recipients of donors > or =55 years established a lower initial GFR (42 vs. 56 mL/min/1.73 m(2), P < 0.0001), and had less stable GFR in the first post-transplant year (-1.5 vs. -0.6 mL/min/1.73 m(2), P <.0001). Recipients from donors > or =55 years with initial GFR > or =50 mL/min/1.73 m(2) and no drop GFR during the first post-transplant year had graft survival that was superior to that of donors <55 years with either initial GFR <50 mL/min/1.73 m(2) or a drop in GFR during the first post-transplant year. CONCLUSION: Donors > or =55 years are a valuable resource. Despite improvements in immunosuppression, rejection, and delayed graft function, the projected increase in long-term graft survival among recipients of donors <55 years was not shared among recipients of donors > or =55 years. Recipients of donors > or =55 years had lower initial GFR, and less stable GFR during the first post-transplant year. Limiting cold ischemic time to <24 hours may improve outcomes among recipients of donors > or =55 years. Future studies to maximize initial GFR and minimize early loss of GFR in recipients of donors > or =55 years may lead to improved outcomes from deceased donors > or =55 years.     

Transplantation with kidney paired donation to increase the donor pool: a single-center experience

Background

A living either related or unrelated donor transplant leads to a better outcome in terms of patient and graft survivals compared with one from a deceased donor. Desensitization protocols are expensive and labor intensive. The use of unrelated living donors has the greatest potential to increase the number of donors in the future, when no willing living donor is available due to blood group and/or human leukocyte antigen incompatibility. Herein, we have reported our results with a living donor exchange program.

Aims

To determine the feasibility and effectiveness of kidney paired donation (KPD) to manage patients with incompatible donors as well as present patient and graft survivals, serum creatinine (S.Cr) levels, and rejection episodes.

Results

Between June 2000 and December 2009, we performed KPD transplants in 36 recipients to avoid blood group incompatibility (n = 28) or to avoid a positive crossmatch (n = 8). At a median follow-up of 27.7 months (range, 5.83-119.8). The patient survival rate was 88.9% and the graft survival rate was 94.4%. Four patients developed acute cellular rejection episodes (11.1%) and 3 (8.3%) acute antibody-mediated rejection. At 1, 3, and 5 years, the mean S.Cr values were 1.42 ± 0.28 mg% (n = 28) 1.61 ± 0.51 (n = 22) and 1.24 ± 0.15 (n = 8), respectively.

Conclusions

The incidence of acute rejection episodes and patient/graft survivals were acceptable in our KPD program. The use of unrelated living donors has great potential to increase the number of donors in the future; a national KPD program should be encouraged in India.     

The changing profile of the cardiac donor.

BACKGROUND: Expansion of traditional donor criteria has become standard in most centers. To determine how this has affected donor profiles, at our institution, we reviewed all adult (age > or = 16) cardiac donors of the past 15 years. METHODS: We separated 261 cardiac donors into 2 groups based on time periods: Group I, 1983 to 1991 (n = 131), and Group II, 1991 to 1998 (n = 130). RESULTS: The groups differed significantly in mean donor age (26.2 years vs 30.9; p < 0.001), percent older than 40 years (6% vs 27%; p < 0.001), percent female (23% vs 35%; p = 0.04), percent distant procurement (54% vs 22%; p < 0.001), and percent minority donors (14% vs 29%; p < 0.001). We found an increase in non-traumatic deaths (24% vs 40%; p = 0.008). Older donors had significantly more non-traumatic deaths than younger donors (79% vs 13%; p < 0.001). Overall 5-year survival of recipients was 64% and was not significantly different between our early and late experiences (60% vs 68%; p = not significant [NS]). Recipients with hearts from older donors had a 5-year survival similar to recipients with younger donor hearts (61% vs 64%; p = NS). Traumatic and non-traumatic donors had similar 5-year survivals (64% vs 63%, p = NS). A stepwise multivariate analysis of the entire cohort identified donor age, donor weight, recipient United Network for Organ Sharing status, and cardiopulmonary bypass time as significant independent risk factors for recipient survival. Recipients of hearts from donors < 90 kg had significantly better 5-year survivals than recipients from donors > or = 90 kg (66% vs 48%; p = 0.01). CONCLUSIONS: Our evolving cardiac donor pool now has more minorities, women, and older donors whose deaths are often non-traumatic. At our institution, donor pool expansion has had no adverse effect on the long-term survival of recipients.     

