Renal transplantation in the elderly
assesses the patient and commissions IC from the above
team if it is agreed that the patient has potential to benefit
from further rehabilitation. Patients are also referred to the
joint care manager by the primary health care team. Patients
Age and Ageing 2005; 34: 583–587
doi:10.1093/ageing/afi200
accepted for IC are then assessed by each discipline in the
IC team and a care plan developed with delivery by the care
assistants. Patients receive input for up to 6 weeks, according
to need.
© The Author 2005. Published by Oxford University Press on behalf of the British Geriatrics Society.
All rights reserved. For Permissions, please email: [email protected]
Renal transplantation in the elderly: does patient
age determine the results?
FERNANDO OTERO-RAVIÑA1, MÓNICA RODRÍGUEZ-MARTÍNEZ2, FRANCISCO GUDE3,
JOSÉ RAMÓN GONZÁLEZ-JUANATEY4, FRANCISCO VALDÉS5, DOMINGO SÁNCHEZ-GUISANDE4
1
Servicio Galego de Saúde, Health Care Coordination Section, Santiago de Compostela, Spain
Centro de Transfusión de Galicia, Blood Donation Service, Santiago de Compostela, Spain
3
Hospital Clínico Universitario, Clinical Epidemiology Unit, Santiago de Compostela, Spain
4
Hospital Clínico Universitario, Department of Medicine, Santiago de Compostela, Spain
5
Hospital Juan Canalejo, Nephrology Service, A Coruña, Spain
2
Address correspondence to: F. Otero-Raviña. Fax: (+34) 9 819 50757 Email: [email protected]
Abstract
Background: transplantation is the best treatment for patients with chronic renal failure, including the elderly. However, the
patient’s age was traditionally considered as a relative contraindication for it.
Objective: to compare the results of renal transplantation in patients over and under 60 years of age.
Methods: analysis of 621 transplant recipients in Galicia (Spain) between 1996 and 2000, divided into two groups, according
to age over 60 years (484) or under 60 years (137). The actuarial method, Kaplan–Meier curves, log-rank test and Cox proportional hazard model were used to study survival.
Results: graft survival for those aged under 60 years was 82% and 70% at 1 and 5 years, while it was 73% and 56% for those
over 60 years. However, censuring the deceased patients with a functioning graft, it was 84% and 76% for those aged under
60 years and 83% and 77% for those over 60 years. A total of 47% of the graft losses in the group over 60 years were due to the
patient’s death. Overall graft survival for all the patients was greater (P < 0.0001) when the donor was under 60 years of age.
Conclusions: recipient age alone cannot be a criterion to exclude patients over 60 years from transplantation, since their
lower survival is influenced by comorbidity and the donor’s age.
Keywords: elderly patients, renal transplantation, graft survival, mortality
Introduction
Life expectancy has increased in recent decades, so that those
over 60 years represent an important segment of the general
population. Thus, more than a quarter of the citizens in NorthWest Spain are older than this age [1]. Due to the characteristics of chronic renal disease, which increases with age, these
demographic changes are clearly reflected in the population
affected. Thus, this disease’s incidence and prevalence have
doubled in those over 60 in the United States during the last
decade, representing more than 60% of the patients who initiated renal substitutive treatment in the year 2002 [2]. This percentage is similar to that of European countries [3] and there is
even a significant proportion of those over 80, for whom renal
replacement therapy is still an effective treatment [4].
Traditionally, the patient’s age was considered as a relative
contraindication for renal transplantation. This is fundamentally due to the elevated comorbidity of the elderly undergoing
renal replacement therapy and because the scarcity of donors
encouraged the selection of those recipients who presumably
583
F. Otero-Raviña et al.
could obtain more important benefits regarding survival. However, there is presently evidence that transplantation is the best
treatment for patients with chronic kidney disease [5], even
those of older age [6, 7]. Thus, even though there is still some
controversy, transplant teams accept older patients, transplantation becoming an increasingly more common therapeutic
alternative in those over 60. In this way, they represent almost
a quarter of the transplant recipients in some countries [8].
The present study aimed to analyse the characteristics
and compare the results of renal transplantations in patients
over and under 60 years and the factors that influence graft
survival to determine if there should be an age limit or, on
the contrary, if transplantation should continue to increase
in elderly patients.
Subjects and methods
We have analysed 672 renal grafts performed in Galicia (Spain),
all from cadaveric donors, from January 1, 1996 to December
31, 2000, extending the follow-up period of the grafts and the
patients until December 31, 2001. However, in an attempt to
eliminate biases derived from their different characteristics,
combined transplants (21), patients in paediatric age (2) and
those who were lost to follow-up (2) were excluded. Thus, the
final analysis was conducted on 647 grafts implanted in 621
patients. These were divided into two groups, according to age
at the time of the transplantation: group A (<60 years) and
group B ( ≥ 60 years). All patients were followed-up for a period
of at least one year, though 354 patients were followed-up for
three years and 109 patients for five years.
