Individualized Decision-Making and Outcomes for the 87-Year-Old Living Kidney Donor: A Case Report

Abstract

Introduction

Latvia faces a challenging shortage of available kidney donors, leading to a significant mismatch between demand for kidney transplantation and supply. Although older adult donors require a thorough pre-donation workup to rule out significant medical comorbidities, it offers hope for potential kidney transplantation candidates.

Case Presentation

This case study presents the unique scenario of an 87-year-old living kidney donor, where individualized decision-making resulted in outstanding outcomes for both the donor and recipient.

Conclusions

The initial assessment for donation, which involves renal scintigraphy, serves as a preventive measure. In cases where one of the kidneys exhibits insufficient function, this approach avoids the necessity for further costly tests, thus preserving resources in the healthcare budget. The decision concerning an older donor should undergo thorough discussion by a multidisciplinary team to minimize perioperative and long-term risks. Nonetheless, a thoughtful approach to elderly donors offers a valuable opportunity to expand the living donor pool in the context of the organ shortage problem.

Introduction

The shortage of available donor organs available in Latvia results in a significant gap between the demand for kidney transplantation (KTx) among end-stage renal disease (ESRD) patients and the supply. However, KTx is the most advantageous approach to improving the quality of life of patients and cost-effectiveness in healthcare [1]. We present a case of elderly living kidney transplantation, where individualized decision-making led to outstanding outcomes for both the donor and recipient. The CARE Checklist has been completed by the authors for this case report, attached as online supplementary material (for all online suppl. material, see https://doi.org/10.1159/000539772).

Case Presentation

An amateur cyclist aged 87 years and 2 months (height = 174 cm, weight = 78 kg, body mass index 25.8 kg/m², O rhesus positive) presented to our clinic as a candidate for a living kidney donor for his 54-year-old son, who was about to undergo his third kidney transplantation due to ESRD secondary to IgA nephropathy. The recipient underwent hemodialysis 3 times weekly. Pre-transplantation, the blood pressure was 160/90 mm Hg, with creatinine levels at 546 μmol/L, urea at 21.6 mmol/L, uric acid at 81 μmol/L, total protein at 66 g/L, albumin at 41 g/L, potassium at 4.01 mmol/L, calcium at 2.36 mmol/L, phosphorus at 2.02 mmol/L, PTH at 28.22 pmol/L, and proteinuria of 1.5 g as indicated by a urine strip test. The donor’s medical history was unremarkable except for primary arterial hypertension (PAH), which was successfully managed by oral perindopril 8 mg and indapamide 2.5 mg once a day. As a part of the current pre-transplant routine, technetium-99 m diethylene triamine penta-acetic acid renal dynamic scintigraphy confirmed excellent renal function with an isotopic glomerular filtration rate (GFR) of 93 mL/min, with the left kidney’s GFR at 41.2 mL/min and the right kidney’s GFR at 51.9 mL/min (shown in Fig. 1a), the chest radiographs were normal. The upper gastrointestinal endoscopy showed a positive test for H. pylori, which was subsequently treated. The donor and recipient work-up process confirmed compatibility of the ABO blood group, and human leukocyte antigens matched 4/8; the CDC crossmatch was negative. The complete blood count, biochemistry and urinalysis were within normal limits, no proteinuria; the creatinine was 73 μmol/L, the cystatin C was 0.9 mg/L with estimated GFR (eGFR) of 89 mL/min/1.73 m² by CKD-EPI Creatinine-Cystatin C Equation (2021). The abdominal vascular anatomy was examined using computerized tomography (CT) angiography, which revealed a proximal 60–70% stenosis in the right renal artery (Fig. 1b) and a normal CT urogram. Additionally, an abdominal CT scan was performed, showing benign prostatic hyperplasia, and the prostate specific antigen level was measured at 0.59 ng/mL A comprehensive cardiac examination revealed a first-degree atrioventricular block on an electrocardiogram. During a treadmill stress test, ventricular bigeminy was observed for the first time. For the first time in his life, paroxysmal atrial flutter and fibrillation were recorded during transthoracic echocardiography. The patient promptly received a daily dose of 60 mg oral edoxaban. Coronary angiography did not show coronary lesions.

Fig. 1.

Kidney examination of a living kidney donor. The result of the renal scintigraphy (a). Pretransplant CT angiography showing renalis dextra stenosis (a) (white arrow, b). c The renal allograft biopsy shows minor and nonspecific changes.

