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.
It's the kind of surgery that many surgeons won't bother to perform. While kidneys from older donors are not suitable for younger patients, they can save seniors' lives, say some transplant surgeons. But a third of people over 65 must wait longer than they should for such organs because they are not listed for them. This puts the patients at higher risk of dying while on dialysis, according to a recent study by Johns Hopkins researchers.
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.
In the Baltimore area, there's a longer than average wait for kidneys, with a large number of patients with renal disease and few willing donors, said Dr. Matthew Cooper, director of kidney transplantation at the University of Maryland Medical Center. Cooper said he supports the use of ECD kidneys and counsels many patients to be listed for them. That there are two big transplant centers in Baltimore - Hopkins and the University of Maryland - has little bearing on the large number of people waiting for organs, he said.
Too often, Cooper said, doctors don't do a good job educating patients about the value of ECD kidneys. Adding a patient's name to the list doesn't mean the patient must take a riskier kidney if it becomes available. It simply amplifies the options, he said.
"I think the term we have used to explain this is a real turn-off," he said. "It sounds like we're trying to sell people a used car - it's been around the block a few times, still, it should do OK for you. But it's not our new model that just came off the factory line. That's a bad way to look at it."
In addition, some patients aren't fully informed of the risks of remaining on dialysis and receive conflicting information from doctors, Melancon said. As a result, they don't want to be listed for riskier organs.
Concern Turns to Confidence
Kavadias didn't know much about kidney transplantation at all. Long before he was offered a kidney, he spent three days a week at the dialysis center near his Olney home, where everyone, it seemed, had a sad story to share. There were tales of organs transplanted but rejected, and complaints from older patients that they would never live long enough to see a transplant.
Once he learned about being listed for a riskier kidney at Hopkins, he was concerned. But he gained confidence that his doctors would not give him a bad organ. If he had the opportunity for a transplant, he was sure it was the right decision, he said.
"I was concerned that if I got one, because of the age, it wouldn't work," he said. "But slowly, I understood what it means. And I realized if it happened for me, I would be OK."
Some transplant centers discourage the use of such kidneys because they do not have the resources to take care of patients whose transplanted organs fail to function, or fail to work right away, Cooper said.
Melancon said while he encourages older recipients to be listed for riskier organs, he's selective about who gets a transplant.
"When you are high-risk, you actually need a better kidney," he said. "You need a kidney that works right away."
But few organs are perfect, and being conservative can be detrimental to patients, said Dr. Robert Stratta, director of transplantation at Wake Forest University School of Medicine.
"It's not like there's the perfect donor out there," he said. "There are many shades of gray. You can always find a reason not to do a transplant, but that's not our job. Our job is to find a way to do a transplant safely and successfully."