Abstract
Rationale:
Kidney transplantation (KT) is the treatment of choice for end-stage kidney disease (ESKD) in all age groups. However, KT in octogenarians is a rare and unique event. We describe the evaluation and clinical course of the world’s oldest kidney transplant recipient at 87 years, 262 days, as recognized by the Guinness Book of World Records.
Presenting Concern of Patient:
An 84-year-old Canadian retired real estate agent of Indian origin with ESKD due to diabetic nephropathy on hemodialysis presented to our center as a potential kidney transplant candidate. Comorbidities included hypertension, coronary artery disease, benign prostatic hyperplasia, and bilateral knee replacements. He was functional, independent, and extremely keen to undergo KT to further improve his quality of life.
Diagnosis:
Extensive pretransplant investigation revealed a reasonable state of health for all major organ systems. Multiple specialists were consulted prior to listing.
Interventions:
After 5 years on hemodialysis, he received a standard neurological determination of death donor kidney transplant.
Outcomes:
Graft function was immediate. Complications experienced in the first posttransplant year included two urinary tract infections—one with bacteremia; uncontrolled blood pressure and blood glucose, cytomegalovirus and BK viremia, and an inferior wall non-ST segment elevation myocardial infarction. In the second year, he developed a scrotal abscess. However, graft function remained stable with a serum creatinine concentration of 82 µmol/L at two years posttransplant.
Teaching Points:
Successful KT in advanced octogenarians is possible. Appropriate patient selection is crucial. Extended screening for infection, cardiac and vascular disease, malignancy, and frailty including cognitive deficits is required. Plans for diabetes care and ensuring adequate social support including home care may mitigate complications. Willingness to investigate identified illnesses and seek assistance from other specialists may reduce but not necessarily prevent posttransplant complications. Neurological determination of death donor organs might be preferable for advanced octogenarian KT recipients even if those organs meet expanded criteria.
Introduction
Canada has more than 861 000 people aged 85 and older, >2.3% of the population, as enumerated in the 2021 Census. From 2016 to 2021, this group grew by 90 000 individuals or by 12%, more than double the growth rate for the overall Canadian population. 1 Among them were more than 1800 incident patients with ESKD above 75 years of age in 2023 alone, 2 which mandates continuous review of ESKD management strategies in the very elderly. Kidney transplantation (KT), the renal replacement therapy of choice for patients with ESKD,3,4 can be offered to octogenarians, with an expected five-year survival rate exceeding 50%. 5 However, published data are limited to early octogenarians younger than 85 years of age. We report the clinical course of the world’s oldest officially recognized kidney transplant recipient at 87 years, 262 days, 6 to share insight into KT feasibility and management strategy in advanced octogenarians, who we define here as individuals above 85 years of age.
Presenting Concerns
An 84-year-old Canadian retired real estate agent of Indian origin with ESKD due to diabetic nephropathy presented to our center as a potential kidney transplant candidate. He had a history of type 2 diabetes since the age of 40, and had learned of his chronic kidney disease (CKD) 10 years earlier. He had been on hemodialysis via an arteriovenous fistula for two years. Other history included mild diabetic neuropathy, hypertension for 22 years, myocardial infarction (MI) with subsequent coronary artery bypass grafting six years earlier, transurethral prostate resection for benign prostatic hyperplasia, and bilateral knee replacements. He had stopped smoking 20 years earlier. He ambulated with a cane and drove a car. He was keen to undergo KT to further improve his quality of life.
Clinical Findings
Initial assessment was performed by telephone due to our transplant center’s COVID-19 pandemic protocol at the time. There were no identified potential living donors although he was counseled about this option. Medications included insulin administered via pump, bisoprolol, hydralazine, amlodipine, aspirin, rosuvastatin, tamsulosin, and erythropoietin. He reported good appetite and energy. His body mass index (BMI) was stable at 26 kg/m2. Systolic blood pressure (BP) was usually 130 to 140 mm Hg and diastolic BP 60 to 80 mm Hg. He could walk two blocks on level ground and climb one flight of stairs without stopping.
He was then reevaluated in-person after a year, once pandemic-related restrictions had been lifted. There was an intervening transient ischemic attack for which he received clopidogrel for six months, although head magnetic resonance imaging was unremarkable. He also had mild COVID pneumonia despite four vaccine doses. On examination, his gait was confident with no evidence of frailty or cognitive impairment, although he did not undergo further formal evaluation for either of these. The BP was 167/92 mm Hg with heart rate 76/min, regular. He had a positive S4 by auscultation. Lung fields were clear bilaterally. Abdomen was soft, nontender, and nondistended, with no palpable masses. There was no edema. Pulses were palpable and symmetrical, and the feet were warm to touch.
