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Overcoming Ageism in Kidney Transplants
Date: September 1, 2012
In the world of kidney transplantation, younger has always been deemed better—at least in terms of selecting recipients and donors. The logic was simple: Younger recipients would appear to have better odds of survival and success, and younger donors would offer organs that had seen less wear and tear.
But in the Department of Surgery here, researchers are finding that this assumption isn’t necessarily true. In fact, says transplant surgeon and researcher Dorry Segev, studies conducted during the last decade have shown that older patients could be just as eligible and hold just as much promise as their younger counterparts. Yet every year, tens of thousands of patients are turned away from—or not even referred to—transplant programs because of their age. Instead, they’re left with only one choice: years and years spent on dialysis, with no end in sight.
“That feels almost as bad as a death sentence for many of these adults,” Segev says. “But for the right patients, older ones included, transplantation offers a chance at survival and a much higher quality of life. Right now, the referral rate for kidney transplantation in older adults is almost one-tenth that of younger adults. But we recently showed that thousands of older adults every year go on dialysis, despite being excellent candidates predicted to do exceptionally well and derive tremendous benefits from a kidney transplant. Yet they never make it to us.”
The challenge today is twofold: First, the medical community needs to accept the possibility that kidney transplantation could be an option for patients 65 and older. Second, those patients—recipients and donors alike—need to be identified.
“The question is how do we decide whether someone is robust enough to get through the transplant operation so they can actually reap the benefits of it?” Segev says. One of the most promising criteria is a condition that in recent years has become increasingly prominent in the field of geriatrics: frailty, or physiologic reserve. In the past, frailty was limited to a vague assessment by an experienced clinician from the foot of the hospital bed; today it can actually be quantified with a simple set of tests.
By measuring walking speed, grip strength, fatigue, physical activity, and muscle loss, physicians can often determine whether an older patient is fit for any procedure—transplantation included. “We recently published that a patient’s level of frailty was a stronger predictor of outcomes than any other criteria that we are able to measure,” Segev says.
It’s not only older recipients who are sometimes overlooked. Older potential donors, too, have often been disregarded, even though they could have excellent outcomes and continue to live a high-quality life. In one study, Segev and his colleagues examined more than 200 living donors, ages 70 and up. They looked at two things: how well the recipients of their organs did and how well the donors themselves did. They then compared those donors to healthy people of the same age who had not donated a kidney. “We found that the surgical risk for a properly screened older adult was no different than for a properly screened younger adult,” Segev says. “We also found that older donors lived just as long as their non-donor counterparts.
That’s not to say that a 70-year-old is necessarily the best donor for a 20-year-old recipient, particularly if other options are available. Older donors, Segev explains, are ideal for older recipients who would generally require a shorter organ shelf life. Still, considering older donors increases a patient’s pool of potential living donors, particularly for older patients whose support networks are often populated by people their own age.
“Patients on dialysis may have to wait years and years before they get a donor offer from a waiting list,” Segev says. “If you can find a living donor, that’s a much better option, because you can spare yourself many years of waiting and possibly dying on dialysis.” Lauren Glenn