At 71, with more than two years of a punishing schedule of dialysis under his belt, William Kavadias thought a new kidney would never come. Transplants, he assumed, were for the young.
But last year, Kavadias' life-saving chance came in an unlikely package - a kidney from an older donor became available. The transplant was successful, and today he's feeling great.
Receiving a transplant doubles a patient's life expectancy. Dialysis, on the other hand, has poor outcomes for seniors. The likelihood that people 65 and older will survive five years on the blood-filtering treatment is just 27 percent, said Dr. Dorry Segev, associate professor of surgery and epidemiology at the Hopkins School of Medicine and the lead author of the study.
"Dialysis is not the answer to kidney failure for many patients," he said. "Quality of life on dialysis is incredibly poor for everybody, especially for older patients."
But many seniors are not offered a choice, Segev said. When a patient is on the transplant list, his doctor might place him on an additional list to accept a kidney from a pool of riskier donors. These organs from Expanded Criteria Donors, or ECD kidneys, come from deceased donors who are older than 60 or from people between 50 and 60 who died of a stroke or hypertension or had a slightly decreased kidney function.
Such organs come with additional risks. They are more likely to fail than younger organs, and they last half as long. Patients who receive them are at higher risk of heart attack, stroke and even death. In addition, complications from the transplant surgery are greater in older patients.
Still, remaining on dialysis long-term poses similar risks, said Segev, and for patients for whom time is critical, such organs are a good alternative. Not listing older patients for older kidneys "disenfranchises" them, he said.
"The bottom line is there is strong evidence that if you are over 65, you will benefit from choosing an ECD kidney transplant versus waiting for a younger donor on the waiting list," he said. "The choice is not whether to take this kidney or a younger kidney, because a younger kidney isn't there right now. The choice is whether to take this kidney or to wait on the list more time for a younger kidney. Do you want to wait two more years and in those years you have a 30 percent risk of dying?"
Even so, that calculation makes some surgeons and transplant centers skittish.
When transplants fail, transplant centers can be penalized. It's not only prestige and image at stake, but centers can lose their ability to do transplants altogether if they continually fall below expected outcomes, said Dr. Keith Melancon, director of kidney and pancreas transplantation at Georgetown University Hospital.
"There is no area of health care as highly policed as transplants and transplant outcomes," he said.
Statistics from the Scientific Registry of Transplant Recipients, which analyzes transplant data for the government, are public. They can influence patients, insurance companies and the United Network for Organ Sharing, or UNOS, which oversees the national organ transplant system and can investigate centers with poor outcomes, Melancon said.
While he supports the use of riskier kidneys, Melancon thinks transplant centers should be evaluated differently so they are not penalized for using such organs.
"While we all agree we would like to use them more, it's a double-edged sword," he said. "These kidneys are associated with poorer outcomes. Since we are judged so strictly by our outcomes, it's hard to justify taking those risks."
Transplantation centers are becoming more conservative because they are being "slapped on the wrist for their outcomes," he said.
That trend is bad for the long line of recipients. Of the nearly 84,000 people waiting for kidneys, about 15,000 of them are older than 65, according to UNOS. In 2009, of the nearly 17,000 kidney transplants that took place nationwide, about 2,600 recipients were older than 65.
A study last year in the Clinical Journal of the American Society of Nephrology found that 46 percent of patients age 60 or older on the transplant list will die before they get a kidney from a deceased donor. Overall, the number of people who need kidneys is growing, while the number of donors has stayed flat.