The data were collected in two hospitals with transplant
teams (Juan Canalejo of A Coruña and Clínico Universitario
of Santiago de Compostela). The clinical records in the hospital files were reviewed and, in the case of the patients who
returned to dialysis after losing the graft, in the respective
dialysis units. The following variables were recorded:
(i) Donor’s age, gender, cause and type of death as well as
generating hospital.
(ii) Recipient’s age, gender, residence site, primary renal disease
and previous time on renal replacement therapy.
(iii) Transplantation hospital, date, previous transplantations
and type of transplantations (simple or combined).
(iv) Existence or not of acute rejection episodes, data and
cause of graft loss, retransplantation date, date and cause
of patient’s death (with or without functioning graft).
Statistical analysis
To verify the association between variables, the chi-squared,
Student’s t test and Mann–Whitney U test have been used,
while the actuarial method, Kaplan–Meier curves, log-rank
test and Cox proportional hazard models were used for the
survival analysis. The method proposed by Grambsch and
Therneau was used to assess hazard proportionality. Based
on regression analysis coefficients, relative risks (RR) and
95% confidence intervals (CI) were calculated.
Results
A total of 621 patients, 484 (77.9%) of whom were under 60
years and 137 (22.1%) were 60 years or older, were included
584
in the analysis. When the characteristics of both groups
were compared (Table 1), significant differences were found
with regards to retransplantation, which was more frequent
in the younger subjects (P=0.003), to the baseline disease
(there was a greater proportion of glomerulonephritis in the
younger subjects (P<0.001) while diabetes mellitus was more
frequent in the older subjects (P=0.008)), and to previous
time in renal replacement therapy, which was greater
(P=0.008) in those over 60 years. In addition, older patients
received grafts from older donors, and while patients in
group A received grafts that originated in the transplant
hospital itself, those in group B came mostly from other
extraction sites.
Patient survival at one and five years was significantly
greater (P<0.0001) in the younger group (96.3 and 86.4%)
than in that of the older one (84.7 and 69.1%). The same
occurred with graft survival (Figure 1A), which was 82.4
Table 1. Patients characteristics
Recipients
Group A
Group B
n=484 (77.9%) n=137 (22.1%) P
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . .
Transplants
Gender
Male
Female
Recipient age (years)
Residence
Rural
Urban
Hospital
Juan Canalejo-A Coruña
Clínico-Santiago
Primary disease
Glomerulonephritis
Pyelonephritis
Polycystic kidney disease
Diabetes mellitus
Vascular disease
Others / unknown
Retransplant
Dialysis duration (months)
Dialysis duration
<1 year
>1 year
Acute rejection episodes
Donors
Age (years)
Gender
Male
Female
Type of death
Brain death
Asystolic
Cause of brain death
Cranial trauma
Acute cerebrovascular
disease
Others
Originate
In hospital performing
transplantation
In another hospital
505 (78.1)
142 (21.9)
NS
321 (63.6)
184 (36.4)
40.2 ± 11.7
86 (60.6)
56 (39.4)
64.2 ± 3.0
242 (47.9)
263 (52.1)
78 (54.9)
64 (45.1)
386 (76.4)
119 (23.6)
111 (78.2)
31 (21.8)
<0.001
NS
NS
131 (25.9)
86 (17.0)
50 (9.9)
33 (6.5)
36 (7.1)
169 (33.5)
106 (21.0)
21.3 ± 29.4
16 (11.3)
23 (16.2)
22 (15.5)
19 (13.4)
14 (9.9)
48 (33.8)
14 (9.9)
24.0 ± 24.2
279 (55.2)
226 (44.8)
91 (18.0)
64 (45.1)
78 (54.9)
20 (14.1)
40.2 ± 16.3
50.7 ± 17.4
<0.001
NS
NS
0.008
NS
NS
0.003
0.008
0.032
NS
<0.001
NS
336 (66.5)
169 (33.5)
99 (69.7)
43 (30.3)
480 (95.0)
25 (5.0)
133 (93.7)
9 (6.3)
222 (44.0)
236 (46.7)
53 (37.3)
75 (52.8)
NS
NS
47 (9.3)
14 (9.9)
NS
0.013
255 (50.5)
55 (38.7)
250 (49.5)
77 (61.3)
NS
Renal transplantation in the elderly
A
1, 0
,8
Proportion s urviving
<60 years
log rank p=0.0012
,6
≥60 years
,4
,2
0, 0
0
365
1
730
2
1095
3
1460
4
1825
5
219
60
Time (years)
B
1, 0
<60 years
Proportion s urviving
,8
≥60 years
log rank p=0.8468
,6
,4
,2
0, 0
0
365
1
730
2
1095
3
1460
4
182
55
2190
6
Time ( ye ars)
Figure 1. Kaplan–Meier analysis of graft survival after kidney
transplantation according to age of recipient. (A) Graft survival in recipients <60 years and ≥60 years at the time of
transplant. (B) Graft survival excluded for patient death with
functioning graft in recipients <60 years and ≥60 years at the
time of transplant.
