Kidney Retransplantation Viable in Elderly Patients, Study Finds

New research is providing clinicians with an overview of the benefits and risks of kidney retransplantation in elderly patients, with study findings pointing to acceptable outcomes and a notable survival advantage compared with long-term dialysis.1

The single-center retrospective cohort study assessed deceased donor kidney transplants (DDKTs) performed in elderly patients ≥ 65 years of age and found a heightened risk of death with functioning graft (DWFG) but comparable death-censored outcomes in retransplant recipients relative to age-matched primary transplant recipients.1

In the United States, there are more than 103,000 people on the national transplant waitlist, nearly 90,000 of whom are seeking a kidney transplant.2 In 2024, only about 1 in 4 people who were on the waitlist for a kidney transplant were able to receive one due to a significant gap between the number of people waiting for transplants and the number of available organs.3

“Given the ongoing shortage of donor kidneys, kidney retransplantation in general and retransplantation of elderly patients in particular raises concerns regarding equity, utility, and the optimal allocation of limited resources,” Robert Stratta, MD, a professor and Jesse H. Meredith Chair in Transplant Surgery and Director of Transplantation at Wake Forest Baptist Health, and colleagues wrote.1

To address the limited data available on the benefits and risks of kidney retransplantation in this patient population, investigators retrospectively reviewed all DDKTs performed at their center in patients ≥ 65 years of age from December 2004 through August 2022, excluding living donors and multi-organ transplants.1

All patients underwent a standard pre-transplant medical, psychosocial, and financial evaluation. No specific chronologic upper age limit was excluded from consideration, but in general, investigators noted those with dementia; nursing home residency; poor overall functional status or frailty; advanced disease or organ failure in an extra-renal organ system; recent malignancy; severe cardiac or vascular disease; or projected life expectancy of <2 years were excluded from consideration for transplant.1

Primary study outcomes included short- and medium-term patient and kidney graft survival rates, including uncensored and censored for DWFG.1

During the study period, 668 DDKTs were performed in elderly patients, including 39 retransplants and 629 primary transplants. Investigators noted the mean donor age was lower in the retransplant group (53.6 vs 43.7 years of age; P <.001), as was the Kidney Donor Profile Index (74% vs 58%; P <.001).1

Additionally, the retransplant group was characterized by lower BMI (28.4 vs 26.4), more patients with a calculated panel reactive antibody level ≥ 50% (10.3% vs 43.6%), and longer time on the waiting list (mean 16 vs 25 months) (all P <.05).1

During a mean follow-up of 71 months in the primary and 59 months in the retransplant group, patient survival (50.9% vs 25.6%) and kidney graft survival rates (42.8% vs 25.6%) were higher in the primary transplant group.1

DWFG occurred in 37.4% of primary and 59.0% of retransplants (P = .01). Death-censored graft survival rates were not different between groups (68.3% primary vs 62.5% retransplant; P = .76).1

Investigators pointed out comparable rates of primary nonfunction (2.6% retransplant vs 3.7% primary) and delayed graft function (23% retransplant vs 32% primary; P = .29) between the groups.1

Of note, 5-year patient (74.3% vs 55.2%; P = .03) and kidney graft survival rates (64.7% vs 55.2%; P = .32) were higher in the primary DDKT group. However, investigators pointed out 5-year death-censored kidney graft survival rates were not different between the groups. (77.7% primary vs 80% retransplant).1

Further analysis revealed DWFG was the most common cause of graft loss, accounting for 65.3% of graft losses following primary transplantation and 79.3% of graft losses following retransplantation (P = .01).1

“Analogous to younger patients, kidney retransplantation in the elderly is associated with slightly inferior outcomes compared to primary transplantation. However, outcomes are acceptable and provide a survival advantage in this population compared to long-term dialysis therapy,” Stratta and colleagues concluded.1 “Although the survival benefit may diminish with increasing recipient age, it is not to the point that elderly patients should be ruled out for transplantation based on age alone.”

References

1. Mujtahedi SS, Jay CL, Sakhovskaya N, et al. Kidney Retransplantation in the Elderly: Are the Benefits Worth the Risks? Clinical Transplantation. https://doi.org/10.1111/ctr.70129

2. Health Resources & Services Administration. Organ Donation Statistics. March 2025. Accessed March 12, 2025. https://www.organdonor.gov/learn/organ-donation-statistics

3. American Kidney Fund. Quick kidney disease facts and stats. February 11, 2025. Accessed March 12, 2025. https://www.kidneyfund.org/all-about-kidneys/quick-kidney-disease-facts-and-stats