Renal transplantation in the elderly

Recent data show that, despite a long period during which few elderly patients in end-stage renal failure received grafts, there are neither medical nor ethical grounds for avoiding kidney transplantation, at least in those aged under 70 or even 75 years of age. Units in which transplantation in older recipients is routine show a good survival of recipients, and comparable survival of grafts to those placed in younger recipients. This equality of graft survival with age arises because, although death with a functioning graft is more common in the elderly (principally from cardiovascular disease and infections, with malignant diseases becoming more important with time), graft losses from rejection are lower, and so overall outcomes are similar. Long-term patient survival is better, quality of life is improved and treatment is cheaper than in comparable elderly patients maintained on hemodialysis or chronic ambulatory peritoneal dialysis. In terms of allocation to older recipients, this success presents major practical and ethical difficulties given the shortage of cadaver organs. Data do not support the idea of 'age-matching' older or marginal kidneys to older recipients: like their younger counterparts, older recipients do better with organs from younger donors. Living donors can be used successfully even in those over 70, and elderly living donors have a place in the treatment of the elderly. The optimum immunosuppressive regimes for elderly recipients have not been determined, given their poorer immune responsiveness and lower rejection rates compared with younger individuals.