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Nadeen Khoury, M.D. was a special contributor to this blog post. Dr. Khoury is a renal transplant fellow at Mayo Clinic in Rochester, Minnesota. Her interests include kidney transplant in the elderly and pregnancy after kidney transplant.
One hot topic in the world of transplant has been what the appropriate cut off age should be for patients in need of a transplant. Across the globe, age criteria have been loosely defined. The American Society of Transplantation’s guidelines state “There should be no absolute upper age limit for excluding patients whose overall health and life situation suggest that transplantation will be beneficial.” This topic continues to be examined as the number of elderly individuals in our society has exponentially increased.
Trends in the national kidney waiting list demonstrate the dynamic of an aging population and their need for transplant due to End Stage Renal Disease (ESRD).
- In 2005, 14.5% of listed patients were over age 65
- In 2015, 22% of listed patients were over age 65
The prevalence of ESRD patients on dialysis is increasing among older age groups, as well. In fact, 44.5% of patients with ESRD receiving maintenance dialysis are 65 and older.
Based on this, it’s not surprising to learn there was a 325% increase in deceased donor transplants performed on patients 65 and older between 1997 and 2014, and a 380% increase in living donor transplants during the same period, according to the United States Renal Data Systems Annual Data Report.
If you are age 65 or older and in need of a kidney transplant, or a caregiver of someone who is, here are three key factors to keep in mind as you begin on your journey to transplantation.
- Thorough evaluation is imperative for determining whether or not you are well-suited for transplant. One key aspect of transplant evaluation in patients age 65 and older is analysis of frailty. Frailty is typically measured by using assessment tools that look at the ability to complete activities of daily living, risk of developing bed sores, and likelihood of falling. Often patients who have frailty pre-transplant are more likely to experience surgical complications, delayed graft function, a longer hospital stay as well as discharge to a skilled nursing facility for further recovery. Do what you can to maintain a level of strength pre-transplant in order to reduce your risk of these complications.
- The best results for kidney transplant in patients 65 and older are when the kidney is from a living donor. These kidneys are more likely to function immediately and provide better outcomes. When living organ donation is not an option, your transplant provider will look at deceased kidney transplant as an alternative.
- Interestingly, older recipient age is associated with lower risk of rejection because the immune system weakens with age. Each transplant center has its own protocol for immunosuppression in the elderly. At Mayo Clinic, immunosuppressant medications are tailored to minimize the risk of infection.
If you're currently awaiting a transplant, has age been a factor in your care plan? If so, how?
HELPFUL LINKS
- Learn about living donation.
- Learn more about kidney transplant at Mayo Clinic.
- Explore Mayo’s Transplant Center.
- Request an appointment.
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Hi
I am 1 year after kindness transplant. All my kidney blood tests over the year and biopsy in year 1 were excellent. I did the second biopsy last week and pathology report indicates markers for pre-rejection. I am taking the additional medication of steroid for 1 week. They also increased bit anti-rejection meds, some of them caused my while blood count to drop so low last year. I guess now the goal is to save the kidney. I feel disappointed that after being super careful last year and took all meds on time, followed healthy diet, did not go out much at all to keep myself out of any infection, at the end I got this unpleasant surprise. My kidney was from linking donor. The questions I have:
1) did anyone go through this? What happens now? How do I know that the inflammation in the kidney is improved or gone? When? My blood tests for the kid met had been very good all last year , so obviously it won’t say about the kidney from the markets of rejection.
Was the anti-rejection treatment last year was not efficient ? How many kidney transplant at Mayo or outside get this pre rejection news!
I believe in patient experience, so if you can help please do.
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1 ReactionHi @future 🥰
It is very nice to meet you! Are all of your blood and urine tests still excellent? And it is just your most recent biopsy that is showing some inflammation?
What are your current meds and dosages (including the new steroid) and how low is your wbc getting?
It may turn out that you will end up with a small increase of your immune suppression once all the med adjustments are made over time.
(They may have adjusted significantly right now to make sure any signs of rejection are quieted quickly.) That's why I am curious how much immune suppression meds you are currently taking.
I am a five year kidney transplant and I have had several med adjustments over the years for different reasons, so this is not unusual at all. Don't be overly concerned or stressed. Do you feel okay?
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1 ReactionHi @future
It is very nice to meet you!
-thank you same here!
Are all of your blood and urine tests still excellent?
-Yes. It has been excellent the whole last year also. Last week in Mayo the provider herself said kidney function test was excellent. Creatinine in blood test 0.93 , I traveled to Mayo independently. all were good. So I went to biopsy as a check mark task. But it was not, and the provider was not communicating well. My stress level was at the roof. Until now I feel upset about being in that situation. You go hopeful and get disappointed like that with no good communication to help.
