INTRODUCTION — Kidney transplantation improves the long-term survival and quality of life of most patients with end-stage kidney disease (ESKD), including older patients. However, individual older patients who have significant comorbidities may not live long enough to realize the benefits of transplantation, which are not observed until a number of months to years after transplantation. It is important to carefully evaluate older patients who are being considered for kidney transplantation in order to avoid subjecting the patient to an invasive procedure from which they will not benefit and to avoid wasting a kidney that could provide years of benefit to another recipient.
This topic reviews issues surrounding kidney transplantation among older adults.
The evaluation of potential kidney transplant donors and recipients, the kidney transplant waiting list, and the allocation of deceased-donor kidneys are discussed elsewhere:
●(See "Kidney transplantation in adults: Evaluation of the potential kidney transplant recipient".)
●(See "Kidney transplantation in adults: Evaluation of the living kidney donor candidate".)
●(See "Kidney transplantation in adults: The kidney transplant waiting list in the United States".)
●(See "Kidney transplantation in adults: Organ sharing".)
EPIDEMIOLOGY — The age of kidney transplant patients has increased over the past 20 to 25 years. Over 50 percent of patients who develop end-stage kidney disease (ESKD) are ≥65 years of age [1]. The percentage of candidates >50 years old on the transplant waiting list increased from 53 to 64 percent between 2003 and 2013, with a corresponding decrease in younger patients [1,2]; in 2016, 21 percent of patients with ESKD waitlisted for a kidney were aged 65 years and older. The number of transplants performed annually among patients aged ≥65 years has more than tripled between 1998 and 2016 [1,3,4]. Since 1995, age disparities in access to first kidney transplantation have been improving [5].
PRETRANSPLANT EVALUATION — A comprehensive evaluation of the prospective older transplant recipient includes the identification of significant comorbid disease that may preclude transplantation. Because the benefits of kidney transplantation on patient survival are generally not realized until 1.5 to 2 years after transplantation, patients who are unlikely to survive this long should not undergo transplantation.
The initial screening evaluation, along with absolute and relative contraindications to transplantation, is presented separately. (See "Kidney transplantation in adults: Evaluation of the potential kidney transplant recipient", section on 'Initial evaluation'.)
In addition, among older individuals, a comprehensive assessment of baseline cognitive and physical function should be conducted, with particular attention to ability to perform daily activities, such as walking, climbing stairs, and lifting groceries [6], as well as frailty [7]. While cognitive impairment does not necessarily preclude transplantation, significant deficits increase the risk of poor outcomes, including all-cause graft loss [8], and also require the provision of strong social support both before and after transplantation [9]. Furthermore, kidney transplant recipients are at higher risk of dementia [10], although the risk among older kidney transplant recipients is lower than that among older patients initiating hemodialysis [11].
A screening tool may help identify suitable candidates for transplantation, although these are not widely used [6]. Using data from the French national registry (REIN), a risk score of mortality within three years was developed from a cohort of 9305 patients who received transplants from 2002 to 2006. The following point system was assigned:
●Male (1 point)
●Age 75 to 80 years (2 points)
●Age 80 to 85 years (5 points)
●Age >85 years (9 points)
●Diabetes (2 points)
●Intermittent hemodialysis (2 points)
●Peripheral vascular disease, stage III to IV (5 points)
●Congestive heart failure, stage I to II (2 points)
●Congestive heart failure, stage III to IV (4 points)
●Arrhythmia (2 points)
●Chronic respiratory disease (2 points)
●Active malignancy (5 points)
●Severe behavioral disorder (6 points)
●Cardiovascular disease (1 point)
●Decreased mobility (needs assistance for transfers) (4 points)
●Totally dependent (9 points)
●Body mass index (BMI) 21 to 25 (1 point)
●BMI <21 to 25 (3 points)
●Central venous catheter (3 points)
The mortality score was validated in a second cohort of 7947 patients who were transplanted from 2007 to 2008. Among patients with a score of 0 to 6 points, the probability of being alive within three years was approximately 70 percent.
A similar screening tool is the Physical Function (PF) score. An analysis that combined United Network for Organ Sharing (UNOS) registry data with pretransplant at the PF scale of the Medical Outcomes Study Short Form-36 (SSF-36) among individuals undergoing kidney transplant from June 1, 2000 to May 31, 2006 found that, in any age group, a poor PF score was associated with a higher incidence of three-year mortality; the association was particularly strong among those older than 65 years, with an almost 30 percent mortality among the quartile with the lowest PF compared with a 15 percent mortality with the highest quartile on the PF scale [12].
