Background: Living donor (LD) kidney transplantation provides improved outcomes compared with deceased donor (DD) kidney transplantation. Little is known about health gains associated with older LD versus standard criteria DD kidney transplantation after waiting on dialysis.

Methods: We conducted a decision analysis using a Markov model from the perspective of a transplant candidate followed from wait-listing to death. We conducted expected value comparisons for a recipient of a kidney transplant from a 60 year-old LD or intermittent hemodialysis followed by transplantation with standard criteria (30 year-old) DD. Probabilistic analysis was used to incorporate parameter uncertainty into the model. Outcomes of interest were life expectancy (LE) and quality adjusted life expectancy (QALE). The base case was a 40 year-old wait-listed hemodialysis patient in the United States. Scenario analyses were performed to identify determinants of the optimal strategy.

Results: In our base case, the older LD vs. dialysis followed by DD strategies provided comparable projected survival (LE: 16.97 ± 0.52 vs. 16.75 ± 0.20 years), yet older LD was preferred in 62.2% of simulations. In 20 and 60 year-old candidates, dialysis followed by DD was preferable in 91.1% (LE in 20 year-old candidate: 22.76 ± 0.60 vs. 23.50 ± 0.39 years) and 100% (LE in 60 year-old candidate: 11.97 ± 0.49 vs. 13.76 ± 0.36 years) of the simulations. These findings were robust to the length of waiting time until DD transplantation. In contrast to older LD, a 20 year-old LD prolonged life expectancy by 4.5 (LE: 27.24 ± 0.24), 4.8 (LE: 21.70 ± 0.33), and 3.8 (LE: 15.75 ± 0.39) years in 20, 40, and 60 year-old candidates, respectively. When evaluating quality of life, the older LD strategy provided similar gains to dialysis followed by DD in the base case (QALE: 9.24 ± 1.83 vs. 8.82 ± 1.27 QALY), the youngest (QALE: 11.32 ± 1.81 vs. 11.27 ± 1.49 QALY) and oldest (QALE: 6.97 ± 1.42 vs. 7.33 ± 1.04 QALY) candidate age groups. LD was preferable in 75.6%, 56.1% and 23.9% of the simulations in the base case, 20, and 60 year-old candidates, respectively.

Conclusions: The survival advantage associated with LD kidney transplantation is less pronounced with older LD, yet the quality of life gains associated with this procedure are comparable to standard criteria DD transplantation. Our findings suggest consideration of older LD transplantation on a case-by-case basis.

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