And it is just your most recent biopsy that is showing some inflammation?
-yes , that is true.
What are your current meds and dosages (including the new steroid) and how low is your wbc getting?
-current meds after last week adjustments; tacrulimus-Enversus: 5 mg morning only, Cellcept back to 500mg twice/day,
Steroid for one week a taper one from 60mg/day to 5mg/per day (60,50,40,…5).
It may turn out that you will end up with a small increase of your immune suppression once all the med adjustments are made over time. (They may have adjusted significantly right now to make sure any signs of rejection are quieted quickly.)
- that is what they did: before last week Cellcept was half of what I take since last week (250mg twice a day, tacrulimus was 4mg morning only). This tacrulimus is long term.
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That's why I am curious how much immune suppression meds you are currently taking.
- last year when the meds were like now, WBC and neutrophils were very very low such that I had injections to increase.
- I am a five year kidney transplant and I have had several med adjustments over the years for different reasons, so this is not unusual at all. Don't be overly concerned or stressed. Do you feel okay?
- Yes physically , but stressed out whether the treatment of last year was not careful enough.
Thanks ver much!
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3 Reactions@future
Good morning @future 🥰
Congrats on wonderful blood and urine lab results...that's the goal!
Most of the kidney transplant patients on Mayo Connect can probably jump in too with their similar story.
I think a lot of us (including me!) had to get injections to bring up our wbc when their immune suppression meds were kept too high (on purpose) to avoid acute rejection in the beginning.
After that crazy time, the team starts to adjust the meds down according to what's happening. For me, it was CMV virus, then the BK virus so I was taking 250mg Cellcept twice a day and 2.5mg Envarsus XR once a day.
Recently, my Allosure blood test (a quarterly blood test that looks for rejection markers in the blood) started creeping up, so now I take 500mg Cellcept in the morning and 250mg Cellcept in the evening with my morning Envarsus XR.
So, if I am reading this correctly, you will only have one week of tapered steroid, right?
And you are back to 500mg Cellcept bid and they increased your Envarsus XR.
What is your new target TAC blood level range?
How often will you test your TAC level to make sure it stays in the new range?
Did your provider mention the idea of taking the Allosure blood test to begin to monitor for signs of rejection? It's non-invasive and it rates the probability of rejection. There are a couple of companies that do this test.
I personally don’t like invasive biopsies unless absolutely necessary, so maybe the quarterly blood test could help keep an eye on the rejection question for you moving forward.
Also, if your Allosure result is good, that may give your doctor confidence to lower your Cellcept back to 250mg bid in the future.
My doctor decided to keep me at 500mg in the morning and lowered to 250mg Cellcept in the evening.
It sounds like everything is beautiful and they are doing a nice job of heading off any potential inflammation for now.
Prepare yourself for on-going med adjustments on this journey. It's the way to navigate the on-going rejection vs infection issue and keep the kidney and the patient happy and healthy.
Enjoy your fantastic kidney function results!
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1 Reaction@hello1234
Good morning to you too!
I never heard of Allosure blood test , I will ask about it.
Honestly o rather have suppressed immune system than living in areas about possibility of rejection that lately I have been going through. The pro user mentioned a possible biopsy in 6 month! I actually said “more holes in the new kidney!” She said it is the only way to make sure. I did it twice so far once in 4 month follow up and second in 1 year follow up. Both were not pleasant experience from the pain point of view.
I am asked to do blood test on weekly basis fir a month. I now think what blood test is for if it dies not show markets of rejection. Predominate week is complex few days ago. So I now on Enversus 5 mg plus 500mg Cellcept in the morning and o ly 500 mg Cellcept in the evening. I rather high doses than facing possible rejection. I requested a zoom appointment with the original (year 1) provider to ask questions , I wonder is lowering cellceot in the second half of year 1 to 250 mg twice a day was not a good move as the immune system needs to be suppressed all the time.
I think you had other questions. I will read your response again.
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1 Reaction@hello1234
Ok about TAC level, they asked to keep around 8 . Is it under my control? No. But this is the level they want to see now. Waiting for blood test results of this week.
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1 ReactionHi @future 🥰
When you were first transplanted, did you start at 1,000 mg of Cellcept twice a day like me (with your Envarsus XR in the morning?).
If so, it sounds like the team decreased the dosage over the first year down to 250 mg Cellcept twice a day with your Envarsus XR.
Were you experiencing very low wbc or infection that encouraged the decrease of dosage? Or something else?
I had CMV virus, then BK virus which caused the decrease of Cellcept in the first year to 250mg bid.
(When you have infection, it came be a sign of over immune suppression).
What was going on for you during the first year? Did you start at 1,000 mg Cellcept twice a day like me, then it was decreased?