Renal transplantation provides a survival advantage for patients including those with multiple co-morbidities and older age compared to remaining on dialysis. The optimal immunosuppressive regime particularly in the elderly population to allow protection of the allograft but avoidance of toxicity and resulting morbidity and hospital admission is not clear.

All patients over 65 years that received a kidney transplant in a two year period with 12 months follow up in a large transplant centre were included in this study. A cohort of patients aged 65 years and under transplanted during the same period provided a control group. We performed between group analysis of factors including mortality, hospital admissions, length of stay, immunosuppressive regimes and graft outcomes.

A total of 35 patients over 65 and 60 patients 65 years and under were included. Mortality at 1 year was numerically greater in those over 65 (20%) compared to ≤65 years (7%). Death due to infection occurred in 4 patients >65 and 3 ≤65 years (p=ns). 77% of over 65s had at least one hospital admissions in 12 months compared with 57% of ≤65s, p=0.0495. Older patients had a higher rate of infective admissions with these being more prolonged, 27.1 hospital days per infective episode versus 11.7. There were no episodes of rejection in the older patients compared to four cases in those ≤65. The 30 day readmission rate was significantly higher for over 65s, 43% patients versus 22%, p=0.037. Early readmission rates in the elderly were mainly related to drug toxicity, 10/15 patients, all resulting in reduction in tacrolimus dose. Initial tacrolimus doses of 0.1mg/kg/day were seen both patients groups on discharge but this produced significantly higher tacrolimus levels in those over 65, 9.74 versus 7.5ng/ml, p=0.0347. By one month the over 65s had a significantly lower dose of tacrolimus 0.08mg/kg/day versus 0.11mg/kg/day to achieve similar trough levels, p=0.0286. Full dose mycophenolate was poorly tolerated in elderly patients (gastrointestinal upset and leucopenia) and by 6 months 70% experienced dose reduction.

Elderly kidney transplant recipients have higher rates of hospitalisation, admissions for infection and longer duration of inpatient stay in the first 12 months after renal transplantation than younger patients. Given the low rates of rejection adjusted protocols for reduced tacrolimus and mycophenolate dosing should be explored in this population.

CITATION INFORMATION: Morton M., Parker K., Morecroft C. Can We Optimise Immunosuppression Strategies in Our Older Renal Transplant Recipients? Am J Transplant. 2017;17 (suppl 3).

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