Does Age Matter for Kidney Transplants

Additional Info

• Audio File:uab/ua160.mp3
• Doctors:Hanaway, Michael
• Featured Speaker:Michael Hanaway, MD
• CME Series:Quality and Outcomes
• Post Test URL:https://cmecourses.som.uab.edu/mod/quiz/view.php?id=4206
• Guest Bio:Dr. Michael Hanaway joined the UAB Division of Transplantation in February 2005. A native of Wisconsin, Dr. Hanaway received his undergraduate degree from the University of Wisconsin, and proceeded to medical school at the University of Wisconsin, graduating in 1992. 
  
  Learn more about Michael Hanaway, MD 
  
  Release Date: October 1, 2020
  Expiration Date: October 1, 2023
  
  Disclosure Information:
  
  Planners:
  Ronan O’Beirne, EdD, MBA
  Director, UAB Continuing Medical Education
  
  Katelyn Hiden
  Physician Marketing Manager, UAB Health System
  
  The planners have no commercial affiliations to disclose.
  
  Presenter:
  Michael Hanaway, MD
  Director of Abdominal Fellowship Program
  
  The speaker has no financial relationships related to the content of this activity to disclose.
  
  There is no commercial support for this activity.
• Transcription:Introduction: UAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA category one credit. To collect credit, please visit UABmedicine.org/medcast, and complete the episodes Post-test. Welcome to UAB Med Cast, a continuing education podcast for medical professionals, bringing knowledge to your world. Here's Melanie Cole.
  
  Melanie Cole: Welcome to UAB Med Cast. I'm Melanie Cole, and today we're examining the changing paradigm about older kidney transplant recipients. Joining me is Dr. Michael Hanaway. He's a Professor of Surgery and the Surgical Director of the Kidney Transplant Program at UAB Medicine. Dr. Hanaway, it's a pleasure to have you join us today. Please speak a little bit about what's changed or the increasing prevalence of older recipients for kidney transplantation.
  
  Dr. Hanaway: Obviously, transplant is changing. It's changing like the demographic is changing. It's changing. Like our population is changing, you know, back in the seventies and eighties and even early nineties, most of the transplant recipients were younger people. There were not as many diabetic patients. A lot of people had diseases just of the kidney or glomerular diseases and things like that. So they tended to be younger and healthier. Over time, the demographic is changing and we're having more and more people who were born in the thirties and forties. The baby boomer generation is aging, and they're getting to the point where they're developing other significant health problems. One of the things that they're developing is kidney disease. And so we see more and more people who are older, who are on dialysis or about to go on dialysis who need kidney transplants. The majority of patients that we see these days are probably in their sixties between, I would say easily between 60 and 70. We do see a good number of people in their early seventies who we think could still benefit from a kidney transplant.
  
  Host: Well, thank you for saying that, because that leads us into my next question. And speaking about patient survival and what they can benefit from can older individuals benefit from this reduction in mortality rate compared with being on dialysis and improved quality of life. Speak about that just a little.
  
  Dr. Hanaway: I think anybody regardless of age probably will do better with a successful kidney transplant than they will on dialysis. I think the one thing that's difficult to say is how long is somebody going to live with a kidney transplant? If they're transplanted, when they're older, most people did not die because of kidney disease. After a kidney transplant, they die from the same things. The rest of the population dies from, which is a cardiovascular disease, cancer, and infections. Those are the top three causes of death after kidney transplant. So even with a very successful kidney transplant, patients can die from other reasons. So really the question always becomes, will there be a benefit? What is the risk and what is the benefit? That's a question that we think about for all of our patients, but it applies even more so to the older patients, what is the risk of them going through the surgery?
  
  What is the risk of them during the recovery? What is the risk of them after a transplant? And what is the benefit? And the clear benefit for people is better quality of life because they don't have to go to dialysis any longer. I have not really talked to anybody who liked dialysis, who said they were really going to miss it. They may miss the people at their units that they like, but they don't miss going. Generally dialysis, doesn't make you a lot healthier. It's just going to make you at best about the same, but for a lot of people, they get worse. So when you think about dialysis and what that means for people, it means being tethered to a dialysis unit three days a week. It means not feeling very well on the days that you have dialysis, and after you have your dialysis. Feeling better the next day, but then having to go back to the following day. And so they're kind of on this endless rollercoaster of feeling okay. And not feeling well because they're tethered to that dialysis unit and it really means they can't travel. They can't go anywhere because it's almost impossible to get a dialysis slot somewhere away from your own unit.
  
  Cause they're all full. So it really means being bound to your home and to your home area, being unable to travel and for people who are older, whoever retire, they would like to travel and, you know, experienced some of the things they always wanted to. Having a kidney transplant can allow them to do that. It helps them to feel better. They don't have to go to dialysis, they get off the rollercoaster and it gives them more independence and more ability to do the things that they want to do. The question for us is, do we think the risk is too high? As you know, when people age, they develop more medical problems. Sometimes it's a cardiac disease. People can have a congestive heart failure. People can have a coronary artery disease. Sometimes they develop other health problems. And those things come to bear, you know, when we're thinking about whether or not their risk is too high with a transplant, as far as the surgery and the recovery afterwards. So if somebody is older, even in their seventies, but they're in really good shape, we still think that they'll benefit from a kidney transplant and we think they should have one.
  
  Host: Well, thank you for that very comprehensive answer. So how do immunologic physiologic and psychosocial, very important factors influenced transplant outcomes, Dr. Hanaway? Should they be recognized in the care of an elderly transplant patient and they help you to predict a complicated post-transplant course? Do you take into account all these factors?
  