Diagnostic Focus and Assessment
Cytomegalovirus (CMV), Epstein-Barr virus (EBV), and varicella-zoster virus (VZV) antibodies were present. Hemoglobin was 109 g/L, platelets 93 000/cu mm, albumin 43 g/L, parathyroid hormone 23.3 pmol/L, thyroid-stimulating hormone 1.17 mU/L, HbA
Therapeutic Focus and Assessment
The patient was counseled about his increased risk of the following: infection, malignancy, osteoporosis and fractures, avascular necrosis, worsening diabetes including increased insulin requirements, peri-transplant adverse cardiac events with their associated increased short-term morbidity risk including delayed graft function (DGF) or primary graft nonfunction, and increased mortality risk. These risks were discussed both during his initial telephone assessment, conducted during the COVID-19 pandemic to reduce his time-to-listing, and subsequent in-person visit. He remained motivated and willing to proceed after being counseled about these risks. Besides receiving approval from his transplant nephrologist, he received formal approval from a transplant surgeon, anesthesiologist, cardiologist, hematologist, and social worker. He was then activated on the transplant waitlist 3 years after the initial assessment, and he received a standard neurological determination of death donor organ offer 2 months later.
His intraoperative course was unremarkable. Immunosuppression consisted of intravenous basiliximab, followed by oral long-acting tacrolimus, mycophenolic acid, and prednisone. Graft function was immediate, and his serum creatinine concentration settled around 95 µmol/L. Graft ultrasound was unremarkable. He ambulated early with assistance, and quickly learned his medications. The indwelling bladder catheter was removed on postoperative day (POD) five and he was discharged on POD 10, after arranging his own home assistance.
Follow-up and Outcomes
He was followed weekly in the outpatient clinic and provided laboratory testing twice weekly. He was readmitted on POD 19 with Pseudomonas urinary tract infection (UTI) and bacteremia, along with uncontrolled hyperglycemia. His mycophenolate was discontinued on POD 19. He developed CMV viremia with DNA by polymerase chain reaction (PCR) 3000 IU/mL on POD 29, and after all these were managed successfully, he was discharged home on POD 38. He came to all his clinic appointments regularly. Other significant events in the first year included suboptimal BP and blood glucose control, BK viremia to 4000 IU/mL by PCR at month three that resolved by month nine without specific intervention, another Pseudomonas UTI during month 4, and an inferior wall non-ST-elevation myocardial infarction during month nine followed by the placement of three coronary artery stents. During month 14, he was diagnosed with a scrotal abscess that required surgical drainage. He quickly recovered from each setback, being discharged to home each time, but his BMI declined to 22 kg/m2. His blood tacrolimus concentration remained in the 4 to 7 ng/mL range. His mycophenolate was reintroduced at 25% of the original dose during month 17. He was maintained on prednisone 5 mg/d. Serum creatinine concentration was 82 µmol/L, urine Albumin-to-Creatinine Ratio (ACR) 10 mg/mmol, and hemoglobin 135 g/L at two years posttransplant. He remained fully functional in all activities of daily living and continued to live independently at home with his wife. Using public transportation, he attended all his clinic visits. His major milestones and events are summarized in Table 1.
Summary of Patient Timeline.
Discussion
We have described the pretransplant and posttransplant course of the world’s oldest KT recipient. This select case demonstrates that KT in advanced octogenarians can succeed. The approval process that included both virtual and in-person visits was extensive and prolonged due to his previously identified comorbidities and new comorbidities that developed, but he was unencumbered due to his enthusiasm and level of physical fitness. He also experienced many significant yet predictable posttransplant events. At his insistence, we applied to register him with the Guinness Book of World Records soon after his transplant. All necessary documentation was supplied, after which he was duly recognized.
