CORRESPONDENCE
Chronic Kidney Disease and the Aging Population e want to thank Tonelli and Riella whom on behalf of the World Kidney Day Steering Committee 2014 puts focus on the epidemiology of aging and development of chronic kidney disease (CKD) (1). Their communication in Transplantation elegantly discusses different treatment alternatives for the elderly patient with CKD. The authors also describe challenges with respect to organ shortage, optimal immunosuppression, and health-related quality of life (HRQOL). We were surprised that Tonelli and Riella’s leave-out transplantation as an option in their concluding remark. During the last decade, our hospital has had a specific focus on elderly renal transplant recipients, and we would like to comment on some of the mentioned challenges. Organ shortage is a challenge. Increasing utilization of expanded criteria donors (ECD) is however possible. In our opinion, too many transplant centers worldwide are reluctant to use older deceased donors. We believe that modern immunosuppression (2) and machine perfusion can improve outcome of kidneys from ECDs (3). Our group has previously published data showing that even kidney transplants from deceased donors more than 75 years old perform acceptable as single transplants and should be considered for use in older recipients (4). In one selected situation, organs from a 90-year-old deceased donor were utilized (5). Both recipients are doing well with eGFR around 50 mL/min almost 5 years after engraftment (personal message). If more centers could be more open-minded and have an old-for-old program, the younger recipients would have shorter waiting time and the older
W
e64
www.transplantjournal.com
recipients would have transplantation as a treatment option. Optimal immunosuppression is not established for older patients. Induction with interleukin-2 antagonist may be preferred. If one wants to use ATG induction, individualized T-cell monitored dosing is recommended. Outcome is improved if rejection is avoided (6). HRQOL also needs to be investigated. With modern dialysis, many older patients might have a better HRQOL in dialysis than after transplantation. Among adult kidney recipients, it is well accepted that transplantation provides a better HRQOL than permanent dialysis. But is this also the fact among older recipients? We are currently exploring HRQOL longitudinally in a population of patients older than 65 years with ESRD stage 5 who are on the active transplant list. Hopefully, this study (QUESTION65) will provide information about how HRQOL is changing between the different stages pre- and posttransplant (registered on www.clinicaltrial.gov). The study is ongoing, but preliminary results indicate improved HRQOL after transplantation (unpublished data). We therefore believe that Tonelli and Riella’s last sentence should be rewritten: Perhaps more importantly, clinicians, patients, and their families can be comforted by the knowledge that timely specialist evaluation can help improve outcomes and reduce symptoms in older people with advanced kidney diseaseVwhether they have selected conservative management, dialysis, or kidney transplantation as their treatment plan. Karsten Midtvedt1 Kristian Heldal2,3
Transplantation
1
Department of Transplant Medicine Oslo University Hospital Oslo, Norway 2 Clinic of Internal Medicine Telemark Hospital Skien, Norway 3 Faculty of Medicine Institute of Clinical Medicine University of Oslo Oslo Norway
The authors declare no funding or conflicts of interest. Address correspondence to: Karsten Midtvedt, M.D., Ph.D., Department of Transplant Medicine, Rikshospitalet, Postboks 4950 Nydalen, 0424 Oslo, Norway. E-mail: [email protected] Received 10 March 2014. Accepted 13 March 2014. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0041-1337/14/9711-e64 DOI: 10.1097/TP.0000000000000172
REFERENCES 1. 2.
3.
4.
5.
6.
Tonelli M, Riella M. Chronic Kidney Disease and the Aging Population World Kidney Day 2014. Transplantation 2014; 97: 490. Heldal K, Thorarinsdottir S, Hartmann A, et al. Induction with interleukin-2 antagonist for transplantation of kidneys from older deceased donors: an observational study. Transplant Res 2013; 2: 11. Morrissey PE, Monaco AP. Donation after circulatory death: current practices, ongoing challenges, and potential improvements. Transplantation 2014; 97: 258. Foss A, Heldal K, Scott H, et al. Kidneys from deceased donors more than 75 years perform acceptably after transplantation. Transplantation 2009; 87: 1437. Midtvedt K, Namtvedt T, Scott H, et al. Single transplanted kidneys from a 90-yearold deceased donor perform acceptably at 1 year. Transplant Proc 2011; 43: 2107. Heldal K, Hartmann A, Leivestad T, et al. Clinical outcomes in elderly kidney transplant recipients are related to acute rejection episodes rather than pretransplant comorbidity. Transplantation 2009; 87: 1045.