  Dr. Hanaway: Well, we do as patients age their immune system, like other things in their body goes downhill a little bit. So their immune system is not as vigorous and strong in their sixties and seventies as it would have been in their twenties. So in a lot of situations, we're not as concerned about patients having rejection after kidney transplant, we're probably more concerned about the other side effects of the medication, which is infection. And so we think that, you know, as long as patients are taking their medications they're probably going to do okay and aren't likely to have rejection. So that's a concern, but not as great a concern as it would be from somebody who's much younger. We have to make sure that patients are physically able to do this. We got to make sure that they are strong enough to be able to get around and help take care of themselves. If they walk in the hospital, we want to make sure that after their recovery they're able to walk out of the hospital.
  
  If patients are very weak, when they come in, are unable to walk or in a wheelchair, we think their risk of really being able to rehab after a transplant is not that great. So we have to take into account their physical status, their frailty, and their overall health along with other health problems like heart disease. Psychosocially, I think it's very important to make sure that especially older patients have lots of support. They're going to really need a caregiver after their transplant to help them recover at home and to be able to help them get through this. You know, the hospitalization and the recovery in the hospital is one thing, but patients are going to continue to recover at home for at least a couple of months afterwards. And it's important that they have the support necessary to help them prepare meals, get to the store, take their medications get the physical therapy, if that's something that they need. So those things are all definitely things that we take into account when we're considering whether or not somebody is a good transplant candidate.
  
  Host: So, here's a somewhat controversial question. Dr. Hanaway, given the persistent shortage we've been hearing about of donor organs in the face of a steadily growing end stage renal disease population and an older population that we're seeing. Are there some important ethical issues concerning the allocation of scarce resources to older patients? Have you heard talks? Are there studies? What do you say about that?
  
  Dr. Hanaway: Well, it is a controversial topic. I will definitely say that. I think that there are, you know, there has been a shortage of organs when compared to the need, based on patients placed on the wait list around the country. And that's been present since the 1980s. So that's not a new thing. It's just something that keeps getting worse. One of the things we have to take into account, if we're going to put somebody on the waiting list is how long they can expect before they'll get a kidney. If we have somebody who's 72 years old, but they may have to wait eight years to get a kidney. Then chances are they probably won't be as good a candidate at 80, after eight years on dialysis as they were at 72. So it does influence our decision making somewhat because we don't want to put somebody on the waiting list and tell them they're going to get a kidney if we really don't think that that's possible. We do encourage everybody to try to find a kidney from a living donor. The big reason for that, especially for older patients, is it really shortens their waiting time. If there's somebody who could donate a kidney to them then you know, then they may not have to wait on dialysis very long or be on dialysis at all. We did a transplant last week.
  
  It was a husband and wife, the husband donated to his wife, the husband was 68 and the wife was 68. So we sometimes get asked questions about how old can a donor be. And it's not a question of chronologic age, how many years old they are? It's how healthy are they? And do we think that we can do this safely for them? So that's a good example of a situation where somebody wasn't on dialysis, was able to get a living donor transplant and never had to go on dialysis. She's being discharged today. She had her surgery on Thursday and she's doing well. Her husband went home yesterday, so it can work in those circumstances. Having a living donor can really help you out though. We do have other options out there for people who don't have living donors. One is the possibility of getting a Hepatitis C kidney or getting a kidney from a donor who had Hepatitis C. We now have a number of medications that are very, very effective at treating Hepatitis C. So we've been able to use these kidneys in patients and then treat them right afterwards with the anti Hep-C medications and get rid of that Hep C after about six to eight weeks of treatment. It's worked really great.
  
  And the benefit of that is that people can get a kidney faster. And we've seen some people who would normally have a waiting time of eight or nine years get transplanted after three or four years. So it can have a big difference. And because of that, we're willing to put some of these older patients on the waiting list that have had a long wait in the past. But we think that if they're willing to accept this kidney, they may not have to wait as long. We're also fairly aggressive about trying to find kidneys from older individuals. So donors who people who've passed away who were in their sixties. And we think that it's a good kidney because that person was otherwise fairly healthy. We think that that's a kidney that might benefit somebody in that situation where they are older and they have to wait a long time to get a kidney, that they might be able to get a kidney a little bit faster and get off dialysis faster. So we're always looking for new ways to try to help some of these people get transplanted because a lot of the people we see in their late sixties and early seventies look really good when we see them. But if they have to wait too long to get a kidney, they may not look as good when the time comes.
  
  Host: What a fascinating topic we're discussing today. Dr. Hanaway, wrap it up for us. Tell us a little bit about your outcomes and what you want referring providers to know about UAB Medicine, your multidisciplinary approach, and this changing paradigm that is older kidney transplant recipients?
  
  Dr. Hanaway: Well, I think our outcomes are very good. We have I think some of the best outcomes in the country in terms of graft and patient survival, and it's been that way really for the last 20 years. So it's not really changing. We've got very good people here. We've got a great group of transplant nephrologists and a very experienced group of surgeons who really help us do a great job for our patients. The one thing I would say to the referring nephrologist is if you have a patient that's in their sixties or seventies and they look really good, they look like they're in their fifties and they need a kidney transplant. We want to see them. We see people periodically they'll come in and say, well, I was told by my doctor, I was too old to get a kidney, but I finally came in anyway and they look fantastic. So it can happen. It's not really about how many years old you are. It's about the type of shape that you're in. And if you're in good shape, you can still get a kidney.
  
  Host: Great information. Thank you so much, Dr. Hanaway for joining us today. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. And that wraps up this episode of UAB Med Cast. For more information on resources available at UAB Medicine, please visit our website at UABmedicine.org/physician. Please also remember to subscribe, rate, and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole.
• Hosts:Melanie Cole, MS