Half of kidney transplant candidates who are older than 60 years now placed on the waiting list will die before receiving a deceased-donor transplant

Abstract

Background and objectives: Waiting times to deceased-donor transplantation (DDTx) have significantly increased in the past decade. This trend particularly affects older candidates given a high mortality rate on dialysis.

Design, setting, participants, & measurements: We conducted a retrospective analysis from the national Scientific Registry of Transplant Recipients database that included 54,669 candidates who were older than 60 yr and listed in the United States for a solitary kidney transplant from 1995 through 2007. Using survival models, we estimated time to DDTx and mortality after candidate listing with and without patients initially listed as temporarily inactive (status 7).

Results: Almost half (46%) of candidates who were older than 60 yr and listed in 2006 through 2007 are projected to die before receiving a DDTx. This proportion varied by individual characteristics: Diabetes (61%), age > or =70 yr (52%), black (62%), blood types O (60%) and B (71%), highly sensitized (68%), and on dialysis at listing (53%). Marked variation also existed by United Network for Organ Sharing region (6 to 81%). The overall projected proportion was reduced to 35% excluding patients who initially were listed as status 7.

Conclusions: These data highlight the prominent and growing challenge facing the field of kidney transplantation. Older candidates are now at significant risk for not surviving the interval in which a deceased-donor transplant would become available. Importantly, this risk is variable within this population, and specific information should be disseminated to patients and caregivers to facilitate informed decision-making and potential incentives to seek living donors.

Figure 1.

Kaplan-Meier plots of time to deceased donor transplantation (DDTx) by year of listing and time to mortality for older candidates. DD, deceased donor. Time to mortality includes all older candidates listed during the study period.

Figure 2.

Projected proportion of candidates who were older than 60 yr and receiving a deceased-donor transplant by year of listing (based on Weibull survival model censored at the times of patient death, last follow up, delisting, and receipt of a living transplant).

Figure 3.

(A) Projected proportion of candidates who were listed in 2006 through 2007 and expected to die before receiving a deceased-donor transplant by patient characteristics (overall 46%). PRA, panel reactive antibody; BMI, body mass index. (B) Projected proportion of candidates who were listed in 2006 through 2007 and expected to die before receiving a deceased-donor transplant by patient characteristics excluding candidates who initially were listed as temporarily inactive (overall 35%).

Figure 4.

Projected proportion of candidates who were listed in 2006 through 2007 and expected to die before receiving a deceased-donor transplant by United Network for Organ Sharing (UNOS) region. Organ Procurement and Transplantation Network regions are defined as follows: Region 1: Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island; region 2: Washington, DC, Delaware, Maryland, New Jersey, Pennsylvania, West Virginia; region 3: Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, Puerto Rico; region 4: Oklahoma, Texas; region 5: Arizona, California, Nevada, New Mexico, Utah; region 6: Alaska, Hawaii, Idaho, Montana, Oregon, Washington; region 7: Illinois, Minnesota, North Dakota, South Dakota, Wisconsin; region 8: Colorado, Iowa, Kansas, Missouri, Nebraska, Wyoming; region 9: New York, Vermont; region 10: Indiana, Michigan, OH; region 11: Kentucky, North Carolina, South Carolina, Tennessee, Virginia.