and 70.2% for group A patients and 72.5 and 55.7% for
those of group B (P=0.0012). However, when graft survival
was analysed excluding patients who died with a functioning
graft (Figure 1B), no significant differences were found:
83.7 and 75.8% for patients under 60 years and 82.6 and
76.6% for the older ones (P=0.8468).
Overall graft survival for all the patients was significantly
greater (P<0.0001) when the donor was under 60 years than
when the donor was older than this age (82.3 and 71.6% versus 71.5 and 45.0%, at one and five years, respectively). When
the results of groups A and B were analysed based on the
donor’s age, older or younger than 60 years, we observed that
when the group A patients were associated with young
donors they had greater survival (84.2 and 73.9%, at 1 and 5
years) than those of group B, both when the latter were associated with old donors (73.2 and 45.8%; P=0.0006) or with
young donors (72.1 and 60.2%; P=0.0036). However, if the
group A patients are associated with old donors (70.1 and
44.3%) there are no significant differences with those of
group B, both if the latter are associated with old donors
(P=0.7631) or with young ones (P=0.211). The difference in
group B patient survival when they are associated with young
or old donors was also not statistically significant (P=0.4852).
In the multivariate analysis, including all the variables
described in Table 1 in the model, the following were
predictive factors for graft loss: recipient age over 60 years
(relative risk [RR]=1.56; 95% confidence interval [CI] 1.09–
2.25), presence of acute rejection episodes in the first year
(RR=2.14; CI 1.52–3.01), donor age above 60 years
(RR=1.63; CI 1.11–2.34) and non-heart beating donor
(RR=3.42; CI 1.68–6.94).
Percentage of graft losses in group B was greater than in
A (40.1 versus 26.3%; P=0.001). In regards to the causes of
the loss, there were no significant differences in both groups,
except in functioning kidneys lost due to the patient’s death.
These represented 47.4% of the losses in group B and 18.0%
in group A (P<0.0001) (Table 2).
A total of 9.5% of the group A patients and 26.3% of those
from group B (P<0.0001) died, however, there were no significant differences between the causes of death, the most frequent being infections (47.2% in group B and 30.4% in group
A) and cardiovascular diseases (32.6% in group A and 27.8% in
group B). When first year mortality was analysed, it was seen
that the standard mortality index is 5.2 for all the recipient
patients, it being 15.3 for group A and 4.2 for those of group B.
Discussion
Ageing of the general population entails an important
increase in the age of patients with chronic kidney disease.
More than 800 patients per one million inhabitants over 65
Table 2. Causes of graft loss in kidney recipients
Cause of loss
Group A
n (%)
Group B
n (%)
P value
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . . . . . . . . .
Primary nonfunction
Acute rejection
Vascular thrombosis
Infection
Chronic dysfunction
Death with functioning graft
Others
Total
13 (9.8)
6 (4.5)
44 (33.1)
6 (4.5)
25 (18.8)
24 (18.0)
15 (11.3)
133 (26.3)
4 (7.0)
2 (3.5)
13 (22.8)
1 (1.8)
8 (14.0)
27 (47.4)
2 (3.5)
57 (40.1)
NS
NS
NS
NS
NS
<0.0001
NS
0.001
585
F. Otero-Raviña et al.
years begin renal substitutive treatment in Spain each year [9].
Consequently, the number of transplantations is increased in
elderly subjects, so that almost a quarter of the transplant
recipients exceed 60 years in some registries [8], which agrees
with our series, in which they represent 22%.
However, transplantation in these patients continues to
represent a controversy in this era of donor scarcity, since it
is considered that survival after 65 years is similar for those
with renal replacement therapy and for the transplant recipients [10]. The results of the many studies published are very
different in regards to the influence of the recipient age on
graft survival. Based on them, there are those that conclude,
even after excluding losses due to the patient’s death, that
age is an important independent risk factor for development
of chronic renal allograft failure [11], while others do not
find statistically significant differences [12, 13].
