Transplantation in the over 60’s 6 year experience E.R Faulconer N.G. Inston D. van Dellen H. Krishnan I. Griveas

Is Age An Issue? Age at starting Dialysis? Age at going on waiting list? Age at actual transplant operation? Does this matter? What do we know and does our data support this?

What is Survival on Dialysis Prognosis –Life expectancy –HD: 8 years Ansell D, Roderick P, et.al. UK Renal Registry 11 th Annual Report. Nephron Clin Pract 2009, 111 (suppl 1): c

Renal registry 2009 vs 2001 The ESRF RRT population is getting older

Why should listing take longer if you are older? More tests Improved health if they stay alive and you get to know them (they probably will be ok)

Incident Patient Survival on Dialysis Without transplantation censoring ( ) Censored for transplantation ( ) Ansell D, Roderick P, et.al. UK Renal Registry 11 th Annual Report. Nephron Clin Pract 2009, 111 (suppl 1): c

Risk/Benefit of Transplantation This applies to US patients – but does it apply to the 73 year old (n=1) in listing clinic? No….

So if you are over 60 it takes longer to get the benefit

So if you are over 60 it takes longer to get the benefit unless you have diabetes (significant comorbidity) Should we transplant elderly Diabetics more readily?

in addition it takes 369 days to get to a survival equal to reference (that is dialysis on W/L ie pre-tx state

For a projected years of life of 10 vs 6

So the graph actually shifts to the left and upwards!

Outline Defined 2 Groups –> 60 –<60 Audited cohort from Outcome measures at 1 year –Survival –Graft loss –CMV –Wound infection –Chest infection Analysed with reference to immunosuppressive protocols

Audited cohort from Overall transplants n= 658 –Under 60n= 551 –Over 60n=107 –Median ages and ranges

Birmingham – transplants by year Number Proportion

Demographics – Confounding Factors? Age <60Age >60p Total Immunosuppression TMP NAP TAP NMP 368 (67%) 66 (12%) 93 (17%) 25 (4%) 81 (76%) 15 (14%) 8 (7%) 3 (3%) Type of Transplant Live Cadaveric NHBD 261 (47%) 226 (41%) 64 (12%) 39 (37%) 57 (53%) 11 (10%) I/S included Basiliximab at D0 and D4 Fisher’s Exact Test

Immunosuppressive Regimen Used

1 year Patient Survival GroupSurvival Total97.7% < 60 y.o.98.5% > 60 y.o.93.4%

1 year Graft survival GroupSurvival Total93.4% < 60 y.o.94.1% > 60 y.o.89.7%

Cause of Death

Immunosuppression Regimens - Complications I/S regimeAgeN=CMVGraft lossWoundChestDeathAR NAPS < > TMPS < > NMPS < > TAPS < >

How do we decide if a patient is listed or not? Standards and guidelines –Against age discrimination –Based on tests and investigations Evidence base –Generally poor with regard to elderly –Most (pharma) RCTs exclude >55yrs –Registry data Gut feeling and experience –Is this really true?...

What are we listing for? Quality of life NOT Quantity of life Is there any proof of this? –This cannot be unbiased because it relies on: Survivors Not controllable – –HD vs PD vs “working” transplant vs “problem” transplant vs….

So how can we optimise and improve outcomes in elderly transplants? Listing –Conservative vs optimistic Assessment –Echo vs Stress vs CPEX Organ allocation –SCD vs ECD Immunosuppression –standard vs Minimise I/S?

Discussion…

Death

Graft Loss

Chest Complications

CMV Infection/Disease

Wound Complications

Chest Complications