January 17, 2012

Seniors lack access to lifesaving organs despite survival benefit

Thousands more American senior citizens with kidney disease are good candidates for transplants and could get them if physicians would get past outdated medical biases and put them on transplant waiting lists, according to a new study by Johns Hopkins researchers.

The investigators estimate that between 1999 and 2006, roughly 9,000 adults over 65 would have been “excellent” transplant candidates, and approximately 40,000 more older adults would have been “good” candidates for new kidneys. None, however, was given the chance.

“Doctors routinely believe and tell older people they are not good candidates for kidney transplant, but many of them are if they are carefully selected and if factors that really predict outcomes are fully accounted for,” said transplant surgeon Dorry L. Segev, an associate professor of surgery at the Johns Hopkins University School of Medicine and leader of the study being published in the January issue of the Journal of the American Geriatric Society. “Many older adults can enjoy excellent transplant outcomes in this day and age,” he said, and should “be given consideration for this lifesaving treatment.”

Those ages 65 and older make up more than one-half of people with end-stage renal disease in the United States, and appropriately selected patients in this age group will live longer if they get new kidneys as opposed to remaining on dialysis, Segev says. The trouble is, he adds, that very few older adults are even put on transplant waiting lists. In 2007, only 10.4 percent of dialysis patients between the ages of 65 and 74 were on waiting lists, compared to 33.5 percent of 18- to 44-year-old dialysis patients and 21.9 percent of 45- to 64-year-old dialysis patients.

Segev cautions that some older kidney disease patients are indeed poor transplant prospects because they have other age-related health problems. But he says that his team’s new findings, in addition to other recent research, show that new organs can greatly improve survival even in this age group.

Segev and his team constructed a statistical model for predicting how well older adults would be expected to do after kidney transplantation by taking into account age, smoking, diabetes and 16 other health-related variables. Using those data to define an “excellent” candidate, they then applied the information to every person 65 and older on dialysis during the seven-year study period. The researchers also determined whether these candidates were already on the waiting list.

“We have this regressive attitude toward transplantation in older adults, one based on historical poor outcomes in older patients, which no longer holds up,” Segev said. “Anyone who can benefit from kidney transplantation should at least be given a chance. They should at least be put on the list.”

Segev says he knows that there is a shortage of kidneys, and that some will question whether scarce organs would be put to better use in younger patients. But Segev’s study predicts that more than 10 percent of older patients would get kidneys from living relatives or friends, which would have little impact on the nationwide shortage of deceased donor kidneys. But finding a living donor first requires referral for transplantation.

“By not referring older adults for transplant, we’re not just denying them a chance at a kidney from a deceased donor, but we’re potentially denying them a kidney from a live donor,” he added.

According to research by Segev and his team published last year in the Journal of the American Medical Association, live kidney donation is very safe for both donor and recipient, and more older adults are donating their kidneys to relatives. Other research done by Segev has shown that older kidney transplant recipients do well with kidneys from older donors, organs that would be rejected for use in younger patients.

The study was supported by grants from the National Institutes of Health and the American Federation for Aging Research.

Other Johns Hopkins researchers involved in the research are Morgan E. Grams, Lauren M. Kucirka, Colleen Hanrahan, Robert A. Montgomery and Alan B. Massie.

Related website

Comprehensive Transplant Center at Johns Hopkins