In our study, age greater than 60 years represented an
independent risk factor for graft loss. In these patients, survival was significantly lower, however, when patients who
died with a functioning graft were excluded, survival was
equal to that of the younger subjects, around 83 and 76%, at
one and five years, respectively. In fact, coinciding with
other series [13, 14], the first cause of graft loss in the group
over 60 years was the patient’s death, which reached almost
half of all the losses and was significantly greater than in the
group of the younger subjects.
On the other hand, when graft survival was compared in
both groups according to donor age, we verified that recipients under 60 years only had greater survival when they
received a graft from a donor who was also young, while if
the donor was over 60 years, no significant differences were
observed. This suggests that the donor age is that which
affects graft survival to the greatest degree. In fact, although
there are controversies in this sense in the literature [15–17],
it represented a risk factor for graft lost in our series independently of the recipient age.
In any event, given that graft survival in the older patient
did not significantly vary based on donor age, together with
the unquestionable benefit of transplantation versus dialysis
in regards to improving quality of life [18], it is clear that
elderly donors should be accepted, using them for patients
of greater age, with less life expectancy, and who would not
have any access to a transplantation otherwise [19].
Logically, mortality was greater in the elderly recipient
group and we consider it important to know what percentage
of deaths can be attributed to the consequences of the
transplantation and which are due to the same circumstances that cause death in the general population. In this
sense, there are studies that indicate that mortality in the
first year may be fourteen times greater than that of the
population mean [20]. However, in our series, it is fifteen
times greater for those transplant recipients under 60 years,
while it is only four times greater in those over 60 years.
Finally, the results of our study show that recipient age
alone cannot be a determining criterion to exclude elderly
patients from the benefits of transplantation, since graft survival seems to be conditioned, to a larger degree, by the
patient’s comorbidity, on the basis of which he/she should
be strictly selected, and by the donor’s age. With respect to
586
this issue, it is true that a debate could be made on the optimal use that should be given to the scarce number of organs
available. However, to the position that younger patients
should be given priority because of greater life expectancy
we respond that the value of human life cannot be judged
on the basis of age, and, thus, we believe that clinical criteria
regarding comorbidity should be the only limitation for elderly patients to have access to renal transplantation.
Key points
• In the graft survival, excluding patients who died with a
functioning graft, there were no significant differences
among patients under 60 years and the older ones.
• Donor age is the factor which affects graft survival to the
greatest degree, it represented a risk factor for graft loss
independently of the recipient age.
• In regards to the causes of graft loss, there were no significant differences in both groups, except in functioning
kidneys lost due to the patient’s death.
• Recipient age alone cannot be a determining criterion to
exclude elderly patients from the benefits of transplantation.
References
1. Instituto Galego de Estatística. Available in: http://ige.xunta.es/
ga/demograficas/Padron/series_2003/pir_galicia.htm
2. US Renal Data System, USRDS 2004 Annual Data Report:
Atlas of End-Stage Renal Disease in the United States,
National Institutes of Health, National Institute of Diabetes
and Digestive and Kidney Diseases, Bethesda, MD, 2004.
3. ERA-EDTA Registry: ERA-EDTA Registry 2002 Annual
Report. Academic Medical Center, Amsterdam, The Netherlands,
May 2004.
4. Ronsberg F, Isles C, Simpson K, Prescott G. Renal replacement therapy in the over-80s. Age Ageing 2005; 34: 148–52.
5. Wolfe RA, Ashby VB, Milford EL et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting
transplantation, and recipients of a first cadaveric transplant.
N Engl J Med 1999; 341: 1725–30.
6. Oniscu GC, Brown H, Forsythe JLR. How great is the survival
advantage of transplantation over dialysis in elderly patients?
Nephrol Dial Transplant 2004; 19: 945–51.
7. Oniscu GC, Brown H, Forsythe JLR. How old is old for transplantation? Am J Transplant 2004; 4: 2067–74.
8. Clèries M, Vela E. Registre de malalts renals de Catalunya.
Informe estadístic 2002. Barcelona: Generalitat de Catalunya;
2004.
9. Lopez Revuelta K, Saracho R, Garcia Lopez F et al. Informe de
diálisis y trasplante año 2001 de la Sociedad Española de Nefrología y Registros Autonómicos. Nefrología 2004; 24: 21–33.
10. Burgos Revilla FJ, Pascual Santos J, Gómez Dosantos V,
Marcén Letosa R. Estudio del receptor del trasplante renal. In
González Martín M, García Buitrón JM eds. Trasplante renal.
