Research paper Balancing risks for older kidney transplant recipients in the contemporary era: A single-centre observational study F. Jackson-Spence a , H. Gillott a , S. Tahir a , J. Nath a,b , J. Mytton c , F. Evison c , A. Sharif a,b, * a University of Birmingham, Birmingham, UK b Department of Nephrology and Transplantation, Queen Elizabeth Hospital, B15 2WB Edgbaston, Mindelsohn Way, Birmingham, UK c Department of Health Informatics, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK 1. Introduction The proportion of older patients with end-stage kidney disease (ESKD) undergoing renal replacement therapy (RRT) is steadily increasing. National registry data consistently shows a trend towards increasing median ages for patients both starting dialysis and awaiting kidney transplantation on deceased-donor waiting lists. For example, national audit data from the UK Renal Registry demonstrates the median age for all incident patients commencing RRT was 64.8 years [1]. Data from the UK Transplant Registry reports 28% of transplant recipients receiving a deceased-donor kidney allograft in the last year were aged 60 and over, while 32% of the active kidney transplant waiting list is aged 60 and over [2]. With chronic kidney disease increasingly recognized as a public health epidemic, the long-term prospects are of an ESKD population with increasing age requiring kidney allografts. While mortality risk is accepted as higher for older versus younger kidney transplant recipients [3], kidney transplantation remains the gold-standard RRT for all age groups. Despite this, older adults with ESKD have a skewed risk-versus-benefit ratio comparing kidney transplantation versus dialysis and questions the optimal RRT for older adults with ESKD [4]. However, older candidates for transplantation may be unfairly disadvantaged by receiving standard post-transplant immunosuppression which is not attenuated or tailored to their individualized risks. Older kidney transplant recipients have increased risk for infections and cancers, but decreased risk for rejection, which likely relates to age-related immunosenescence [5]. Tailored immunosuppression for older transplant recipients could attenuate post-transplant complications and improve overall graft survival [6] but no European Geriatric Medicine xxx (2016) xxx–xxx A R T I C L E I N F O Article history: Received 29 September 2016 Accepted 7 November 2016 Available online xxx Keywords: Older age Kidney transplant Outcomes Cancer Rejection A B S T R A C T Introduction: Age-adapted immunosuppression may be warranted for older kidney transplant recipients but post-transplant risks stratified by age in the contemporary era of immunosuppression are lacking. Materials and methods: We undertook a retrospective single-centre analysis of 1140 consecutive patients receiving kidney-alone allografts, with median follow-up 4.4 years’ post-transplantation, undertaken at a single-centre between January 2007 and January 2015. All patients received standardized immunosuppression. Descriptive analyses were stratified by age groups (age: < 60, n = 918; age: 60– 64, n = 111; age: 65–69, n = 82; age:  70, n = 29). Incidence of death, kidney allograft rejection, function/ loss and immunosuppression-related complications was analyzed across age groups. For Cox regression analysis, older kidney transplant recipients were classified as age  60 (n = 222). Results: Kidney transplant recipients had increased risk for cardiac events, cerebrovascular accidents, cancer and CMV viraemia with increasing age. Rejection rates were similar but kidney transplant recipients with increasing age were significantly less likely to develop anti-HLA antibodies. Older kidney transplant recipients progressively had worse patient survival and overall graft survival, but equivalent death-censored graft survival. In Cox regression analysis, age  60 was a strong independent risk factor for mortality in addition to preexisting diabetes, development of post-transplant cancer and development of rejection. Conclusions: Older kidney transplant recipients have increased risk for immunosuppression-related complications (contributing to increased mortality) but rejection rates and death-censored graft losses are similar. Clinical trials for age-adapted immunosuppression are warranted for older adults but require balancing risks for cancer and rejection to achieve optimal long-term clinical outcomes. ß 2016 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved. * Corresponding author. Queen Elizabeth Hospital, B15 2WB Edgbaston, Birmingham, United Kingdom. E-mail address: adnan.sharif@uhb.nhs.uk (A. Sharif). G Model EURGER-820; No. of Pages 6 Please cite this article in press as: Jackson-Spence F, et al. Balancing risks for older kidney transplant recipients in the contemporary era: A single-centre observational study. Eur Geriatr Med (2016), http://dx.doi.org/10.1016/j.eurger.2016.11.004 Available online at ScienceDirect www.sciencedirect.com http://dx.doi.org/10.1016/j.eurger.2016.11.004 1878-7649/ß 2016 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.