In addition, frailty has emerged as a screening tool. Analyses from a prospective cohort study suggest that frailty at the time of evaluation is associated with waitlist mortality [13], and frailty at the time of admission for kidney transplantation is associated with adverse posttransplant outcomes including delayed graft function [14], delirium [15], length of stay [16], early hospital readmission [17], and mortality [18]. Frailty is easily measured through five components: weight loss, walking speed, physical activity, weak strength, and exhaustion [7]. (See "Frailty".)
Frailty can be used to identify patients who are vulnerable to the surgical stress during kidney transplantation. Frailty is distinct from comorbidity, disability, and cognitive impairment in this population [19-21]. While there are a number of tools that are being used to measure frailty in kidney transplantation [22], the Physical Frailty Phenotype (also known as the Fried or Hopkins Frailty Phenotype) [23] is the most commonly studied measure of frailty among older adults. It is particularly useful to identify vulnerable patients who do not have otherwise apparent disability or comorbidity [20,24]. An abridged version of this frailty assessment has been developed for assessing kidney transplant candidates [25]. A patient's frailty status should be considered at kidney transplant evaluation and monitored while on the waitlist [26]. Importantly, screening for frailty could identify robust older adults who would be ideal candidates for kidney transplantation. (See "Kidney transplantation in adults: Evaluation of the potential kidney transplant recipient", section on 'Frailty'.)
A discussion of the evaluation of the general transplant recipient is presented separately, with reviews of some age-related issues. (See "Kidney transplantation in adults: Evaluation of the potential kidney transplant recipient".)
IMMUNOSUPPRESSIVE THERAPY
Considerations in older adults — As for all kidney transplant recipients, the immunosuppressive regimen for older recipients consists of both induction and maintenance therapy. In general, the specific agents are the same as for younger recipients.
We start with the same induction and maintenance immunosuppression regimen for older recipients as for younger recipients. As for all recipients, we modify the regimen in individual recipients based upon their response to therapy, including the development of adverse side effects, such as leukopenia, thrombocytopenia, infection, or malignancy. (See "Kidney transplantation in adults: Induction immunosuppressive therapy" and "Kidney transplantation in adults: Maintenance immunosuppressive therapy".)
Some centers modify the regimen from the outset to decrease net immunosuppression. The rationale for this includes:
●The relatively decreased immunocompetence in older adults provides a rationale both for and against altering the immunosuppressive regimen. Decreased immunocompetence may decrease the risk of acute rejection, as is suggested by some studies [27]. However, the differential rates of acute rejection in older versus younger patients has been attenuated in more recent years due to an overall decline in the risk of rejection with improved immunosuppression. An additional consideration is that preventing acute rejection is critically important in older recipients because it may have a greater impact on long-term graft survival in older as compared with younger recipients. Similarly, on the one hand, decreased immunocompetence may increase the risk of infection, the most common cause of readmissions, death, and, therefore, graft loss among older patients [28-32].
●Donor kidneys that are transplanted into older adults tend to be from older donors and therefore may be more vulnerable to the adverse effects of immunosuppressive medications, such as calcineurin inhibitors. (See 'Maintenance therapy' below.)
●The pharmacokinetics of drugs, particularly calcineurin inhibitors, may also be altered in older adults. Initial calcineurin inhibitor doses that are similar to those recommended for younger patients may result in higher blood concentrations among older recipients because of a decline in cytochrome P450 activity.
Our induction and maintenance regimens are discussed below. (See 'Induction therapy' below and 'Maintenance therapy' below.)
Induction therapy — We administer induction therapy to most older recipients. However, in some centers, induction therapy with antibodies is not administered to older individuals, given the theoretically lower risk of acute rejection. One reason that we use induction therapy is to allow modification of maintenance therapy, if necessary, including reduction in the target tacrolimus trough concentration and discontinuation of the antimetabolite.
The optimal induction regimen for older patients is not known. Approaches are center specific and based upon expert opinion rather than published data. Our approach to older patients is the same as for younger patients. (See "Kidney transplantation in adults: Induction immunosuppressive therapy".)