Role of donor age and acute rejection episodes on long-term graft survival in cadaveric kidney transplantations

Cadaveric donors can provide an effective solution to the problem of organ shortage, and many factors that may affect the functioning and survival of cadaveric kidneys have been studied. We aimed to clarify the impact of donor age and acute rejection episodes on long-term graft and patient survival in patients receiving cadaveric renal transplants. We retrospectively evaluated the long-term outcomes of 207 patients who had received cadaveric renal transplants between 1985 and 2004. Mean recipient age, HLA mismatch, mean donor age, delayed graft function (DGF), mean cold ischemia time, acute rejection episodes in the first 6 months after transplantation, and 1-, 3-, and 5-year graft survivals were evaluated. Two study groups were created according to donor age: group 1 (n = 126) was composed of patients receiving kidneys from donors younger than 50 years, and group 2 (n = 81) was composed of patients receiving kidneys from donors 50 years of age or older. Mean recipient age, HLA mismatch, and mean cold ischemia time between groups were not different. The DGF rate in group 1 was 40% (n = 50) and in group 2 was 46% (n = 37) (P > .05). The 1-, 3-, and 5-year survival rates of patients without acute rejection within the first 6 months after transplantation in group 1 (58/126; 46%) versus those in group 2 (46/81; 57%) were 95% versus 90%, 65% versus 60%, and 40% versus 35%, respectively (P > .05). The 1-, 3-, and 5-year graft survival rates of patients with acute rejection within the first 6 months in group 1 (n = 68) versus those in group 2 (n = 35) were 93% versus 89%, 71% versus 55%, and 44% versus 28%, respectively (P = .005). There was no significant difference in 1-, 3-, and 5-year survival rates between patients with DGF in both groups. Acute rejection episodes within the first 6 months after cadaveric transplantation, especially in patients receiving kidneys from donors older than 50 years, were shown to affect 5-year survival of the kidney graft. However, cadaver age alone had no negative effect on 5-year graft survival rates. Cadaveric donors older than 50 years may be a solution to the organ shortage in the treatment of end-stage renal disease.     

Routine use of livers from deceased donors older than 70: is it justified?

Since 1998, our institution has routinely accepted livers from deceased donors older than 70 years for transplantation. The aim of this study was to determine whether these older donor livers should be used in a routine manner. Twenty-five patients received livers from older donors between 1998 and 2002. Older donor liver recipients' actuarial survival was 95.4% at 1 year and 89.8% at 3 years. Graft survivals were 82.7% at 1 year and 71.7% at 3 years. Five older donor liver recipients with hepatitis C had worse patient survival (80% at 1 year and 40% at 3 years) and graft survival (80% at 1 year and 20% at 3 years). In conclusion, use of livers from deceased older donors affords excellent patient and graft survival, comparable with results achieved with younger donor organs. However, use of older donor livers for patient with hepatitis C may result in worse outcome.     

Donor-recipient age difference and graft survival in living donor kidney transplantation

Background

In paired living kidney exchange donation from an old donor to a young recipient, it may be argued that elderly donors provide an inferior quality kidney. However, the impact of donors older than recipients on transplant outcomes remains unclear.

Methods

We retrospectively reviewed the charts of primary living kidney transplantation patients who were divided into two groups based on the age difference between donor and recipient (recipient age subtracted from donor age, donor-recipient < 20 vs ≥ 20). The donor-recipient age difference < 20 group comprised 75 and donor-recipient age difference ≥ 20 group, 25 subjects. Outcome measures included serum creatinine, acute rejection episodes as well as graft and patient survivals at 1 and 5 years after transplantation.

Results

The mean donor age difference cohorts of < 20 and ≥ 20 years showed donor ages of 33 ± 8 and 54 ± 8 years, respectively. The mean recipient age in both groups averaged under 40 years. The acute rejection rate within the first year posttransplantation was greater among age difference ≥ 20 years. The mean serum creatinine values of the donor-recipient age difference < 20 group was lower than the ≥20 years group at 1 and 5 years posttransplant. The 1-year difference was associated with an increased creatinine value at 5 years. However, death-censored graft survival of the age difference of the ≥ 20 years group was not different (hazard ratio [HR] = 0.1, 95% confidence interval [CI] = 0.01-1.37, P = .08). Patient survival of the age difference ≥ 20 years group showed no difference compared with the age difference < 20 years group (HR = 0.25, 95% CI = 0.01-6.35, P = .4).

