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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2007  |  Volume : 18  |  Issue : 3  |  Page : 391-396
Kidney Transplantation in Elderly Iranian Patients


Department of Internal Medicine, Imam-Reza Hospital, Mashad University of Medical Sciences, Mashhad, Iran

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   Abstract 

The population of elderly people with chronic renal insufficiency is increasing around the world. It has been shown that renal transplantation (RT) may be the best treatment for these patients. However, it has been observed that older patients who have received a RT have a higher mortality rate than those who are younger. The aim of this study was to evaluate the outcome of RT in recipients over 50 years of age. During the period between 1988 and 2002, 650 renal transplantations were performed at the Imam Reza Hospital in Mashad, Iran, of which 83 were performed in patients older than 50 years (50 to 66 years). We studied the one, three, and five-year patient and graft survival rates as well as the prevalence of urinary tract infection (UTI) after transplantation in these patients. We also evaluated the effect of the recipient's age and sex and the type of donor (related or unrelated) on patient survival as well as the prevalence of UTI. Patient survival at one, three, and five years after RT were 92.4%, 84.7%, and 75.6%, respectively. The graft survival at one, three, and five years after RT were 91.1%, 79.7%, and 66.7%, respectively. UTI occurred in 67.1% of patients after transplantation. The patient and graft survival rates were not related to the age and sex of the recipients and the type of donors. Also, there was no correlation between the prevalence of UTI and the age and sex of the recipients. Our study suggests that RT can be performed safely and with acceptable prognosis in elderly patients after appropriate clinical evaluation.

Keywords: Kidney, Transplantation, Elderly, Urinary Tract Infection, Iran

How to cite this article:
Nazemian F, Naghibi M, Farazi E. Kidney Transplantation in Elderly Iranian Patients. Saudi J Kidney Dis Transpl 2007;18:391-6

How to cite this URL:
Nazemian F, Naghibi M, Farazi E. Kidney Transplantation in Elderly Iranian Patients. Saudi J Kidney Dis Transpl [serial online] 2007 [cited 2019 Sep 15];18:391-6. Available from: http://www.sjkdt.org/text.asp?2007/18/3/391/33758

   Introduction Top


Treatment modalities available for patients with end-stage renal disease (ESRD) fall into three categories: hemodialysis, peritoneal dialysis, and transplantation. [1] While hemo­dialysis and peritoneal dialysis are asso­ciated with significant morbidity, mortality, and poor quality of life, renal trans­plantation (RT) is considered to be the best form of replacement therapy for patients with ESRD. The prevalence of ESRD increases with advancing age, [2] and elderly people with chronic renal insufficiency represent an important group requiring renal replacement therapy. Kidney transplantation in elderly patients is a therapeutic option. However, the prognosis of RT in this population remains poorly defined, and few data on long­term follow-up in elderly transplant recipients are available. Moreover, due to the scarcity of organs, a shorter life expectancy, and the higher incidence of co-morbid diseases such as cardiovascular disease in this population, allocating cadaveric kidneys to these patients is still controversial. On the other hand, elderly patients show a decrease in cellular immunity due to dysfunction in T­cell and macrophage activity. [3],[4] This results in these patients being more vulnerable to developing infections, especially of the respiratory and urinary tracts. Immuno­suppression also plays an important role in the increased rate of infections in elderly kidney transplant patients. [5],[6] It has been observed that older patients who have received a renal transplant have a higher mortality rate associated with infections than those who are on dialysis [7] or younger in age. [6] Urinary tract infection (UTI) is the most common bacterial infection after trans­plantation, [1] and as such, the incidence of UTI in elderly transplant recipients is worth evaluating. In this single-center study, we report on the five-year outcome of kidney transplantation in patients older than 50 years over a period of 16 years follow-up. The aims of this study were to determine one, three, and five year patient and graft survival as well as the incidence of UTI in the first five years after RT. We also evaluated the effect of the recipient's age and sex and the type of donor (related or unrelated) on patient survival and the effect of the recipient's age and sex on the incidence of UTI.


   Patients and Methods Top


This study spans the period between 1988 (when the kidney transplantation centre of Imam-Reza hospital was established) and 2002. The Imam-Reza hospital is a tertiary level university hospital and one of the major hospitals in Iran. During this period, more than 650 kidney transplantations were performed in this center. Eighty-three of these 650 kidney transplantations were performed in 83 non­diabetic patients who were older than 50 years. All of the study patients received their kidneys from living donors and all were first kidney transplant recipients. We chose the age of 50 years to define the age of elderly, because life expectancy in Iran is shorter than that in developed countries and also because patients with renal insufficiency are physiologically older than the general population.

