Protected: KIDNEY TRANSPLANTATION IN THE ELDERLY PATIENT

Abstract

The increasing number of patients waiting for a kidney transplant is mainly due to the increase in the number of patients over 65 year old.

Kidney transplantation from cadaveric or living donors confer benefits in terms of improved patient survival in suitably selected elderly recipients. The net gain in survival becomes evident two years after transplantation.

The old for old allocation strategy aims to ensure an appropriate match of kidney and patient life expectancy, simultaneously providing a more immunogenic graft to a less immune-responsive recipient.

The entity of life expectancy gain after transplantation should be evaluated taking into account the improvement in dialysis life expectancy that has been observed in the last years, especially in the elderly patients.

By recognizing who the frail patients are, and by measuring their frailty, we can improve our ability to select older patients for transplantation.

The mostly adopted immunosuppressive regimens for older recipients are not different from those adopted in other patients, at least in the induction phase. The maintenance therapy is kept to the lower limits of standard immunosuppression.

Due to the unfavorable effect of a long dialysis vintage on graft and patient survival, it is important to lead older patients to transplantation with no delays.

It has been demonstrated that kidney transplantation from expanded criteria donor in patients 60 years or older is associated with higher survival rates than remaining on dialysis, whereas living donor renal transplantation is superior to all other options.

 

Keywords: Kidney transplantation, aging, immunosuppressive agents, frailty

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Protected: Kidney transplantation from older living donors

Abstract

Recently, living donor kidney transplantation has become a suitable therapeutic option for many elderly patients with ESRD. In this setting, the living donor will often be an equally elderly subject. This entails a process of selection that is complex and not always well codified.

Elderly donors (EDs) are aged between 65 and 80. In EDs, the minimum glomerular filtration rate (GFR) acceptable for donation decreases with increasing age, but according to the KDIGO guidelines it should never be less than 60 ml / min / 1.73m2. However, the United Kingdom Guidelines also accept slightly lower values.

After donation, also in the elderly there is an increase in the volume of the residual kidney and an increase in GFR of about 20% (mainly due to increased renal plasma flow). This allows maintaining a stable GFR over time, without an increased risk of ESRD.

For GFR evaluation, the suggested formulas are CKD-EPI or MDRD. However, creatinine clearance, although little considered by the guidelines, in the elderly may be reliable, and is still widely used.

Graft survival from EDs may be lower to those from younger donors but as high as those from standard deceased donors

The selection of the donor requires many other investigations. In the elderly, unlike in the young, it may be difficult to distinguish between a pathological or a para-physiological result. In order to correctly interpret these conditions, it is necessary to have great experience and expertise that only transplant centers with a high volume of activity can guarantee

 

Keywords: living donor, elderly donor, kidney transplantation

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The Good Samaritan Donor Experience

Abstract

The need for patients with a chronic kidney failure and on dialysis to embark on a kidney transplant process, poses the challenge to identify alternative and effective surgical strategies to overcome the insufficient number of deceased donors. The purpose is to allow the considerable number of patients on the kidney transplant waiting lists to receive appropriate treatment in time and under the most favorable clinical conditions. Living donation from a significant other is becoming increasingly widespread, on a national and international level. Furthermore, in the last years clinical experience is showing a special kind of kidney living donation: the Good Samaritan donation, i.e. when the donor has no emotional or blood bond with the recipient and decides to become a donor as a mere act of generosity, with no remuneration or reward in return. This article, after a brief analysis of the phenomenon through data obtained from recent international studies, shares the direct experience of the Clinical Psychology Service at IRCCS – ISMETT with regard to the psychological assessment and support throughout the clinical process of a Good Samaritan kidney donor. Sharing our experience and starting a discussion on this issue is the result of the need to define shared guidelines on the psychological approach to be used with potential Good Samaritan donors.

 

KEYWORDS: Kidney transplantation, living organ donation, good Samaritan donation, psychological assessment, altruism

Sorry, this entry is only available in Italian.

Nutritional diet therapy in the management of the patient with Chronic Kidney Disease in advanced phase to delay the beginning and reduce the frequency of dialysis. An option also in the pre-emptive transplant program

Abstract

The Italian nephrology has a long tradition and experience in the field of dietetic-nutritional therapy (DNT), which is an important component in the conservative management of the patient suffering from a chronic kidney disease, which precedes and integrates the pharmacological therapies. The objectives of DNT include the maintenance of an optimal nutritional status, the prevention and / or correction of signs, symptoms and complications of chronic renal failure and, possibly, the delay in starting of dialysis.

The DNT includes modulation of protein intake, adequacy of caloric intake, control of sodium and potassium intake, and reduction of phosphorus intake. For all dietary-nutritional therapies, and in particular those aimed at the patient with chronic renal failure, the problem of patient adherence to the dietetic-nutritional scheme is a key element for the success and safety of the DNT and it can be favored by an interdisciplinary and multi-professional approach of information, education, dietary prescription and follow-up. This consensus document, which defines twenty (20) essential points of the nutritional approach to patients with advanced chronic renal failure, has been written, discussed and shared by the Italian nephrologists together with representatives of dietitians (ANDID) and patients (ANED).

Keywords: CKD, Nutritional treatment, diet, dialysis, kidney transplant, chronic renal failure.

Sorry, this entry is only available in Italian.

mTOR inhibitors in kidney transplantation

Abstract

A changing paradigm of treatment of kidney transplant recipients is a new, wider approach to immunosuppression, which should take into account both antiviral and anticancer effects, in addition to cardiovascular protection. Recent observations suggest that the early introduction of mammalian target of rapamycin inhibitors (mTORi) in association with low dose CNI may offer many of these effects. The present manuscript summarizes benefits and contraindications of combinations with mTORi in kidney transplant immunosuppressive strategies.

Key words: kidney transplantation, mTOR inhibitors, immunosuppressive therapy

Sorry, this entry is only available in Italian.