Conclusion

Although the cohort of a donor-young recipient age difference ≥ 20 years showed a greater risk of an acute rejection episode early posttransplantation, it did not affect graft or patient survivals. When considering paired kidney donation, older age donors should not necessarily be limited.     

Impact of recipient and donor ages on patient and graft survival after kidney transplantation

BACKGROUND: The purpose of the study was to evaluate the impact of donor and recipient ages on patient and graft survival after kidney transplant. METHODS: Patients in a hospital database undergoing kidney transplant for end-stage renal disease (ESRD) during the period 1985 to May 2006 (n = 410; mean age 42 +/- 10 years; 61% men and 39% women) were divided into two groups: group A, patients of 60 years or older (6%, n = 24), and group B, those younger than 60 years (94, n = 386). In 204 patients (49.8%) the pancreas was transplanted simultaneously with the kidney. RESULTS: Overall 1-, 3-, 5-year patient survivals were 92%, 90%, 88% in group A and 95%, 90%, 87% in group B (P = .6, NS). Overall 1-, 3-, 5-year kidney graft was 92%, 75%, 65% in group A and 92%, 84%, 79% in group B (P = .7, NS). Donors were divided into two groups: group 1, 55 years or older (15%, n = 62), versus group 2, those younger than 55 years (85%, n = 348). Overall 1-, 3-, 5-year patient survivals were 91%, 86%, 76% in group 1 and 97%, 94%, 90% in group 2 (P = .0009). Overall 1-, 3-, 5-year kidney graft survivals were 87%, 82%, 76% in group 1 and 94%, 86%, 82% in group 2 (P = .02). CONCLUSIONS: Renal transplantation is an effective option for the treatment of ESRD in elderly patients. The overall rates of patient and kidney graft survival are comparable to those of younger patients. Donor age > or =55 years had a negative effect on patient and kidney graft survival.     

Effect of cold ischemic time and HLA matching in kidneys coming from "young" and "old" donors: do not leave for tomorrow what you can do tonight.

BACKGROUND: Kidneys from older donors are likely to have a lower nephron mass. Nevertheless they constitute a valuable source of kidney allografts. Long cold ischemic time (CIT), with or without delayed graft function (DGF), has been associated with reduced graft survival. The aim of this study was to review the experience of a single UK center to assess the interaction of cold storage time, donor age, organ exchange, and HLA-DR mismatching on short- and long-term survival. METHODS: We analyzed 788 first cadaver kidney transplants that were performed in our center from 1990 to 1997 and had complete data available. A donor age of 55 years was the cutoff age for "old" and "young" donor kidneys. The primary outcome measured was graft failure from any cause. RESULTS: There were 132 grafts from donors 55 years or older (16.7%), with 76.8% of the kidneys implanted after >20 hr of CIT. Kidney grafts from donors older than 55 years had worse graft survival than grafts from donors younger than 55 (87% vs. 78% at 1 year and 80% vs. 58% at 5 years after transplant, P=0.0001). A CIT of >20 hr significantly reduced graft survival (91% vs.74.3% at 5 years after transplant, P=0.0002) in the young donor group and was associated with an overall graft survival in the old donor group of 57.5% at 5 years. In the same group, ignoring the HLA-DR mismatching to achieve shorter CIT, the predicted initial cost on graft survival at 1 year would have been 3.7% but would have increased to 9% 5 years after transplant. For young donors a CIT of >20 hr had a cost of approximately 18% at 5-year graft survival, far higher than a single DR mismatch. Occurrence of DGF decreased survival in both short (P=0.001) and long (P=0.00001) CIT groups. CONCLUSION: Forming local alliances (common recipient lists) and minimizing delays within the hospital might reduce CIT and DGF while achieving excellent HLA matching. This should improve significantly the outcome of both old and young donor kidney grafts.     

