February 22, 2010

Seniors stymied unnecessarily in wait for kidney transplants

One-third of people over the age of 65 wait longer than necessary for lifesaving new kidneys because their doctors fail to put them in a queue for organs unsuitable to transplant in younger patients but well-suited to seniors, research from Johns Hopkins suggests.

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,” said transplant surgeon Dorry L. Segev, associate professor of surgery at the Johns Hopkins 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 that they have been widely and successfully transplanted.

By accepting one of these kidneys, an older person’s chances for survival increase significantly, Segev said. 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 said.

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 only a standard-criteria donor kidney—basically, one from a donor under 60—or consenting 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 willing to accept only 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 said 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 said. Failing to list older patients for ECD kidneys “disenfranchises” them, he said, calling for patients to be better educated about their options.

Segev said he 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 said. “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 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 are Morgan E. Grams, Karl L. Womer, Richard M. Ugarte, Niraj M. Desai and Robert A. Montgomery.

Related Web site

Dorry Segev