& Volume 97, Number 11, June 15 , 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Chronic Kidney Disease and the Aging Population e want to thank Tonelli and Riella whom on behalf of the World Kidney Day Steering Committee 2014 puts focus on the epidemiology of aging and development of chronic kidney disease (CKD) (1). Their communication in Transplantation elegantly discusses different treatment alternatives for the elderly patient with CKD. The authors also describe challenges with respect to organ shortage, optimal immunosuppression, and health-related quality of life (HRQOL). We were surprised that Tonelli and Riella’s leave-out transplantation as an option in their concluding remark. During the last decade, our hospital has had a specific focus on elderly renal transplant recipients, and we would like to comment on some of the mentioned challenges. Organ shortage is a challenge. Increasing utilization of expanded criteria donors (ECD) is however possible. In our opinion, too many transplant centers worldwide are reluctant to use older deceased donors. We believe that modern immunosuppression (2) and machine perfusion can improve outcome of kidneys from ECDs (3). Our group has previously published data showing that even kidney transplants from deceased donors more than 75 years old perform acceptable as single transplants and should be considered for use in older recipients (4). In one selected situation, organs from a 90-year-old deceased donor were utilized (5). Both recipients are doing well with eGFR around 50 mL/min almost 5 years after engraftment (personal message). If more centers could be more open-minded and have an old-for-old program, the younger recipients would have shorter waiting time and the older
W
e64
www.transplantjournal.com
recipients would have transplantation as a treatment option. Optimal immunosuppression is not established for older patients. Induction with interleukin-2 antagonist may be preferred. If one wants to use ATG induction, individualized T-cell monitored dosing is recommended. Outcome is improved if rejection is avoided (6). HRQOL also needs to be investigated. With modern dialysis, many older patients might have a better HRQOL in dialysis than after transplantation. Among adult kidney recipients, it is well accepted that transplantation provides a better HRQOL than permanent dialysis. But is this also the fact among older recipients? We are currently exploring HRQOL longitudinally in a population of patients older than 65 years with ESRD stage 5 who are on the active transplant list. Hopefully, this study (QUESTION65) will provide information about how HRQOL is changing between the different stages pre- and posttransplant (registered on www.clinicaltrial.gov). The study is ongoing, but preliminary results indicate improved HRQOL after transplantation (unpublished data). We therefore believe that Tonelli and Riella’s last sentence should be rewritten: Perhaps more importantly, clinicians, patients, and their families can be comforted by the knowledge that timely specialist evaluation can help improve outcomes and reduce symptoms in older people with advanced kidney diseaseVwhether they have selected conservative management, dialysis, or kidney transplantation as their treatment plan. Karsten Midtvedt1 Kristian Heldal2,3
Transplantation
1
Department of Transplant Medicine Oslo University Hospital Oslo, Norway 2 Clinic of Internal Medicine Telemark Hospital Skien, Norway 3 Faculty of Medicine Institute of Clinical Medicine University of Oslo Oslo Norway
The authors declare no funding or conflicts of interest. Address correspondence to: Karsten Midtvedt, M.D., Ph.D., Department of Transplant Medicine, Rikshospitalet, Postboks 4950 Nydalen, 0424 Oslo, Norway. E-mail: [email protected] Received 10 March 2014. Accepted 13 March 2014. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0041-1337/14/9711-e64 DOI: 10.1097/TP.0000000000000172
REFERENCES 1. 2.
3.
4.
5.
6.
Tonelli M, Riella M. Chronic Kidney Disease and the Aging Population World Kidney Day 2014. Transplantation 2014; 97: 490. Heldal K, Thorarinsdottir S, Hartmann A, et al. Induction with interleukin-2 antagonist for transplantation of kidneys from older deceased donors: an observational study. Transplant Res 2013; 2: 11. Morrissey PE, Monaco AP. Donation after circulatory death: current practices, ongoing challenges, and potential improvements. Transplantation 2014; 97: 258. Foss A, Heldal K, Scott H, et al. Kidneys from deceased donors more than 75 years perform acceptably after transplantation. Transplantation 2009; 87: 1437. Midtvedt K, Namtvedt T, Scott H, et al. Single transplanted kidneys from a 90-yearold deceased donor perform acceptably at 1 year. Transplant Proc 2011; 43: 2107. Heldal K, Hartmann A, Leivestad T, et al. Clinical outcomes in elderly kidney transplant recipients are related to acute rejection episodes rather than pretransplant comorbidity. Transplantation 2009; 87: 1045.
& Volume 97, Number 11, June 15 , 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