Impact of cadaveric renal donor morbidity on long-term graft function

The significance of donor age, cause of death, and morbidity for the outcome of renal cadaveric transplantation was evaluated in 534 cases from 1994 through 2001. Half of the kidneys (49.4%) were from donors without identified risk, the others were age 50-64 or > or =65 years, had died of cerebrovascular lesion (CVL), or had known cardiovascular disease, or hypertension. Only death from CVL influenced cumulative graft survival (P=0.04), the actual survival at 6 months being 87% vs 95% with other donors (P=0.004). Clearance of 51Cr EDTA (glomerular filtration rate, GFR) after 1 year was a more sensitive marker of graft quality and was significantly reduced with each tested risk factor. For instance, the median GFR (range) in the three donor age groups was 52 (9-125), 37 (13-83), and 29 (15-60) ml/min, respectively (P<0.0001). Combinations of risk factors significantly increased their impact on GFR. However, the overall results with such suboptimal donors should rather encourage a widening of the donor acceptance criteria.     

Expanded criteria donor kidneys for younger recipients: acceptable outcomes

Introduction

European senior programme (ESP) is well known for acceptable outcomes using expanded criteria donor (ECD) kidneys from donors older than 65 years for recipients older than 65 years. The incidence of end-stage renal disease (ESRD) is 229/million in India with a mean age of 45 years. We performed a retrospective analysis of transplantation of ECD versus standard criteria donor (SCD) kidneys into younger recipients.

Methods

Forty-three ECD transplantations among 158 deceased donor organ transplantation (DDOT) were performed between January 2006 and December 2009. Among 43 transplantation from 30 donors, 14 were dual kidney transplantations (DKT) performed based upon biopsy evaluation. All recipients received thymoglobulin (rATG) induction followed by immunosuppression with a steroid, mycophenolate mofetil (MMF), and a calcineurin inhibitor. Statistical analysis used chi-square test and unpaired Student t test. Kaplan-Meier curves were used for survival analysis.

Results

For ECD the mean donor age was 64 ± 11 years. Cerebrovascular accidents (CVA) were the cause of death among 60% of donors, 73.13% of whom were hypertensive and 23.13% diabetic.Mean DKT donor age was 75 ± 9.17 years versus 60 ± 8.0 years for single kidney transplantation (SKT). Mean recipient age of DKT versus SKT was 44 ± 12.4 years versus 43 ± 14 years. Mean serum creatinine (SCr; mg/dL) of SKT patients was 1.64 ± 0.75 versus 1.68 ± 0.46 in DKT. Mean follow-up was 455 ± 352 days. Mean SCr of 43 ECD recipients of mean age, 43.4 ± 14.2 years was 1.61 ± 0.61 mg/dL. Among 43 recipients, 23.25% were diabetic, 41.86% displayed delayed graft function (DGF), and 23.25% experienced biopsy-proven acute rejection (BPAR). Patient survival rate was 72.09% and graft survival rate was 67.44%. For SCD transplantations (n = 115), the mean donor age was 36 ± 14 years and recipient mean age was 32.8 ± 14.07 years. Mean SCr was 1.32 ± 0.46 mg/dL with 26.95% recipients displaying DGF, whereas 20.86% had BPAR. In the SCD group the patient survival rate was 79.13% and the graft survival rate was 72.17%. Thus, although the ECD group showed poor graft function (P = .042), they had acceptable patient and graft survivals (P = .34 and P = .56, respectively).

Conclusion

Because of the organ shortage, DDOT using ECD transplants for younger recipients is a feasible option with acceptable outcomes.     

The influence of donor age on initial and long-term renal allograft outcome

Abstract To investigate the impact of donor age on the immediate and long-term graft outcome, 808 primary cadaveric renal allograft recipients, transplanted between January 1983 and December 1992, were divided into six groups according to donor age: 10–19 years ( n = 142), 20–29 years ( n = 214), 30–39 years ( n = 136), 40–49 years ( n = 146), 50–59 years ( n = 142), 60–69 years ( n = 28). The six groups were comparable with regard to donor origin (local/ distant), serum creatinine, cold ischemia and reanastomosis time, recipient sex, degree of presensitiza-tion, number of pretransplant blood transfusions, number of HLA-B and B/DR mismatches. The incidence of delayed graft function was linearly correlated with increasing donor age, from 11.9% (donors 10–19 years) to 39.3% (donors 60–69 years) (P< 0.0001). Graft survival at 3 years was not influenced by donor age (from 89.3% for the youngest donors to 84.4% for donors 60–69 years). After the 3rd decade, the creatinine clearance linearly decreased with donor age (6.2ml/min, P<0.01). This progressive decline could not be attributed to the recipient age (-7 ml/decade for 485 recipients <50 years, and -6.1 ml/decade for 323 patients ≥ 50 years). Despite the decreased function in older kidneys, recipient renal function remained remarkably stable between 1 and 3 years after transplantation within each donor age group.     