While our choice of agent is largely based upon studies in younger individuals, retrospective analyses of data from older individuals have also suggested better outcomes among those who received rabbit antithymocyte globulin (rATG) rather than anti-IL-2 receptor antibody or alemtuzumab. As examples:
●In a retrospective analysis of United Network for Organ Sharing (UNOS) data from 2003 to 2008, among high-risk older (>60 years) recipients who received high-risk kidneys, those who received rATG had the lowest cumulative rate of acute rejection within the first year after transplantation compared with those who received anti-IL-2 receptor antibody or alemtuzumab [33]. Compared with rATG, the adjusted odds of acute rejection at one year for anti-IL-2 receptor antibody was 1.65 (95% CI 1.45-1.89) and for alemtuzumab was 1.35 (95% CI 1.08-1.69).
There was no difference between groups in death-censored graft survival, but, compared with rATG, there was an increased risk of death among recipients of anti-IL-2 receptor antibody (adjusted hazard ratio [HR] 1.12, 95% CI 1.02-1.21). Compared with rATG, alemtuzumab was associated with an increased risk of death-censored graft loss (adjusted HR 1.60, 95% CI 1.34-1.92) and death (adjusted HR 1.32, 95% CI 1.14-1.53).
Black patients, those with a peak panel reactive antibody >20 percent, or patients with a prior kidney transplantation were defined as high-risk recipients. High-risk donor kidneys included expanded-criteria-donor kidneys, kidneys following cardiac death, or kidneys having a cold ischemia time >24 hours. (See "Kidney transplantation in adults: Organ sharing", section on 'Kidney donor profile index (KDPI)'.)
There did not appear to be any difference in outcomes by treatment among low-risk older patients who received low-risk kidneys, although there was a higher risk of rejection if either the recipient or donor was high risk. (See 'Source of donor kidney' below.)
●Another registry study that did not distinguish risk of rejection by recipient or donor included 14,907 patients aged ≥65 years who were transplanted from January 2000 to July 2009 and followed through 2009 [34]. Acute rejection rates were lowest with rATG (5 percent) compared with alemtuzumab (7 percent) and basiliximab (7 percent). Alemtuzumab was associated with an increased risk of allograft loss.
Centers vary in their choice of induction therapy in recipients who have another functioning solid organ transplant and are already on immunosuppressive agents; some clinicians give anti-IL-2 receptor antibody, whereas others give rATG.
Studies comparing induction regimens in younger individuals are discussed elsewhere. (See "Kidney transplantation in adults: Induction immunosuppressive therapy".)
Maintenance therapy — While the optimal maintenance immunosuppression regimen for older adults is unknown, our approach to maintenance therapy for older adults is the same as for the general adult transplant population. We generally administer a maintenance regimen consisting of triple immunosuppression therapy. This includes a calcineurin inhibitor (usually tacrolimus), an antimetabolite (usually mycophenolate), and prednisone. (See "Kidney transplantation in adults: Maintenance immunosuppressive therapy", section on 'Approach to maintenance therapy'.)
By contrast, some clinicians advocate using regimens that spare calcineurin inhibitors for older adults since, as noted above, some studies suggest that lower levels of immunosuppression may be sufficient in older patients to achieve adequate patient and graft survival without incurring increased rates of rejection [28]. However, such regimens, as well as those associated with the withdrawal of calcineurin inhibitors, have been associated with an increased incidence of acute rejection [35-37]. (See 'Considerations in older adults' above.)
We modify the regimen in individual recipients based upon their response to therapy, including the development of adverse side effects, such as leukopenia, thrombocytopenia, infection, or malignancy. (See "Kidney transplantation in adults: Maintenance immunosuppressive therapy", section on 'When and how to modify therapy'.)
Few data exist concerning the choice of the antimetabolite (ie, mycophenolate or azathioprine) in older adults. Some findings suggest worse outcomes, while others report benefits associated with mycophenolate [38-40]:
●In a retrospective study of 91 older transplant recipients, a regimen consisting of mycophenolate, prednisone, and cyclosporine resulted in a higher rate of infectious complications than that associated with azathioprine, prednisone, and cyclosporine [38]. A similar increased rate of infections with mycophenolate compared with azathioprine was reported in a second retrospective study [39].
●A retrospective study of over 5000 older transplant patients found that, compared with azathioprine, mycophenolate was associated with improved patient and allograft survival and lower rates of acute rejection [40]. However, these results must be interpreted with caution since azathioprine was principally used during a period in which overall transplant results were inferior for a variety of reasons.
Overall, the combined use of either mycophenolate mofetil or azathioprine and a calcineurin inhibitor in most older patients appears to provide acceptable outcomes [41]. (See "Kidney transplantation in adults: Maintenance immunosuppressive therapy", section on 'Approach to maintenance therapy'.)
