Hospitals reassess the age factor in evaluating candidates for kidney transplants
By Judith Graham,
Robert Brown was healthy, willing and a good match: So why not give a kidney to his wife, who otherwise would need dialysis?
There was just one potential obstacle: Brown was 74, an age once unthinkable for a kidney donor.
For this retired psychologist from Columbia, that wasn’t an issue. “I didn’t think about the age thing, not at all,” Brown said about his decision two years ago to offer a kidney to his wife, Sue. She was 71 at the time and ill with Fabry disease, a rare genetic disorder that can lead to a harmful buildup of fat in the kidneys.
For the Browns’ physicians, what counted was the couple’s physiological age — how healthy and strong both of them were — rather than their chronological age.
“We feel very strongly that healthy older adults should receive organ transplants and be considered as organ donors,” said Dorry Segev, an associate professor of surgery at the Johns Hopkins University School of Medicine, whose colleagues operated on the Browns.
Many of the nation’s transplant centers agree, at least in part. More than half of them do not have upper age limits for kidney transplant recipients.
But physicians are conservative about living kidney donors: Nearly three-quarters of transplant centers have not accepted organs from people older than 70, according to Johns Hopkins research.
Caution makes sense because the long-term effects of kidney donation on older adults are unknown, Sameh Abul-Ezz, a professor of nephrology at the University of Arkansas for Medical Sciences, noted in a 2010 commentary in the journal Kidney International.
In 2011, 96 people age 65 and older served as living kidney donors in the United States, according to data from the United Network for Organ Sharing, which manages the nation’s transplant system. Between 1990 and 2010, 219 men and women between the ages of 70 and 84 donated kidneys, according to an article published in 2011 by Segev and colleagues.
Most commonly, these seniors gave the organs to middle-aged and older adults whom they know well, unlike the system that distributes kidneys from deceased donors anonymously. The usual recipients were their children (37 percent), followed by their spouses or partners (35 percent), siblings (14 percent) and other relatives and friends.
Data about medical outcomes when using older kidneys, while relatively scarce, are encouraging. In his 2011 study, Segev found that 93 percent of patients who received kidneys from live donors 70 and older were alive one year after transplant surgery, and 74.5 percent survived five years. As for patients who got kidneys from live younger donors, 96 percent were alive at one year and 83 percent at five years, a result considered statistically equivalent.
A separate report from Sandip Kapur and colleagues from New-York-Presbyterian/Weill Cornell Medical Center found that kidneys from living donors age 60 and older were equally likely to be going strong after five years as those from younger donors. No differences were observed in results for a subset of donors 70 and older.
Who’s fit for surgery?
These and other good results “argue for the expansion of older living-donor transplantation because this may represent an important solution to the organ shortage,” Kapur and his colleagues concluded.
But other transplant experts such as Abul-Ezz are less sanguine, citing evidence that raises red flags.
In one analysis of 12 clinical studies, patients who received kidneys from older living donors were less likely to be alive five years after the operation than patients transplanted with kidneys from younger donors. Also, organs that came from older living donors were more likely to fail during this time period than those from younger donors.
While short- and intermediate-term outcomes for older kidney donors are generally positive — Segev’s study found that nearly 96 percent of living donors 70 and older survived five years after surgery — some experts worry that older donors might experience potentially harmful, age-related declines in the functioning of their remaining kidney. Long-term research examining this question has not been done.
Then there is the reality that surgery can present additional risks for older patients; this requires physicians to be especially careful about whom they deem fit to undergo transplant procedures.
“Evaluating patients in their 70s [for receiving or donating a kidney] is one of the most difficult things we have to do. Fifteen years ago, we wouldn’t have even seen these patients,” said Gabriel Danovitch, medical director for the kidney and pancreas program at Ronald Reagan UCLA Medical Center.
