Access to kidney transplantation among the elderly in the United States: a glass half full, not half empty

Abstract

Background and objectives: Few elderly ESRD patients are ever wait-listed for deceased-donor transplantation (DDTX), and waiting list outcomes may not reflect access to transplantation in this group. Our objective was to determine longitudinal changes in access to transplantation among all elderly patients with ESRD, not just those wait-listed for DDTX.

Design, setting, participants, & measurements: Using data from the US Renal Data System, we determined changes in the adjusted likelihood of transplantation from any donor source as an indicator of access to transplantation among all incident ESRD patients aged 60 to 75 years between 1995 and 2006.

Results: Access to transplantation doubled between 1995 and 2006 despite an apparent decrease in the likelihood of DDTX after wait-listing. A threefold increase in the likelihood of living-donor transplantation, including a 1.5-fold increase in living-donor transplantation after wait-listing, was a key factor that led to increased access to transplantation. When a lead-time bias related to the increased practice of placing patients on the waiting list before dialysis initiation in more recent years was accounted for, there was no decrease in the likelihood of DDTX after wait-listing. The likelihood of receiving a DDTX after placement on the waiting list was maintained by a threefold increase in expanded-criteria-donor transplantation and a 26% reduction in the risk for death on the waiting list.

Conclusions: Although transplantation remains infrequent, elderly patients were twice as likely to undergo transplantation in 2006 versus 1995. Elderly patients with ESRD should not be dissuaded from pursuing transplantation.

Figure 1.

Cumulative probability of transplantation from any donor source by year of first ESRD treatment.

Figure 2.

Adjusted likelihood of transplantation from any donor source in 2006 compared with 1995 in different patient subgroups. The increased likelihood of transplantation from any donor source was consistently observed in a number of sociodemographic and clinical patient subgroups. The likelihood of transplantation in 2006 versus 1995 was significantly higher in patients who were 65 to 69 and 70 to 75 years compared with those who were aged 60 to 64 years. Deceased donation quintile (states were grouped into quintiles on the basis of rate of deceased donation per million population). $, 0 to 30,117; $$, 30,178 to 37,370; $$$, 37,371 to 47,814; $$$$, >47,418.

Figure 3.

Number and type of transplants performed in study patients within 2 years of first treatment for ESRD, grouped by year of first ESRD treatment. The proportion of LD and ECD transplants was higher in more recent years.

Figure 4.

Adjusted likelihood of SCD, ECD, and LD transplantation by year of first ESRD treatment. There was no change in likelihood of transplantation from an SCD during the study period until after 2005. In contrast, the likelihood of ECD transplantation increased progressively during the study period, particularly after 2000. Similarly, the likelihood of LD transplantation increased markedly between the years 1995 and 2000 but remained relatively unchanged after 2000.