OUTCOMES OF TRANSPLANTATION
Survival — The long-term mortality of older transplant recipients is higher than that of younger recipients [42,43]. In an analysis of 108,188 recipients who were transplanted between 1995 and 2008, the 5- and 10-year survival rates for recipients >70 years were 58 and 24 percent, respectively [42].
In another study of 31,178 patients older than 60 years who were transplanted between 2000 and 2008, at two years, survival was lower for those 80 years and older (73 percent) and those 70 to 79 years (86 percent) compared with recipients 60 to 69 years (89 percent) [44]. There was also a greater risk of graft loss among recipients 80 years and older compared with those 60 to 69 years (hazard ratio [HR] 1.78); however, no difference in death-censored graft survival was observed.
However, transplantation confers a survival benefit compared with dialysis [45-51]. Among the 6900 older (60 to 74 years) patients on dialysis placed on a waiting list for transplantation, approximately 3000 subsequently underwent a first cadaveric transplant. Compared with waiting-list patients, the relative risk (RR) of death at 18 months posttransplantation was significantly lower among transplant recipients (RR 0.37). This survival advantage also extended to older patients with diabetes [45]. Survival is also better among older patients with end-stage kidney disease (ESKD) who undergo kidney transplantation than among those who initiate home hemodialysis [52].
It is estimated that, among those aged 60 to 74 years, projected remaining years of life are approximately 6 and 10 years for those who remain on a waitlist or undergo kidney transplant, respectively [45]. However, one study found that for patients older than 65 years, there was no life expectancy advantage with transplantation as compared with dialysis among those who were on dialysis for four or more years prior to transplant [53].
One study of 41,716 patients aged 70 years and older who initiated hemodialysis in France found that those who underwent kidney transplantation had a lower risk of mortality starting at three months posttransplant; as compared with those on the waitlist, the perioperative risk was offset by 36 months [54].
The predominant causes of death among older transplant recipients are infection and cardiovascular disease [28,55].
●Infections – Most infections occur in the first six months posttransplant and are related to the degree of immunosuppression. A greater degree of immunosuppression results in an increased risk of infectious complications in all patients (young and old). However, as previously mentioned, immunocompetence decreases with age; as a result, older individuals are more susceptible to infectious complications at lower levels of immunosuppressive therapy. Agents associated with the highest infection risk are high-dose glucocorticoids and antilymphocyte antibodies used in the induction immunosuppressive regimen.
●Cardiovascular disease – Even in the absence of immunosuppression, older subjects have an increased risk of cardiovascular disease and an increased risk of cardiovascular-related death [56]. In addition, some risk factors for heart disease, such as hypertension and diabetes mellitus, may be exacerbated or induced by immunosuppressive medications. However, real-world evidence suggests that statin therapy is safe and effective, especially when combined with mammalian (mechanistic) target of rapamycin (mTOR) inhibitor-based immunosuppression [57,58]. (See "Risk factors and epidemiology of coronary heart disease in end-stage kidney disease (dialysis)".)
●Other – Older transplant recipients have a high rate of death due to malignancy and gastrointestinal hemorrhage [28]. Death due to malignancy appears to increase disproportionately with time posttransplantation among older versus younger allograft recipients [28]. Additionally, older kidney transplant recipients are at the greatest risk of posttransplant delirium, which increases the subsequent risk of a longer length of stay, institutional discharge, graft loss, mortality, cognitive decline, and dementia [15,59,60].
Data on factors that impact survival in older kidney transplant recipients are limited. In one analysis of 802 kidney transplant recipients aged ≥65 years from the Australia and New Zealand Dialysis and Transplant (ANZDATA) registry, factors associated with all-cause death included coronary artery disease (adjusted HR 1.47), cerebrovascular disease (adjusted HR 1.99), increasing graft ischemic time (adjusted HR 1.06), donor age (adjusted HR 1.02), delayed graft function (adjusted HR 1.64), and peritoneal dialysis pretransplantation (adjusted HR 1.71) [61].
Graft loss — As noted in the Scientific Registry of Transplant Recipients (SRTR) database, the five-year allograft survival rates for those ≥65 years of age are 68 percent for recipients of deceased-donor kidneys and 82 percent for recipients of living-donor kidneys [62]. By comparison, the five-year allograft survival rates for those aged 18 to 34 years are 81 percent for recipients of deceased-donor kidneys and 89 percent for recipients of living-donor kidneys.