Highlighting risks that older transplant recipients face, Danovitch said he often tells medical students about an Army veteran in his 70s with severe kidney disease who hated being on dialysis and pushed for a transplant. “He had struggled all his life and always beaten the odds, and he did superbly well for two weeks after the operation,” the doctor said. But then, a small abdominal sac known as a diverticulum ruptured, and the patient went into septic shock.
Despite the man’s eventual recovery, “he was never the same, and I’ve often asked myself if we did him a favor,” Danovitch said. “I’m not so sure.”
Years on the waiting list
There’s no question about the burgeoning need for kidneys. Almost half of the 871,000 Americans with advanced kidney disease are older than 65, and rates of chronic kidney disease in this age group more than doubled between 2000 and 2008, according to the National Institutes of Health.
There are two options for patients with advanced kidney disease: a transplant or dialysis. With a transplant, the risk of death from severe disease is cut by about half, compared with patients who depend on dialysis, and quality of life is significantly improved, according to 2003 research. Adults 50 and older now make up 64 percent of the 94,374 people waiting for kidneys. (Only a portion of people with end-stage kidney disease meet medical criteria for transplants and are considered healthy enough to undergo these procedures, said Leslie Spry, a spokesman for the National Kidney Foundation.)
Waits are lengthening because so-called cadaveric kidneys remain a scarce resource. Median wait times for patients 50 to 64 years old are 1,573 days (4.3 years) while those for patients 65 and older are 1,454 days (3.98 years), according to the data from the national Organ Procurement and Transplantation Network, operated by UNOS. In some parts of the country, including the Washington area, it can take six to eight years for someone to rise to the top of transplant lists, according to transplant surgeons.
The harsh reality is that more than half of kidney transplant candidates over the age of 60 will die before receiving an organ from a deceased donor, researchers estimate.
That is why such experts as Kapur, Segev and Mikel Prieto, surgical director of the kidney and pancreas transplant program at the Mayo Clinic in Rochester, Minn., are trying to broaden the pool of potential living donors to include adults in their 60s and 70s.
Studies indicate that 10 to 20 percent of seniors who need a transplant would find living donors, many of them among people of their own age, if they looked, Segev said.
But many doctors don’t believe this is a reasonable option, and many patients don’t believe they could be good candidates.
Although older kidney donors haven’t been studied extensively, a handful of reports suggest that this surgery is safe and complications are relatively uncommon when donors are carefully selected.
“It’s very common that patients in their 70s want to donate. It’s less common that they are fit to donate,” said Prieto. Anyone with a history of heart disease, stroke, diabetes, cancer, cognitive impairment and several other conditions common in older people are excluded from donation. Often, a host of minor medical issues that might seem insignificant individually will also disqualify a prospective elderly organ donor, he noted.
‘A good decision’
Like Robert Brown and his wife, Shirley Hall and her brother-in-law Hilding “Joe” Johansson did not see age as an impediment to transplant surgery. Hall, who divides her time between Howard, S.D., and Apache Junction, Ariz., is 75. Johansson, of Sioux Falls, S.D., is 71.
Johansson has polycystic kidney disease, and over 15 years he had two operations to remove growths on his kidneys.
After donating a kidney to Johansson at the Mayo Clinic last fall, Hall felt “a little bit of pain” but not enough to take the medication doctors ordered. Several months later, she said, “I’m feeling great.” Johansson said he has a lot more energy and is looking forward to traveling and bow hunting in the year ahead.
After his September 2010, surgery at Johns Hopkins, Robert Brown developed an infection at an abdominal incision made to remove his kidney. But it responded to topical treatments, and several weeks later he began exercising again.
Sue Brown’s post-transplant medication regimen made her “unbalanced” and “lightheaded” and it had to be adjusted over the course of several months, but looking back over the experience, she said she was convinced that it was a “good decision.”
“We’re taking great care of each other, and I appreciate that,” she reflected, noting that their 50th wedding anniversary is coming up this year. “For one thing, I know he loves me and enjoys being with me and doesn’t want to get rid of me.”
Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.