The mean follow-up period was 86 months. Among these patients, there were 63 males and 20 females with a median age of 54.9 years (range, 50 to 66 years). The study patients were divided into three groups according to their age: more than 60 years old (12 patients), between 55 and 60 years old (27 patients), and between 50 and 54 years old (44 patients). Detailed pre­transplant evaluation was performed in all patients, and those declared fit were included on the transplant waiting list. The main exclusion criteria were: positive cross­match for T-cell lymphocytes, evidence of active infection, clinically significant cardiac abnormality, malignancy within the previous five years, and associated psychiatric disorders. The standard post-transplant immuno-suppressive regimen consisted of cyclosporine, corticosteroids, and azathioprine triple therapy. Anti-lymphocyte serum (ALS) and methyl­prednisolone were used for treat-ment of acute rejection episodes. Prophylaxis with cotrimoxazole was administered every day during the first six months post­transplantation. Episodes of UTI after trans­plantation were diagnosed on the basis of the presence of significant pyuria on urinary analysis. The data were analyzed at one, three, and five years, and actuarial patient survival and the incidence of UTI (in the first five­years after transplantation) were compared between the two sex groups, three age groups, and two donor types. We also analyzed one, three, and five-year graft survival. All statis­tical analyses were performed with the SPSS statistical package (version 11.5). The characteristics of research samples were evaluated with descriptive statistics. A comparison of parametric data was done with Fisher's exact test. The confidence interval was established at 95% and values of P < 0.05 were considered significant.


   Results Top


The actuarial patient survival at one, three, and five years was 92.4%, 84.7%, and 75.6%, respectively [Figure - 1]. The graft survival at one, three, and five years after trans- plantation was 91.1%, 79.6%, and 66.7%, respectively [Figure - 1].

The maximum patient survival at one, three, and five years was 92.7%, 86.7%, and 78.3%, respectively and was observed in the patient group with ages from 50 to 54 years [Figure - 2]. Patient survival at one, three, and five years in the patient group older than 60 years was 90.9%, 80%, and 66.7%, respectively. In patients from 55 to 60 years old, patient survival at one, three, and five years was 92.6%, 83.3%, and 73.7%, respectively [Figure - 2]. No significant differ­rence was observed between the three age groups for patient survival at one year (P = 0.950), three years (P = 0.850), and five years (P = 0.740) post-transplantation.

The one and three-year patient survival tended to be higher in females, although the difference failed to reach statistical signif­icance (P=0.329 and 0.670 respectively [Figure - 3]. However, the five-year patient survival was higher in males (77.5%) than in females (60%) [Figure - 3], although this difference also was statistically not signifi­cant (P=0.582). In our study group, only 6% of patients received kidneys from related donors. No significant difference was noted in patient survival between patients who received related or unrelated kidneys at one year (P = 1.00), three years (P = 0.163), and five years (P = 0.247) following transplantation.

Forty-seven patients developed at least one episode of UTI during their follow-up. Twenty-three patients did not develop any episodes of UTI during the first five years after transplantation. Among those who had a complete five-year follow-up, 67.1% developed UTI [Figure - 4]. UTI was most common in patients with ages ranging from 55 to 60 years (73.9%) and was less common in patients with ages ranging bet-ween 50 and 54 years [Figure - 4]. However, no statistically significant difference was observed for UTI between the three age groups (P = 0.650). The UTI tended to be more common in females (72.2%) than in males (65.4%), although the difference did not show any statistical significance (P = 0.773).


   Discussion Top


Despite the limited life expectancy in patients older than 50 years, it seems that they benefit from renal transplantation. Patient survival after one, three, and five years of follow-up in the transplanted elderly patients at our center compares favorably with patient survival among children younger than 15 years old at one, three, and five years after transplantation (93%, 83%, and 71%, respectively) and of young adults at one, three, and five years after transplantation (93%, 89%, and 76%, respectively) at our center. [8] Some centers in America have reported five-year patient and graft survival in recipients over 60 years old ranging from 64% to 68% and from 55% to 62%, respectively. [9],[10] These studies included 18 to 30% of patients transplanted with living donor kidneys. In Europe, Cantarovich et al. [11] have reported an 80% patient and graft survival at five years for elderly recipients of cadaveric kidneys. However, published data from The UK National Data Base show slightly more than 50% cadaveric kidney graft survival at five years for patients older than 60 years. [12] In another study in Galicia (Spain), patient and graft survival has been reported to be 84% and 76% respectively for those of ages less than 60 years and 83% and 77% respectively for those over 60 years. [13]

Many centers, including ours, still hesitate to accept older patients for renal transplantation due to their shorter life expectancy. However, our results, as well as those from other studies, show that recipient age alone cannot be a convincing criterion for excluding patients from transplantation. Patient survival following renal transplantation in elderly recipients can be improved by careful selection and thorough assessment of cardiac and infectious risk factors as well as the use of a tailored immunosuppression protocol. [14] In elderly transplant recipients, the most frequent causes of death are cardiovascular diseases, infections, and neoplasms. [15],[16] A recent study by Isabel Trouillhet et al. showed that the majority of infections in elderly groups were urinary infections. Numerous other studies have also confirmed that the most frequent cause of infection during the first year after transplantation is urinary, with a global incidence of 61%. [17],[18] However, our study shows that the incidence of UTI in elderly recipients after five years of follow-up is higher (67.1%). In a retrospective cohort study that included all adult patients who received a renal transplant at two US transplant centers from January 1996 to December 2002 (500 patients), 213 patients (43%) developed one or more episodes of post-transplant UTI over a mean follow-up period of 42 months. Significant risk factors for post-transplant UTI were advanced age, female gender, reflux kidney disease, use of azathioprine, and cadaveric donor. UTI did not increase the risk for renal graft loss in this study but was associated with increased mortality. [19] In Hong Kong, the overall incidence of UTI in the Queen Mary Hospital renal transplant population was 30.9%, and UTI had little effect on graft function and survival up to three years post-transplant. [20] In conclusion, renal trans-plantation seems to be a good option for elderly patients with chronic renal failure, even though they may have a higher incidence of infectious episodes, especially urinary infections.