Multivariate analysis of donor risk factors for graft survival in kidney transplantation

BACKGROUND: The results of the transplantation of marginal donor kidneys remain controversial. This study aimed to investigate the impact of donor risk factors as predictors of kidney-graft outcome. METHODS: Allograft failure risk factors were studied in 7,209 cadaveric kidney-transplant recipients reporting to the Etablissement fran?ais des Greffes (EfG) from 1996 to 2000, of which 544 (7.6%) were from donors aged over 60. Both univariate and multivariate analysis were used to assess the effect of donor risk factors and were stratified according to recipient age. RESULTS: Overall graft survival was 91.1% (95% confidence interval [CI] 90.5-91.8) at 1 year, 88.6% (95% CI 87.8-89.4) at 2 years, and 85.6% (95% CI 84.6-86.6) at 3 years posttransplant. Univariate analysis of risk factors showed a significant reduction of graft survival in recipients transplanted with kidneys coming from donors older than 60 years, donors with a history of hypertension, a cerebrovascular cause of death, and a preharvesting serum creatinine greater than 150 micromol/L. Multivariate analysis revealed significantly higher failure rate associated with cerebrovascular cause of death (RR=1.2, P=0.02), history of hypertension (RR=1.2, P=0.04), and elevated serum creatinine (RR=1.3, P=0.03), whereas donor age greater than 60 years was not found as an independent risk factor. CONCLUSIONS: Our results suggest that cerebrovascular cause of death, history of hypertension, and elevated creatinine are significant independent donor risk factors for graft survival, whereas donor age is a statistically significant, but dependent, risk factor. This result is important for the design of allocation and transplantation strategies for kidneys procured in elderly donors.     

Severe glomerular sclerosis is not associated with poor outcome after kidney transplantation

BACKGROUND: The increased utilization of expanded criteria kidney donors has necessitated the reevaluation of multiple donor risk factors to insure the best outcome from this valuable resource. Reports of decreased graft survival in recipients of kidneys from donors with > or =20% glomerular sclerosis (GS) have led many transplant centers to refuse these donor kidneys. The purpose of this study is to compare outcome in recipients of cadaveric donor kidneys with > or =20% GS versus those with <20% or no GS at our center. METHODS: We retrospectively reviewed 18 donor and 19 recipient and outcome variables in 89 recipients of kidneys, which were biopsied at the time of transplantation, between February 1995 and November 1998. We evaluated outcome based upon the percent of GS and the degree of vasculopathy. RESULTS: Donors with > or =20% GS were older and had more hypertension. Recipients of kidneys with > or =20% GS were older, had higher serum creatinine values at 1 and 2 years, but similar rates of delayed graft function and 2-year graft survival. Vasculopathy did not correlate to any important donor criteria except the percent GS. However, serum creatinine was significantly higher in recipients of kidneys with moderate vasculopathy versus none, up to 2 years after transplantation. There was no significant difference in graft loss based upon vasculopathy. CONCLUSION: Kidneys from donors with > or =20% GS provide excellent outcome similar to kidneys from donors with no GS.     

Advanced donor age alone is not a risk factor for graft survival in kidney transplantation

Background

The use of kidneys from elderly deceased donors has substantially increased organ supply, although it is associated with worse graft function and survival rates. The risk of kidneys from elderly donors as well as expanded criteria donors (ECDs) on kidney transplant outcome was investigated.

Patients and methods

Seventy-five kidney transplants from ECDs over a 5-year period were reviewed retrospectively. Old age and increased donor risk variables were analyzed separately in relation to graft function and survival.