Madrid: Aula Médica Ediciones; 2000. pp. 25–37.
11. Meier-Kriesche HU, Ojo AO, Arndorfer JA et al. Recipient
age as an independent risk factor for chronic renal allograft
failure. Transplant Proc 2001; 33: 1113–14.
12. Solá R, Rodríguez S, Guirado LL et al. Renal transplant for
recipients over 60 years old. Transplantation 2000; 69: 2460–62.
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13. Saudan P, Berney T, Leski M, Morel P, Bolle JF, Martin PY.
Renal transplantation in the elderly: a long-term, single-centre
experience. Nephrol Dial Transplant 2001; 16: 824–8.
14. Palomar R, Ruiz JC, Cotorruelo JG et al. Influencia de la edad
del receptor en la evolución del trasplante renal. Nefrología
2001; 21: 386–91.
15. Valdés F, Pita S, Alonso A et al. The effect of donor gender on
renal allograft survival and influence of donor age on posttransplant graft outcome and patient survival. Transplant Proc
1997; 29: 3371–2.
16. Ojo AO, Hanson JA, Meier-Kriesche HU, Okechukwu CN,
Wolfe RA, Leichtman AB. Survival in recipients of marginal
cadaveric donor kidneys compared with other recipients and
wait-listed transplant candidates. J Am Soc Nephrol 2001; 12:
589–97.
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17. Pessione F, Cohen S, Durand D et al. Multivariate analysis of
donor risk factors for graft survival in kidney transplantation.
Transplantation 2003; 75: 361–7.
18. Dew MA, Switzer GE, Goycoolea JM et al. Does transplantation produce quality of life benefits? A quantitative analysis of
the literature. Transplantation 1997; 64: 1261–73.
19. Otero-Raviña F, Romero R, Rodríguez-Martínez M et al.
Factores de riesgo para la desestimación de riñones en Galicia.
¿Es posible incrementar su utilización?. Nefrología 2005; 25
(in press; accepted 22 nov 2004).
20. Arend SM, Mallat MJ, Westendorp RJ, Van der Woude FJ, Vans
Es LA. Patient survival after renal transplantation; more than 25
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Received 30 April 2005; accepted in revised form 5 August 2005
© The Author 2005. Published by Oxford University Press on behalf of the British Geriatrics Society.
All rights reserved. For Permissions, please email: [email protected]
Improving care for patients with dysphagia
SALLY K. ROSENVINGE1, IAN D. STARKE2
1
Guy’s and St Thomas’ NHS Trust, St Thomas’ Hospital, Lambeth Palace Road, London SE1 7EH, UK
University Hospital Lewisham, Lewisham High Street, London SE13 6LH, UK
2
Address correspondence to: S. K. Rosenvinge. Tel/Fax: (+44) 20 7188 2522. Email: [email protected]
Abstract
Background: early diagnosis and effective management of dysphagia reduce the incidence of pneumonia and improve quality of care and outcome. Dysphagic stroke patients rarely perceive that they have a swallowing problem, and thus carers have
to take responsibility for following the safe swallow recommendations made by the Speech and Language Therapist (SLT).
Published work and observations in our own Trust indicated that patients with dysphagia may be fed in a manner which
places them at significant risk of aspiration, despite SLT advice for safe swallowing.
Objective: to determine compliance with swallowing recommendations in patients with dysphagia and to investigate the
effectiveness of changes in practice in improving compliance.
Design: sequential observational study before and after targeted intervention.
Setting: an acute general and teaching hospital in an inner city area.
Subjects: all patients with dysphagia on the caseload of the speech and language therapy department at the time of the study.
Methods: observations were made on compliance with the recommendations of SLTs regarding consistency of fluids, dietary modifications, amount to be given at a single meal/drink, swallowing strategies, general safe swallow recommendations
and whether supervision was required. A dysphagia link nurse programme was established, together with modification of an
in-house training scheme, use of pre-thickened drinks and modification of swallowing advice sheets. The same observations
were repeated after this intervention.
Results: thirty-one patients were observed before and 54 after the intervention. There was improvement in compliance with
the recommendations on consistency of fluids (48–64%, P< 0.05), amount given (35–69%, P<0.05), adherence to safe swallow
guidelines (51–90%, P<0.01) and use of supervision (35–67%, P<0.01). There were no significant differences in compliance
with dietary modifications or swallowing strategies. Improvement in compliance was demonstrated in medical and geriatric
wards and the stroke unit, but not in the surgical wards. Compliance with ‘nil by mouth’ instructions was 100% throughout.
The work was done at University Hospital Lewisham, Lewisham High Street, London SE13 6LH, UK.
587