Clinical guidelines emphasize comorbidities including frailty rather than age in assessing transplant candidates. 7 Transplantation in octogenarians has been dubbed “worthwhile” as long as candidates are carefully selected, 5 but it remains a very rare event, 8 with rates of about 0.15% of all KT in the United States. 9 A large case series of 47 octogenarians (oldest 83.6 years) demonstrated median patient and uncensored graft survival of 4.7 and 4.1 years, respectively. 5 Notably, only organs obtained after neurological death were used in this large case series from the Norwegian Renal Registry. 8 Although more than half received expanded criteria donor kidneys, their favorable results may not be applicable to recipients of organs donated after circulatory death. 8 Disproportionately, more than 80% of octogenarian recipients are men. 9 Elderly recipients of elderly circulatory death donor kidneys have significantly higher acute rejection and DGF rates. 10 Conversely, a US registry analysis of more than 450 octogenarians in whom the cause of donor death was not differentiated suggests that DGF in octogenarians is similar to non-octogenarians, although acute rejection rates are less than half. Nonetheless, hospital length of stay significantly increases, while 30-day mortality more than doubles. 9
Infection and major adverse cardiovascular events contribute extensively to mortality although granular data for these outcomes in the elderly are sparse. 11 Immune function reduces and the atherosclerotic-arteriosclerotic burden is extensive. These increased risks might attenuate from the selection bias provided by pretransplant investigation. Despite higher prevalent diabetes and incident posttransplant diabetes, 12 octogenarians demonstrate acceptable five-year patient and graft survival rates.5,9 Urine retention 13 and deep vein thrombosis 14 from delayed ambulation may complicate posttransplant care. Old-for-old allocation policies help mitigate organ shortages but might increase many complications especially if they increase DGF rates. Somewhat counterintuitively, malignancy rates may not be higher. 15 Non-white ethnicity, which delays the survival benefits of KT in the elderly, 16 may by extension also increase complication rates.
Frailty may be especially concerning in octogenarian KT candidates. Decreased physiological reserve, muscle loss, chronic inflammation, malnutrition, and comorbidities worsen from dialysis. Subtle cognitive impairment, polypharmacy, dependence on caregivers, osteoporosis, and hyperkalemia may require increased attention, similar to other patients with CKD. 17 Dementia results in increased resource utilization. 18 Frailty can result from all the CKD-related morbidity that candidates bring to KT, and this frailty worsens especially in the early postoperative period. In the context of frailty, old comorbidities worsen and new comorbidities manifest from perioperative stress and immunosuppression.
Kidney transplantation in octogenarians invites considerable ethical discussion. Benefits include the autonomy of therapeutic choice, improved survival and physical function, restored quality of life with fewer dietary and fluid restrictions, preserved independence, and increased overall life satisfaction. 19 Kidney transplantation decreases the risk of death after listing. 20 These benefits must be balanced against an increased long-term mortality risk in elderly KT recipients that leads to lost allograft survival potential, as well as more hospitalizations, infections, and cardiovascular events. 19 Our advanced octogenarian KT recipient experienced the many benefits of transplantation while also experiencing many of the complications. The overall benefits of KT may outweigh the risks when an organ of sufficient quality is implanted, such as a kidney from a living donor, a deceased donor kidney fulfilling standard criteria, or a deceased donor kidney fulfilling expanded criteria but also meeting criteria for a neurological determination of death. Shared decision-making is crucial, 19 but should be contextualized to the clinician’s assessment of the KT candidate’s frailty and cognition among other parameters. At the same time, higher quality kidneys are scarce, and so KT should be pursued only when there is a high likelihood of survival benefit to the potential recipient as determined holistically by the experienced clinician’s own use of Gestalt cognition. 21
To optimize posttransplant success in advanced octogenarians, appropriate patient selection is crucial. Despite the advantages of utilizing virtual visits in assessing complex elderly patients including sparing them from difficult travel and addressing specialist service maldistribution, 21 in-person visits remain indispensable to determining their suitability and ultimate success. Extended screening for infection, cardiac and vascular disease, malignancy, frailty including cognitive deficits, a plan for diabetes care, and ensuring adequate social support including home care may help mitigate complications. Willingness to investigate identified illnesses and seek assistance from other specialists prepares all in advance about what to expect. While posttransplant complications in the advanced octogenarian may be unavoidable, some might at least be predictable. Based on the reported experience to date, neurological determination of death donor organs might be preferred for advanced octogenarians even if those organs meet expanded criteria.
Patient Perspective
“They told me I should not do it, it’s risky, you are 87, anything might go wrong, you may die on the table, blah blah blah. I said I don’t care, dialysis is killing me. I don’t want dialysis. So I took a chance [. . .] at the operation time they again asked me, I said yes [. . .] now when I go to the clinic they all clap and talk to me.”
Footnotes
Acknowledgements
The authors especially thank Monica Farcas MD, Kamel Kamel MD, Meriam Jayoma-Austria RN, Alexandra Manzo RN, Galo Meliton RN, and Jaspreet Sidhu RN for their assistance in caring for the patient.
Ethical Considerations
Informed consent for publication of this case report was provided by the patient.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.