Almost half of kidney transplant candidates older than 60 who are put on the waiting list for a deceased-donor organ will die before getting a transplant, according to new findings from the University of Florida, Cleveland Clinic and Case Western Reserve University.
Wait times to receive a deceased donor kidney transplant have increased over the years, but this study is the first to define and quantify what this wait time means for older patients. Researchers suggest that some candidates should consider live-donor options rather than wait for deceased-donor organs to become available.
The findings give firm data that can guide patients in making decisions, and policymakers in allocating donated organs.
"If someone knows that they have a 10 percent chance of dying before transplantation, they might consider it differently than if they know they have an 80 or 90 percent chance," said Jesse Schold, an assistant professor of medicine and first author of the paper published 18 June in the Clinical Journal of the American Society of Nephrology. "Understanding what these survival estimates are may provide a more objective and useful basis for evaluating donor options for this population."
The researchers suggest that some patients need to ask their doctors about their chances of surviving to receive a transplant, and, once they decide, to speed through the steps necessary to get on the waiting list. It can take several months for patients to go from primary care provider referral to a transplant centre and through the medical tests and additional steps involved in getting their name on the list.
"Older patients must be referred for transplantation sooner than they are now, and they need to be guided through the process of pursuing live donor kidney transplantation," said Harvard transplant psychologist Jim Rodrigue, director of behavioural health services and research in the Transplant Institute at Beth Israel Deaconess Medical Center. "The older population is least likely to pursue a live donor transplant and is less likely to have healthy living donors available."
That’s because the older people get, the older their siblings and peer network become, with potentially more medical problems than when they were younger. And older patients tend to say they do not want to burden their adult children, other relatives or friends by asking them to be live donors.
About 50 percent of the more than half a million people in the United States who have end-stage renal disease are older than 60. In medically eligible patients, kidney transplantation gives a better survival chance than dialysis.
The UF team examined data from the national Scientific Registry of Transplant Recipients for almost 55,000 candidates older than 60 who were listed for a single-kidney deceased-donor transplant from 1995 through 2007. They used statistical models to estimate the time to receive a transplant and time to death after getting on the list.
Although overall about half of the over-60 group was projected to die before transplant, different subgroups had even higher likelihood of dying before a transplant.
Long-standing racial disparities are borne out by the data, with black patients having a higher probability than white patients of dying before a transplant: Sixty-two percent of black patients older than 60 will likely die before getting a transplant.
"That is an important finding because African-Americans are substantially less likely than whites to receive a live donor transplant, regardless of age," Rodrigue said. "For those who are over 60, this is simply more bad news."
Another notable disparity is that people’s survival chances vary greatly – from 8 percent to 81 percent – depending on where in the country they happen to live.
"It seems inherently unjust that we have such significant geographic disparity in survival on the waiting list based on where you live," Rodrigue said.
It is true that some regions are better than others at recovering organs and have better donor rates. But based on the study’s results, one thing for policymakers to consider might be redrawing geographical boundaries of designated transplant regions so that more people have a better shot at getting an organ.
"We like to promote equity and policies that give a fair chance," Schold said.
While the study findings support broad conclusions about patients’ survival chances, they might not apply to individual patients.
Still, Rodrigue said, they will change the doctor–patient conversations at his institute, for one. In the past, the underlying assumption was that patients will eventually get a deceased donor organ.
"Now we’ll have a more directed conversation with patients about the risk of death," he said. "It’s not just how long you wait."
(Source: University of Florida: Clinical Journal of the American Society of Nephrology: June 2009)