*Purpose: In the recent past, older age was a contraindication to kidney transplantation (KT). New kidney allocation schemes with use of longevity matching, initiation of frailty testing, and enhanced psychosocial assessment have improved kidney access for the elderly population, age 75 and higher.

*Methods: We retrospectively reviewed outcomes in adult patients (pts) ≥75 years of age transplanted at our center with kidneys from deceased donors. All patients (pts) received antibody induction in combination with reduced dose FK, MMF, and steroids. Protocol adjustments included frailty testing, stricter psychosocial clearance, and demonstration of stable comorbidities.

*Results: Over a 16-year period, we performed 92 KTs (4.7% of all adult KTs) in pts age ≥75 (mean 77 years, range 75-84). The recipient group included 40 women and 52 men (58 white, 31 black, 3 other) with a mean waiting time of 13 months and dialysis duration of 30 months. 11 pts (12%) were transplanted prior to starting dialysis. 55 pts (60%) received kidneys from expanded criteria donors (ECDs, including 25 ≥ age 65), 8 pts received dual kidney transplants, and 6 were retransplants. Mean KDPI was 74%. The incidence of delayed graft function (need for dialysis post-KT) was 23%. With a mean follow-up of 53 months (60 pts had at least 5 years f/u), actual pt and kidney graft survival rates were 57% and 49%, respectively; death-censored kidney graft survival (DCGS) was 70%. One year pt and kidney graft survival rates were 95% and 88%, respectively. Of 47 graft losses, 11 occurred within 1 year and 28 (60%) were secondary to death with a functioning graft (DWFG). Half of the deaths and DWFGs occurred ≥ 5 years post-KT. At present, 45 of the 52 surviving pts (87%) have functioning grafts. Major causes of death were cardiovascular (10), stroke (7), sepsis (6), and respiratory failure (6). The incidences of surgical complications, acute rejection and major infection were 9%, 20%, and 25%, respectively. In 28 cases, the mate kidney from the same donor was transplanted into a <75 year old pt (mean age 60 years) at our center. DCGS rates in the donor-matched pairs were comparable in the older (56%) and younger (59%) age cohorts.

*Conclusions: New kidney allocation policies should not discriminate against older recipients who are physically active and functional, have good psychosocial support, and have stable comorbidities. Acceptable medium-term outcomes can be achieved in appropriately selected elderly patients, improving both their quality and quantity of life compared to dialysis. By using predominantly ECD kidneys, which otherwise may not be appropriate for younger patients, we have enhanced opportunities for KT in the elderly while simultaneously reducing the risk for organ discard, thus permitting liberalization of both donor and recipient eligibility criteria.

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