WHO SAYS THE US DOES NOT RATION CARE?

Nearly half of kidney transplant waitlist patients over age 60 are at risk to die before they receive a deceased-donor organ, researchers found. The risk of death before acquiring a kidney for senior citizens is high and even higher for patients age 70 and older, for African Americans, and for diabetics.

These findings provide incentive for older patients to consider living donors as an alternative or to get on the list and navigate the deceased-donor process as quickly as possible.

Kidney transplant can nearly double the life expectancy of end-stage renal disease patients over age 60. But an increasing gap between supply and demand has produced longer waiting times and increased mortality on the waiting list, the researchers said. Expanding waiting times clearly affect all portions of the transplant candidate populations.However, older and frailer patients may be the most directly affected because of rapid mortality rates before receiving a deceased-donor transplant.

The number of newly listed kidney transplant candidates nearly tripled from 2,367 in 1995 to 6,982 in 2006, researchers found in an analysis of the Scientific Registry of Transplant Recipients database. The study included all 54,699 patients age 60 and older when placed on the U.S. waiting list for a single kidney transplant from 1995 to July 2007. Half of these older candidates were age 60 to 64 at the time of listing, and 79% were on dialysis at the time of listing.

Overall, 61% of the older population received a transplant within five years of going on the list, but the proportion projected to receive a transplant within five years declined during the study period. For those waitlisted in 2006-2007, it was projected that 46% would die before receiving a deceased-donor transplant, up from a projected 22% in 1995.

The waiting time for a deceased-donor transplant rose significantly from 1995 to 2007, but the gap between time to transplantation and average survival from waitlisting narrowed during the study period. However, the projections for the rate of death before receipt of a deceased-donor kidney varied widely within the older population:
• 61% for those with diabetes
• 52% for those older than 70
• 62% for black patients
• 60% for blood type O
• 71% for blood type B
• 68% for highly sensitized patients
• 53% for those on dialysis at listing

Where patients lived also made a big difference in projected rate of death before kidney transplantation. The mortality rate ranged from 81% for those in United Network for Organ Sharing region five (Arizona, California, Nevada, New Mexico, and Utah) to just 6% for those in region six (Alaska, Hawaii, Idaho, Montana, Oregon, and Washington).
These factors may help clinicians and patients in decision-making, the researchers said. "As these results demonstrate, a white candidate with type AB blood in region one [Connecticut, Maine, Massachusetts, New Hampshire, and Rhode Island] is in a very different circumstance than a black candidate listed with type B blood in region five," they noted. They cautioned, though, that the study was limited by its retrospective, population-based design: its database did not include many factors that ultimately influence patients' prognoses and likelihood of receiving a transplant.

"In this sense, these results provide a general framework that can be used to guide patients and illustrate the importance of various factors, but should not be used exclusively ignoring individual circumstances," they concluded. The practice of transplantation is rapidly changing, but not in favor of older patients, they noted. In particular, they cited a proposed policy for organ allocation that would give younger patients more rapid access to deceased-donor transplants than older candidates.

Clinical Journal of the American Society of Nephrology 2009
Schold J, et al "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"

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