9/26/2018 Transplant Debate: How Old is Too Old for Kidney Transplant Chris E. Freise, M.D UCS F Professor of S urgery Interim Chief of Transplant More Difficult Decision What if no living donor ? L.D., 86 yo male, ESRD from HTN, on HD for 4 yrs. Wait time in our area 6-9 years for standard donor Good pulses, “ Y ounger t han his st ated age” Time might be shortened by 1-3 yrs if patient interested in high KDPI or PHS increased risk donor Living donor transplant What age is reasonable to “ start at” in this scenario Discharged POD 4 No complications/ readmission Now 1 year post op Cr 0.96 Age 70 seems like a sensible age cutoff for listing candidacy 1
9/26/2018 S hould There Be an Age Cutoff for Listing ? ? The Aging ESRD population: Difficult YES Decisions Considerations 48% of all new ES RD patients >65 30% are >70 Deceased donor kidneys are a scarce resource Over 500,000 patients on dialysis never make it to transplant listing Need to choose recipients that will maximize UTILITY of kidney The need far outstrips the supply Outcomes as patients age are less good Transplant cares utilize more resources in higher risk patients Of listed patients > age 60, 47% removed within 3 years Difficult to use other measures, and by default age is a reasonable surrogate to determine candidacy Patients over age 60 do not tolerate waiting vol 2 Figure 6.3 Percentage of incident patients who were wait‐listed or received a kidney transplant within one year of ESRD initiation, by age, 1998‐2014 Data Source: Reference Table E.5(2). Waiting list or transplantation among incident ESRD patients by age (0‐74 years). Note that trends may be The Seattle Artificial Kidney Center Admissions and Policy Committee influenced by changes to the kidney allocation system (KAS) policy that were implemented in December 2014. Abbreviation: ESRD, end‐stage renal disease. 2017 Annual Data Report 7 Volume 2, Chapter 6 2
9/26/2018 Final Rule 2000: Organ Allocation Justice vs. Utility (1) Shall be based on sound medical j udgment; The principle of utility, applied to the allocation of organs, thus specifies that (2) Shall seek t o achieve t he best use of donat ed allocation should maximize the expected net amount of overall good (that is, organs; good adj usted for accompanying harms. Justice, as used here, refers to fairness in the pattern of distribution of the (5) Shall be designed to avoid wasting organs, to benefits and burdens of an organ procurement and allocation program. Thus, we are concerned not exclusively with the aggregate amount of medical good avoid futile transplants, to promote patient access to that is produced, but also with the way in which that good is distributed among potential beneficiaries. This does not mean treating all patients the transplantation, and to promote the efficient management same, but it does require giving equal respect and concern to each patient. of organ placement; Sometimes the principle of j ustice will be in conflict with the principle of utility; in such cases both are worthy of equal consideration and play a role in shaping a decision about the morally preferable allocation. Ethical Principles in the Allocation of Human Organs vol 2 Figure 11.1 Geographic variations in the incidence rate of treated vol 2 Figure 11.16 Kidney transplantation rate, by country, 2015 ESRD (per million population/year), by country, 2015 (b) Per 1,000 Dialysis Patients Data source: Special analyses, USRDS ESRD Database. Data presented only for countries from which relevant information was available. All rates are unadjusted. ^United Kingdom: England, Wales, & Northern Ireland (Scotland data reported separately). Data for France exclude Martinique. Data from Italy represent five regions. Data for Sri Lanka is from seven government hospitals. Data for Canada excludes Quebec. Abbreviation: sp., Data source: Special analyses, USRDS ESRD Database. Data presented only for countries from which relevant information was available. All rates are unadjusted. United Kingdom: England, Wales, Northern Ireland (Scotland data reported separately). Data speaking. NOTE: Data collection methods vary across countries, suggesting caution in for Italy include five regions. Data for Indonesia represent the West Java region. Data for France exclude Martinique. Data for making direct comparisons. Canada excludes Quebec. Japan includes dialysis patients only. Abbreviation: ESRD, end‐stage renal disease. NOTE: Data collection methods vary across countries, suggesting caution in making direct comparisons. 2017 Annual Data Report 2017 Annual Data Report 11 12 Volume 2 ESRD, Chapter 11 Volume 2 ESRD, Chapter 11 3
