In the second of two parts, Dr. Kamyar Kalantar-Zadeh (KK) from the University of California, Los Angeles, continues to discuss his recent study on advanced age and kidney transplantation published in AJKD with Dr. Vinay Nair, eAJKD advisory board member and a transplant nephrologist from the Mount Sinai School of Medicine. For the first part of this interview, please check out the previous post.
eAJKD: In your manuscript, there was not a large benefit in graft survival between elderly patients with a living donor transplant and ECD kidney transplant patients. It can be argued that many elderly patients with living donors can be expected to die with a functioning graft. However, at the same time you showed improved patient survival with living donor transplantation. Based on this, do you think transplant centers and nephrologists should really push living donation as a first option for elderly patients?
KK: Thank you very much for noticing that provocative finding. Among all types of donors, we noticed persistent association between living donor kidneys and mortality. This included the group of very elderly individuals who were 75 and older, indicating that living donor maintains a favorable outcome even in advanced age. So, this may have important implications for the practice of transplant nephrology in the elderly in that we should not discourage living donors for recipients who are considered very old.
Frequently these potential candidates have family members or other individuals who would be happy to donate a kidney. We located these elderly patients with living donors and studied them. The data showed very clearly that they have survival advantages. So, we are hoping that this paper instigates interest and enthusiasm in discussing living kidney donors for advanced age groups.
eAJKD: I also noticed that there are much fewer African American and female elderly patients being transplanted. Do you have any thoughts on why the number is low? Do you think we need to be more aggressive in transplanting elderly African Americans and women?
KK: I think this probably shows some background biases that African Americans tend to be less likely transplant candidates, and with advanced age this becomes more prominent (this differential across race). We are hoping that this studywill encourage kidney transplantation for the elderly across all races and gender groups.
eAJKD: In your study, the elderly again had excellent death-censored graft survival, but the worst mortality. Based on this information, do you or your center adjust induction and maintenance immunosuppression in elderly patients? Should we be doing something different from our standard patient?
KK: The best course of action for induction or initial immunosuppression therapy for the elderly remains unclear. Other studies have suggested your hypothesis that immune system conservation may be more favorable for elderly individuals, and therefore different approaches for these people may be indicated. There could also be risk stratifying approaches to try to ascertain who would benefit more or less from induction therapy.
eAJKD: To sum it up, what do you think should be the take-home message that clinicians and transplant centers obtain from this study?
KK: I think an important conclusion is that elderly individuals should be considered, including those who are 75 years or older, as kidney transplant candidates the same way that younger individuals are considered and worked up. If they are going to receive deceased donor kidneys, they are good candidates for ECD organs. The same individuals 75 and older should also be considered favorably for living kidney donation. We hope that the doubts and discouragement from the part of the healthcare providers could be mitigated by examining the results of this and similar studies in terms of encouraging elderly individuals to receive kidney transplants and encouraging potential donors to offer them a kidney.