Patient death with a functioning allograft accounts for the majority of graft loss in older transplant patients. As noted above, acute rejection occurs less commonly and accounts for a smaller percentage of graft loss among older patients compared with younger patients. As an example, in the analysis cited above, although total allograft survival declined with increasing recipient age, the allograft survival improved for every decade of recipient age when allograft survival rate was censored for patients who died with functioning grafts [42].
There is an increased risk of chronic allograft nephropathy among older patients, which is enhanced if the allograft is from an older donor [63].
SOURCE OF DONOR KIDNEY — As may younger individuals, older adults may receive kidneys from living, related or unrelated donors or from deceased donors. Compared with younger patients, older recipients are less likely to receive a living-donor kidney [64].
Living-donor kidneys — A living-donor kidney is preferred if it is available. Among all recipients, including older adults, living-donor kidneys are associated with better patient and graft survival compared with deceased-donor kidneys. The use of a living-donor kidney allows for preemptive transplantation before the candidate needs to start dialysis. Among most patients, preemptive transplantation is associated with superior outcomes compared with transplantation after initiation of dialysis. (See "Kidney transplantation in adults: Risk factors for graft failure", section on 'Type of kidney' and "Kidney transplantation in adults: Risk factors for graft failure", section on 'Type of kidney donor' and "Kidney transplantation in adults: Timing of transplantation and issues related to dialysis", section on 'Preemptive transplantation' and "Kidney transplantation in adults: Patient survival after kidney transplantation", section on 'Allograft source'.)
Older patients who receive living-donor kidneys are likely to have older donors (usually a sibling or spouse of comparable age as the recipient) [65,66]. There is an increasing trend in utilizing organs from older donors [67]. Some data have demonstrated that recipients of older living-donor kidneys have shorter graft survival compared with older recipients of younger living-donor kidneys but better survival than extended-criteria-donor (ECD) recipients [67]. In one study from the United States Renal Data System (USRDS) of over 73,000 first kidney-only transplant recipients, three- and five-year allograft survival from older living donors (>55 years of age) was 85 and 76 percent and 89 and 82 percent from younger living donors (<55 years of age) [68]. A lower risk of allograft loss after living donation was also noted with living donors aged 55 to 64 years versus that with relatively older donors aged 64 to 69 years (hazard ratio [HR] 1.3, 95% CI 1.1-1.7) and donors >70 years (HR 1.7, 95% CI 1.1-2.6).
Nonetheless, outcomes with kidneys from older living donors are acceptable and are superior to those with deceased-donor kidneys:
●An analysis of data from USRDS and United Network for Organ Sharing (UNOS) suggested that, among those who received kidneys from living donors between the ages of 18 and 64 years, donor age had virtually no effect on graft survival [69]. The graft half-life in this group of recipients who received living-donor kidneys was equal or superior to the half-life seen in patients who received standard-criteria, deceased-donor kidneys.
●In a study of 23,754 transplantations in recipients older than 60 years, kidneys from living donors older than 55 years were associated with slightly inferior four-year graft and patient survival rates compared with kidneys from living donors younger than 55 years (graft survival was 77.7 versus 80.7 percent, respectively, and patient survival was 82.4 versus 84.2 percent, respectively) [65]. However, overall and death-censored graft survival was better for all recipients of living-donor kidneys compared with deceased-donor kidneys.
●A review of live kidney donations between 1991 and 2006 identified from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) determined that recipients of living kidneys from donors who were significantly older than the recipients have similar graft and patient survival compared with recipients of kidneys from donors of the same age group as themselves [70].
Deceased-donor kidneys — If a living-donor kidney is not available, appropriately selected patients should be registered for a deceased-donor kidney. Because of the relative scarcity of available deceased-donor kidneys, the waiting list is prolonged for most patients. (See "Kidney transplantation in adults: The kidney transplant waiting list in the United States", section on 'Waiting time'.)
In the United States, the waiting-list time may increase even more for older adults since the implementation of a revised kidney allocation policy in 2014. An analysis of national registry data found that deceased-donor kidney transplant rates have declined for candidates aged 50 years and older and particularly for those aged 70 years and older [71]. (See "Kidney transplantation in adults: Organ sharing".)
A prolonged waiting-list time increases candidate mortality. In one study of 5667 individuals older than 70 years who were waitlisted between 1990 and 2004, transplanted patients had a 41 percent lower mortality compared with candidates who remained on the waiting list [50]. Under the former kidney allocation schema, over 50 percent of kidney transplant candidates older than the age of 60 years would be expected to die before receiving a deceased-donor transplant [72].