9/26/2018 Listing Practices vol 2 Table 5.4 Expected remaining lifetime (years) by age, sex, and treatment modality of prevalent dialysis patients and transplant patients, and the general U.S. population, 2013 ESRD patients General U.S. population 2013 2013 Dialysis Transplant Age Male Female Male Female Male Female 0‐14 23.8 23.1 59.3 60.3 70.7 75.4 15‐19 21.8 19.1 47.6 48.7 59.7 64.4 20‐24 18.8 16.1 43.4 44.5 55.0 59.5 25‐29 16.2 14.1 39.4 40.7 50.3 54.6 30‐34 14.1 12.6 35.1 36.6 45.7 49.7 35‐39 12.6 11.5 31.1 33.0 41.0 45.0 40‐44 11.0 10.3 27.2 28.9 36.5 40.3 45‐49 9.3 8.8 23.3 25.2 32.0 35.6 50‐54 7.9 7.7 19.9 21.8 27.7 31.1 55‐59 6.6 6.6 16.7 18.4 23.7 26.8 60‐64 5.5 5.7 13.9 15.4 19.9 22.6 65‐69 4.6 4.8 11.4 12.7 16.2 18.6 70‐74 3.8 4.0 9.4 10.3 12.8 14.8 75‐79 3.2 3.5 7.6 a 8.6 a 9.8 11.4 80‐84 2.6 2.9 7.1 8.4 85+ 2.1 2.3 3.8 4.4 Data Source: Reference Table H.13; special analyses, USRDS ESRD Database; and National Vital Statistics Report. “Table 7. Life expectancy at selected ages, by race, Hispanic origin, race for non‐Hispanic population, and sex: United States, 2013 (2016).” Expected remaining lifetimes (years) of the general U.S. population and of period prevalent dialysis and transplant patients. a Cell values combine ages 75+. Abbreviation: ESRD, end‐stage renal disease. 2017 Annual Data Report 16 Volume 2, Chapter 5 4
9/26/2018 Other Resource Considerations Resources utilized for evaluations Resources for workup of patients Hospital costs and readmission rates Legeai, et.al. AJT 2018 TX Center Resources: UCS F DATA UCS F Referrals FY 2018 2373 UCSF Evaluations FY 2018 1303 Last three years Referrals over age 70 786 Evals over age 70 306 Listed Patients 21 Transplants Deceased Donor 1 Living Donor 7 5
9/26/2018 Other Measures of S uitability Mortality and Readmission Rates Frailty measurements Weight Loss Weakness Slow Gait Low Physical Activity Easily exhausted ESRD patients < 40 yo 44% met criteria > 70 yo 78% met criteria Age 70 Cutoff For Deceased Donor Listing Age > 70 will not tolerate wait ing times more than 3 years Outcomes are less good than in younger patients Resources are further stretched in all phases of care Other measures besides age lack validation with outcome Living donor transplant can and should be considered 6
9/26/2018 May you stay-- forever young Bob Dylan vol 2 Table 6.3 Unadjusted kidney transplant rates, all donor types, by age, sex, race, and primary cause of ESRD, per 100 dialysis patient years, 2006‐2015 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Age 0‐21 38.6 32.7 33.1 35.3 33.6 32.2 32.9 32.2 33.1 34.7 22‐44 10.9 10.1 9.3 9.2 8.6 8.3 8.1 7.9 7.8 9.3 45‐64 5.9 5.6 5.3 5.1 4.9 4.7 4.4 4.4 4.2 4.2 65‐74 2.7 2.6 2.6 2.6 2.6 2.6 2.5 2.5 2.5 2.2 75 and older 0.3 0.4 0.3 0.4 0.4 0.4 0.4 0.3 0.4 0.3 Sex Male 5.6 5.1 4.8 4.6 4.4 4.3 4.0 4.0 3.8 3.9 Female 4.3 4.0 3.8 3.8 3.7 3.5 3.3 3.3 3.2 3.3 Race White 6.0 5.5 5.2 5.0 4.7 4.5 4.3 4.3 4.1 4.0 Black/African American 3.3 3.1 2.9 3.0 3.0 2.9 2.6 2.6 2.5 2.8 American Indian/Alaska Native 3.9 2.9 3.6 3.7 2.9 3.0 2.5 2.2 2.7 3.2 Asian 5.9 5.3 5.5 5.1 5.1 4.8 4.7 4.8 4.7 5.2 Primary Cause of ESRD Diabetes 3.2 3.1 2.9 2.8 2.6 2.5 2.3 2.3 2.2 2.0 Hypertension 3.2 3.1 3.0 2.9 2.8 2.6 2.6 2.5 2.5 2.6 Glomerulonephritis 9.9 9.0 8.7 8.6 8.7 8.2 7.9 7.8 7.5 8.3 All 5.0 4.6 4.4 4.3 4.1 3.9 3.7 3.7 3.6 3.6 Data Source: Reference Table E.9. Note that trends may be influenced by changes to the kidney allocation system (KAS) policy that were implemented in December 2014. Abbreviation: ESRD, end‐stage renal disease. 2017 Annual Data Report 28 Volume 2, Chapter 6 7
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