Results

Sixty-four of 75 (85.3%) recipients had functioning grafts 5 years posttransplant. The overall actuarial graft survivals from 1 to 5 years were 87.5%, 68.1%, 57.3%, 55.4%, and 47.3%, respectively. Early graft function gave 47 (62.7%) kidneys remarkable actuarial survivals of 100.0%, 88.3%, 75.8%, 75.8%, and 68.4% at 1 to 5 years posttransplant, and 28 (37.3%) kidneys had delayed graft function with substantially decreased actuarial survival rates, ranging from 66.7% to 23.2%. Kidneys from elderly donors had considerable actuarial graft survival rates of 100.0%, 83.3%, 76.9%, 76.9%, and 67.0% from 1 to 5 years, respectively; these were the best graft survival rates compared with kidneys from the other donor categories. The other donor risk variables when associated with advanced age of any had an adverse effect on recipient graft function and survival, but no single risk variable alone, or a combination of any two, showed any statistically significant variability.

Conclusion

Elderly kidney donors provided a substantial organ pool expansion without affecting patient and graft survival in many patients. ECDs can be utilized safely if adequate measures are taken.     

Survival after kidney transplantation does not differ with 50-59- or over 60-year-old expanded-criteria donors

Background

Use of expanded-criteria donors (ECDs) for kidney transplantation has progressively increased in the past years with the intent to improve the number of available grafts. However, it is still uncertain if ECD kidneys have worse survivals than standard-criteria ones. The aim of this study was to retrospectively analyze a cohort of ECD patients comparing the 2 subgroups of 50-59- and >60-year-old donors in terms of donor, recipient, and transplant features and survival rates.

Methods

Ninety-one cases were analyzed. The cohort was stratified into 2 subgroups according to donor age: group 1, age 50-59 years (n = 26); and group 2, age ≥60 years (n = 67).

Results

Group 2 represented older donors and a higher percentage of donors with a previous history of hypertension. In Group 1, preharvest creatinine values showed higher results. No difference was detected regarding patient and graft survivals, with 5-year survival rates of 92.3% versus 86.7%, and 70.8% versus 69.8%, respectively. The best way to select the donors is still under debate. In our experience, a biopsy-driven selection was performed exclusively for group 2 ECDs. Considering the similar survivals obtained, we speculated that an accurate biopsy-based selection of older grafts allows one to avoid “bad” donors from the allocation system, thereby obtaining improved survival results.

Conclusions

Biopsy-driven pretransplantation selection appears to be the main system to optimize results, to achieve outcomes similar to nonbiopsied younger donors. Routine biopsies also in the younger subgroup of ECD may achieve a further improvement in survival.     

Expanding the donor pool: lung transplantation with donors 55 years and older

The scarcity of donor organs is one of the major limitations to lung transplantation. This has led to a progressive expansion of criteria for donor selection in lung transplantation. This study evaluated the outcome of recipients of lungs from donors >/=55 years. We performed a retrospective analysis of 212 consecutive lung transplantations. Recipients were divided into two groups, those receiving lungs from donors >/=55 years (older donor group) and those receiving lungs from donors <55 years (younger donor group). Recipient baseline characteristics, time in the intensive care unit (ICU), early mortality, and long-term survival (Kaplan-Meier) were compared between the groups. Forty-one donors (19%) were >/=55 years. Mean recipient age in the older donor group was higher than in the younger donor group (52 +/- 8 vs. 47 +/- 12 years; P = .015). Indication for transplantation did not differ between the groups. ICU stay was comparable between the two groups (6 +/- 12 vs. 7 +/- 11 days; P = .64). Actual 30-day mortality (10.8% vs. 6.4%; P = .32), 1-year mortality (17.1 vs. 19.6%; P = .50), and cumulative long-term survival (65% and 62% at 5 years, P = 1.00) did not differ between the older and younger donor group. This study indicated that transplantation of lungs from selected donors aged >/=55 years did not impair short-or long-term results. The use of lungs from elderly donors may help to increase the number of donor organs for lung transplantation.     

Influence of cadaver donor age on posttransplant renal function and graft outcome

