Kidney Transplantation in the Elderly. Kristian Heldal, MD, PhD Telemark Hospital Trust, Skien, Norway and University of Oslo

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1 Kidney Transplantation in the Elderly Kristian Heldal, MD, PhD Telemark Hospital Trust, Skien, Norway and University of Oslo

2 Agenda Background: Age and chronic kidney disease End stage kidney disease: Selection of treatment Comorbidity Kidney transplantation in the elderly Survival HRQoL

3 The aging population! Female 80 years Female years Male 80 years Male years July 2015

4 Prevalence of End Stage Kidney Disease (ESKD)

5 Prevalence of ESKD by age and time Increasing prevalence Most prominent in % of newly diagnosed ESKD are older than 65 No increase from 2000 Increased old population will increase the number of patients Knoll GA. Kidney transplantation in the older adult. Am J Kidney Dis May;61(5):790-7.

6 New RRT patients are getting older Leivestad T: Norwegian Renal registry Annual report 2014

7 Comorbidity High prevalence of comorbid conditions among ESKD patients Cardiovascular disease Cerebrovascular disease Diabetes Hypertension Age-related comorbidities Malignancies Chronic obstructive pulmonary disease (COPD) Infections Dementia

8 Kidney transplantation Best treatment option for ESKD patients Survival Quality of Life Limited data on older patients Few older recipients Prolonged waiting time for kidney transplantation Marked differences between countries US 4-5 years Norway months Formal or practical age limit

9 Who should receive a transplant? Those who derive the most benefit! The recipient should tolerate the treatment Age-independent selection criteria Exclude serious heart and lung diseases (contraindications for surgery) Exclude malignancies and infections (contraindications for immunosuppression) Exclude cognitive dysfunction that may interfere with the follow-up

10 Outcomes after kidney transplantation in the elderly

11 Survival after kidney transplantation in patients > 70 years (US) 5667 patients > 70 years 2078 (37%) received a transplant Rao PS et al. Renal transplantation in elderly patients older than 70 years of age: results from the Scientific Registry of Transplant Recipients. Transplantation Apr 27;83(8):

12 Norwegian results in recipients > 70 Heldal K et al Benefit of kidney transplantation beyond 70 years of age. Nephrol Dial Trans 2010 May;25(5):1680-7

13 Variables associated with survival after kidney transplantation Heldal et al. Transplantation (7):

14 Pre-transplant time on dialysis Heldal et al. Clinical Outcomes in Elderly Kidney Transplant Recipients are Related to Acute Rejection Episodes Rather Than Pretransplant Comorbidity Transplantation. 87(7):

15 Changes in treatment and outcome Intensified immunosuppression Less acute rejection episodes : 50% : 24% Older donors : 50.0 yrs : 57.8 yrs Heldal K et al. Benefit of kidney transplantation beyond 70 years of age. Nephrol Dial Trans 2010 May;25(5):1680-7

16 Risk variables in the new millennium Variable Univariable analysis Multivariable analysis HR 95 % CI P-value HR 95 % CI P-value Age (per year increase) Donor age 60 years Time on dialysis (/yr) CIT (/hr) Pre-tx DM Pre-tx ICH Deceased donor CMV-positive donor Delayed graft function Early acute rejection CCI Heldal et al. Nephrol Dial Transpl 2011 Aug;26(8):

17 Glucose tolerance Heldal et al. Nephrol Dial Transpl 2011 Aug;26(8):

18 Even octogenarians can be transplanted with success Lønning et al. Transplantation 2016

19 Re-transplantation Uncensored graft survival Death censored graft survival Heldal et al. BMC Nephrology 2017

20 How to measure comorbidity? Several available indexes CCI 559 hospitalized patients (1984) 684 breast cancer ( ) Liu USRDS dialysis ( ) RoCKeT (KTx) Laging et al A High Comorbidity Score Should Not be a Contraindication for Kidney Transplantation. Transplantation. 100(2): , February 2016.

21 Liu comorbidity score in Tx candidates > 65 years % 73% 31% 21% Male Female Total

22 Conclusion - survival Transplantation results in better survival than dialysis Short time on dialysis before transplantation is associated with better outcome Important to initiate the transplant work-out early Increased availability of organs may shorten the transplant waiting time Improved immunosuppression have neutralized the negative impact of donor age and acute rejection Re-transplantation is an option even in older patients Comorbidity is important, but we miss a validated tool for measurement of comorbidity in older recipients

23 Quality of Life after kidney transplantation

24 PD: N=25 HD: N=44 KDQOL-SF: Before KTx 12 months post KTx Kostro et al Transplantation Proceedings, 48, (2016)

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26 HD: N=83 PD: N=27 7 months 40 months Von der Lippe N. From dialysis to transplantation: a 5-year longitudinal study on self-reported quality of life. BMC Nephrology 2016

27 Quality of Life in older recipients Limited information about effect of transplantation on HRQoL in older patients. ASSOCIATIONS FOR TRANSPLANT:SF-36 SF-36 PF: Physical function RP: Role physical BP: Bodily pain GH: General health V: Vitality SF: Social function RE: Role emotional MH: Mental health PF** BP* GH** V** SF** NO TRANSPLANT TRANSPLANT *p<0,05 **p<0,01 Rebollo P. Health-related quality of life (HRQOL) in end stage renal disease (ESRD) patients over 65 years. Geriatr Nephrol Urol 1998;8(2):85-94.

28 Older (65+) vs. younger (<65) and normal population Physical domains Mental domains Weber M et al. Quality of life in elderly kidney transplant recipients. J Am Geriatr Soc Oct;62(10):

29 QUESTION65 Evaluate HRQoL in older KTx candidates Aim: 280 KTx candidates 65 years Inclusion period Follow them prospectively from time of wait listing until five years post transplant KDQOL-SF

30 Study design INCLUSION ESRD > 65 year accepted for KTx 6 months on waitinglist 12 months on waitinglist etc. Kidneytransplantation 10 weeks post KTx 6 months post KTx 1 year post KTx 3 years post KTx 5 years post KTx

31 289 patients included mean age 71 years (65-82) 67% male Results: 170 patients transplanted by (16%) LD Median waiting time (DD): 15,4 months (18 days 4.6 years) Pre-emptive transplantation in 44 patients (26%)

32 HRQOL scores* in 78 recipients: p=0,019 p=0, p=0,002 P<0,001 P<0, Pre tx TX + 10 w Tx + 6 months *Mean values at each point PF RF BP GH VT SF RE MH

33 How can we increase the number of organs available for older patients? Living Donor Unrelated (spouse, friends) Older < 1 Year 1-5 Years 6-10 Years Years Years Years Years 65 +

34 How can we increase the number of organs available for older patients? Living Donor Unrelated (spouse, friends) 100 % Older Expanded Criteria Donor Old for old 90 % 80 % 70 % 60 % 50 % 40 % 30 % 20 % 81 % 75 % 59 % 77 % 72 % 59 % 1 år 3 år 5 år Foss A et al. Transplantation % 0 % Pasient overlevelse Transplantat overlevelse

35 Take home messages The number of older transplant candidates is increasing Kidney transplantation improves life expectancy and quality of life (?) even in older recipients Best results with modern immunosuppression and short pre-transplant time on dialysis Important to select the right patients and have strategies for increasing the number of available donor organs

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