 
   References Top

1.Chan L, Wang W, Kam I. Outcomes and complications of renal transplantation. In: Schrier RW, ed. Diseases of the kidney and urinary tract. 7 th ed, Philadelphia: Williams & Wilkins; 2001. p. 2871-2925.  Back to cited text no. 1    
2.Pedroso S, Martins L, Fonseca I, et al. Renal transplantation in patients over 60 years of age: a single-center experience. Transplant Proc 2006;38(6):1885-9.  Back to cited text no. 2    
3.Rao VK. Kidney transplantation in older patients: benefits and risks. Drug Aging 2002;19:79-84.  Back to cited text no. 3    
4.Ismail N. Renal replacement therapy in the elderly: an old problem with young solution. Nephrol Dial Transplant 1997;12:873-6.  Back to cited text no. 4    
5.Morales JM, Campistol JM, Andres A, Herrero JC. Immunosuppression in older renal transplant patients. Drugs Aging 2000;16:279-87.  Back to cited text no. 5    
6.Meier-Kriesche HU, Ojo AO, Hanson J, et al. Increased immunosuppressive vulner­ability in elderly renal transplant recipients. Transplantation 2000;69:885-9.  Back to cited text no. 6    
7.Meier-Kriesche HU, Ojo AO, Hanson JA, Kaplan B. Exponetially increased risk of infectious death in older transplant recipients. Kidney Int 2001;59:1539-43.  Back to cited text no. 7    
8.Mohammadzadeh MS. Evaluation of renal transplantation in children in kidney transplantation centre of Imam reza hospital from 1992-2002. General Practitioner thesis. Mashhad university of medical sciences; 2003.  Back to cited text no. 8    
9.Benedetti E, Matas AJ, Hakim N, et al. Renal transplantation for patients 60 years of age or older: A single institution experience. Ann Surg 1994;220:445-60.  Back to cited text no. 9    
10.Tesi RJ, Elkhamamas EA, Davies EA, et al. Renal transplantation in older people. Lancet 1994;343:461-4.  Back to cited text no. 10    
11.Cantarovich D, Baatrad R, Baranger T, et al. Cadaveric renal transplantation after 60 years of age: a single centre experience. Transplant Int 1994;7:33-8.  Back to cited text no. 11    
12.Morris PJ, Johnson RJ, Fuggle SV, et al. Analysis of factors that affect outcome of primary cadaveric renal transplantation in the UK. Lancet 1999;354:1147-52.  Back to cited text no. 12    
13.Otero-Ravina F, Rodriguez-Martinez M, Gude F, et al. Renal transplantation in the elderly: does patient age determine the results? Age Ageing 2005;34(6):583-7.  Back to cited text no. 13    
14.Ponticelli C. Should renal transplantation be offered to older patients? Nephrol Dial Transplant 2000;15:315-7.  Back to cited text no. 14    
15.Basu A. Greenstein SM, Clemetson S, et al. Renal transplantation in patients above 60 years of age in the modern era: a single centre experience with a review of the literature. Int Urol Nephrol 2000;32:171-6.  Back to cited text no. 15    
16.Jassal SV, Opelz G, Cole E. Trans­plantation in the elderly: a review. Geriatr Nephrol Urol 1997;7:157-65.  Back to cited text no. 16    
17.Maraha B, Bonten H, Van Hoof Fiolet H, et al. Infectious complications and antibiotic use in renal transplant recipients during a 1­year follow-up. Clin Microbial Infect 2001;7:619-25.  Back to cited text no. 17    
18.Takai K, Tollemar J, Wilczek HE, Groth CG. Urinary tract infections following renal transplantation. Clin Transplant 1998;12:19-23.  Back to cited text no. 18    
19.Chuang P, Parikh CR, Langone A. Urinary tract infections after renal transplantation: a retrospective review at two US transplant centers. Clin Transplant 2005;19(2):230-5.  Back to cited text no. 19    
20.Chan PC, Cheng IK, Wong KK, et al. Urinary tract infections in post-renal transplant patients. Int Urol Nephrol 1990;22(4):389-96.  Back to cited text no. 20    

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Correspondence Address:
Fatemeh Nazemian
Nephrology Ward, Imam- Reza Hospital, Mashad
Iran
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PMID: 17679752

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  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]

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