In the United States, since late 2014, the allocation of kidneys is based in part upon donor kidney and candidate characteristics. As a result, older patients are matched with kidneys that are predicted to have a lower survival (see "Kidney transplantation in adults: Organ sharing", section on 'National deceased-donor kidney allocation policy'). Outcomes using this system are not yet available. However, under the previous allocation system, kidneys from deceased donors with some adverse prognostic features, such as increased age, history of hypertension, death from stroke, or an elevated serum creatinine concentration, were allowed to be transplanted into selected recipients. These kidneys are referred to as ECD kidneys. Overall, studies suggest that, while transplantation of ECD kidneys may be associated with increased mortality compared with non-ECD kidneys [73-75], the survival of older transplant recipients is significantly better with an ECD kidney than in those who remain on dialysis [50]. (See 'Survival' above.)
Furthermore, the increased mortality associated with ECD kidneys depends in part on the age of the recipient:
●In an analysis of the Scientific Registry of Transplant Recipients (SRTR) database, among patients >70 years of age, transplantation of an ECD kidney was not associated with significantly increased mortality compared with a non-ECD kidney (HR 1.12, 95% CI 0.93-1.36 [for patients between 70 to <75 years] and 1.04, 95% CI 0.74-1.47 [for patients >75 years]) [75]. Transplantation of an ECD kidney was associated with increased mortality for patients <70 years, however.
●In a review of over 50,000 kidney transplant recipients from the UNOS database, among recipients >55 years of age, donor age groups between 0 to 17, 18 to 29, 30 to 41, 42 to 54, and >55 years of age were associated with adjusted 10-year patient survival rates of 48, 46, 45, 37, and 35 percent, respectively [73].
The Eurotransplant Senior Programme (ESP) has also instituted a policy in which organs retrieved from donors >65 years of age are allocated to those of similar age [35,76-80]. A five-year analysis of data from this program revealed that, among 1406 patients, graft and patient survival are similar among recipients of kidneys allocated using this system compared with those allocated kidneys via the standard system [79].
Long-term patient and allograft survival with dual-kidney transplants obtained via an ECD program appears to be equivalent to those who undergo standard, single-kidney transplantation [81,82]. One study, for example, reported outcomes at eight years posttransplant of 61 and 31 patients ≥55 years of age who received single or double ECD kidney transplants, respectively [81]. Patient survival was 74 and 82 percent after single- and dual-kidney transplants, respectively, while allograft survival was 49 and 70 percent, respectively. These outcomes after dual-kidney transplants are comparable with those reported with standard, single-kidney transplants.
SUMMARY AND RECOMMENDATIONS
●Overview – Kidney transplantation improves the long-term survival and quality of life of most patients with end-stage kidney disease (ESKD), including older patients in whom they are being increasingly performed. (See 'Introduction' above and 'Epidemiology' above.)
●Pretransplant evaluation – A comprehensive evaluation of the prospective older transplant recipient that identifies significant comorbid disease may preclude transplantation. The evaluation of the older patient is similar to the younger patient but should also include a comprehensive assessment of baseline cognitive and physical function, with particular attention to ability to perform daily activities and frailty. (See 'Pretransplant evaluation' above and "Kidney transplantation in adults: Evaluation of the living kidney donor candidate".)
●Immunosuppression – As for all kidney transplant recipients, the immunosuppressive regimen for older recipients consists of induction and maintenance therapy. The specific agents are the same as for younger recipients, although the regimen is commonly modified in older recipients because of decreased immunocompetency or increased side effects. (See 'Immunosuppressive therapy' above.)
●Outcomes – Kidney transplantation improves the long-term survival in older patients. The predominant causes of death among older transplant recipients are infection and cardiovascular disease. A majority of infections occur in the first six months posttransplant. Patient death with a functioning allograft accounts for the majority of graft loss in older transplant patients. (See 'Graft loss' above.)
●Source of donor kidney – Living-donor kidney transplants are associated with the best patient and graft survival. While older transplant patients are more likely to receive a kidney from an older donor, it is uncertain that this influences outcomes. Similarly, while older patients are more likely to receive deceased extended-criteria-donor (ECD) kidneys, outcomes are still improved compared with those who remain on dialysis. (See 'Source of donor kidney' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Emilio Ramos, MD, FACP, now deceased, who contributed to an earlier version of this topic review.
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