To assess the impact of cadaver donor age on posttransplant renal function and graft survival, we analyzed our clinical results in 17 recipients of younger donor kidneys (less than 10 years) and 48 recipients of older donor kidneys (greater than 50 years) and compared them with a control group of 598 patients who received kidneys from donors between 11 and 50 years of age. The 3 groups were comparable with respect to recipient age, duration of dialysis, prior transfusions, previous transplants, cold ischemia time, HLA AB mismatches, cytotoxic antibody profile, posttransplant ATN, and prophylactic ALG treatment. The cumulative patient survival at 1, 2, and 3 years was not significantly different among the 3 groups, but the graft survival in recipients of older donor kidneys was significantly lower than the control (71% vs. 62% at 2 years, P = .09 and 66% vs. 55% at 3 years, P = .0003. The short-term renal function assessed at 1 month posttransplant was significantly lower in the older donor group compared with the control (creatinine clearance 45 mL/min vs. 59 mL/min, P = .0003). Likewise, the long-term renal function assessed at the last follow-up was also lower in the older donor group than the control (creatinine clearance 40 mL/min vs. 49 mL/min, P = .07). There were no significant differences in graft survival or short- or long-term renal function between the younger donor group and the control group. These observations suggest that transplantation of a kidney from an older cadaver donor is associated with an inferior posttransplant outcome. The practical decision whether or not to use an older donor kidney should be individualized taking this as well as other factors into account.     

Renal transplantation in recipients over the age of 60: the impact of donor age

BACKGROUND: Kidneys from older donors exhibit a series of changes characterized by glomerular, vascular, and tubular senescence. These changes may be aggravated by atherosclerosis, hypertension, or diabetes, which are highly prevalent in older individuals. METHODS: We analyzed the outcome after transplantation in 230 recipients over the age of 60, who received transplants between February 1990 and December 1996. We assessed the 1- and 5-year patient and graft survival, the quality of renal function, tacrolimus levels, the incidence of rejection, and the incidence of delayed graft function, and compared the outcomes in recipients of kidneys from donors over the age of 60 (group 1, n = 40) with those in recipients of kidneys from donors under the age of 60 (group 2, n = 190). There were no differences between the two groups in terms of recipient sex, race, age, and cold ischemia time. Immunosuppression was with tacrolimus and steroids in 61% of cases; in the remainder of the patients, a third agent, either azathioprine, cyclophosphamide (for 1 week), or mycophenolate mofetil was administered as well. The median follow-up was 31.5 months (range: 1-86). RESULTS: In recipients over the age of 60 receiving tacrolimus-based immunosuppression, overall patient survival at 1 and 5 years was 90% and 76%, and was not significantly compromised in recipients receiving a kidney from a donor over the age of 60. The overall 1-and 5-year actuarial graft survival was 84% and 64%; in recipients from donors over the age of 60, it was 73% and 52%, whereas in recipients of kidneys from donors under the age of 60, it was 87% and 66% (P<0.05). Most of the effect on graft survival was seen by 1 year. The mean serum creatinine was 2.6+/-2.7 mg/dl, without any difference between the two groups. Although the incidence of delayed graft function was higher in recipients of kidneys from donors over the age of 60, this difference did not reach statistical significance. CONCLUSIONS: Although the overall outcomes of transplantation in older recipients remain reasonable, the inferior outcomes with older donor kidneys call into question proposals to utilize older donor kidneys preferentially in older recipients.     

The impact of donor variables on the outcome of orthotopic liver transplantation for hepatitis C

Morphologic characteristics of the graft have been proposed as a major contributor to the long-term outcomes in orthotopic liver transplantation (OLT). Our objective was to determine the impact of donor variables, including donor age, donor-recipient HLA match, and type of donation (DCD vs donation after brain death [DBD]), on the outcome of OLT in 192 patients with hepatitis C virus (HCV). Fourteen patients underwent OLT from donation after cardiac death (DCD) donors and 188 from DBD donors. Mean donor age, warm ischemia time at recovery, and cold ischemia time were similar between the groups. Overall graft survival rate at 1 year (55% DCD vs 85% DBD) and 5 years (46% DCD vs 78% DBD) was significantly lower in the DCD group (P = .0003). Similarly, patient survival rate at 1 year (62% DCD vs 93% DBD) and 5 years (62% DCD vs 82% DBD) was significantly lower in the DCD group (P = .0295). Incidences of hepatic artery thrombosis, portal vein thrombosis, and primary nonfunction were similar between the DCD and DBD groups. The incidence of liver abscess with ischemic-type biliary stricture was higher in recipients from DCD as compared with DBD (42% vs 2%). A trend toward lower graft survival was noted in recipients from donors older than 60 years of age in the HCV population (P = .07), with statistically lower patient survival (P = .02). Donor- recipient HLA matching did not appear to correlate with OLT outcome in patients with HCV. DCD donors and donors older than 60 years of age significantly impact patient and graft survival. Lower graft and patient survival in recipients from DCD donors does not appear to be related to early disease recurrence.