Despite the unilateral renovascular abnormality, the clinician team and the patient engaged in a shared decision-making process, considering the increased future risk of the donor, and ultimately opted to move forward with the donation. The donor underwent an open right side nephrectomy with a 12 cm long pararectal laparotomy incision in right epigastrium, with total preservation of peritoneum and peritoneal cavity, operation lasted 4 h 15 min; the intraoperative and early postoperative period was without complications. Edoxaban was discontinued 24 h prior to the nephrectomy, and at that time, the patient was administered a low molecular weight heparin (LWMH) 9,500 IU. Intraoperative and postoperative patient care included the use of opioid-based analgesia, monitoring and regulating fluid balance, and anti-thromboembolic prophylaxis with heparin 2,500 units. No complications were recorded. Subsequently, it was transitioned to LWMH for 1 day and then back to edoxaban. The creatinine level at discharge was 137 μmol/L, cystatin C 1.48 mg/L, and the eGFR of 44 mL/min/1.73 m² by CKD-EPI Creatinine-Cystatin C Equation (Fig. 2). The PAH was controlled during the postoperative period. The kidney graft biopsy was performed post-revascularization during the operation. Upon histopathological examination of the renal allograft biopsy, nine glomeruli were observed, one of them globally sclerosed. Pathological changes in the glomeruli, interstitium, or blood vessels were not observed (Fig. 1c).

Fig. 2.

The dynamic of the creatinine and eGFR of the donor and the recipient. The function of both the donor’s and recipient’s kidneys stayed constant after 1 and 2 years.

One year and 2 years later, the function of the left kidney remained stable, with creatinine levels of 118 and 129 μmol/L, respectively, and eGFR of 51 mL/min/1.73 m² and 46 mL/min/1.73 m² (Fig. 2), proteinuria was not observed. One and 2 years after the kidney transplant, the recipient’s kidney function was with creatinine levels of 149 and 169 μmol/L, respectively, and eGFR of 48 and 41 mL/min/1.73 m² (Fig. 2), proteinuria was not detected.

Discussion

We want to highlight here a case in which an elderly donor who met the extended criteria for live kidney donation remains in good general health 2 years after the kidney donation, which could serve as an encouragement for future KTx candidates. Advanced age should not automatically disqualify someone from donating. Still, careful assessment of the cardiovascular status before the surgery is essential to prevent severe complications and a prolonged hospital stay. The available data present 2 case reports of living kidney donors over the age of 85, each highlighting various aspects of managing elderly individuals during the living kidney donation process [2, 3]. The uniqueness of the case report lies not only in the age of the donor but also in the comorbidities that might have adversely affected the donor’s outcome. However, thorough assessment of co-existing risk factors preoperatively, along with available literature data on the positive aspects of elderly living donation and the great courage to shorten the waiting time for kidney transplantation of the recipient, led to good control of all possible risk factors during the acute period and long term. The identification of right renal artery stenosis during pre-transplantation screening and the administration of perindopril did not significantly affect renal function. Therefore, excluding other risk factors was sufficient to deem this donor appropriate.

According to the European Society of Cardiology, Latvia is classified as a country with a very high risk for both fatal and non-fatal cardiovascular diseases [4]. The recent report has shown that arterial hypertension affects one third of the population with high proportion of underestimation of this medical condition [5]. The exact proportion of target organ damage remains uncertain. However, the data available so far indicates that in older living kidney donors with PAH, hypertension has no significant effect on the annual decline in eGFR and the survival of the allograft [6, 7]. Currently, there is no evidence indicating that older living kidney donors have greater risk of cardiovascular diseases or mortality compared to a matched population [8, 9]. Moreover, the existing data on the quality of life of elderly donors demonstrate even more favorable outcomes when compared to younger living donors [10]. Long-term monitoring, including the regular evaluation of biomarkers of kidney function, urine analysis, microalbuminuria screening, and the assessment of cardiovascular disease risk, should occur at least annually or in response to any patient-reported complaints.

In 2021, the rate of KTx from living donors in Latvia was among the lowest in Europe, with an annual rate of 1.1 per million people, and this rate has been consistently decreasing over the past few years [11]. However, the annual KTx over the past 5 years hovers at approximately 20 per 1 million population, with a 17% increase until 2022. It must be acknowledged that the number of transplants in 2021 has declined, as is the case elsewhere in the world, due to the ongoing COVID-19 pandemic. Expanding the criteria for living kidney donors is essential to allow KTx for patients with ESRD and highly sensitized recipients. In this case, the recipient was awaiting his third KTx, highly sensitized, and already undergoing hemodialysis. Given the limited availability of deceased donors in Latvia, he may experience a prolonged wait for a kidney transplant, further exacerbating his medical condition. The strong desire of both the donor and recipient to proceed with the transplant from the father was reinforced by their positive experience with a previous KTx from the mother. These factors were further supported by recent published findings suggesting that an older donor is a preferable option for the recipient compared to an extended spectrum kidney donor or any form of dialysis [8]. The numerous discussions involving the multidisciplinary team of medical professionals, as well as the donor and recipient, demonstrated the donor’s determination to undergo the nephrectomy, despite concerns regarding perioperative risks.

The initial screening before donation also includes renal scintigraphy. When one of the kidneys shows inadequate function, this step prevents the need for additional expensive tests and saves a healthcare budget. The cornerstone of our center for living kidney donors is to investigate clinically significant abnormalities in other organ systems. This approach is crucial to prevent major complications after donation. The personalized decision for an older donor should be discussed by a multidisciplinary team, and more data should be collected regarding elderly donors and outcomes after KTx. Nevertheless, presenting such patient medical data could also boost awareness and a greater willingness to accept elderly donors.

Acknowledgments

The authors are immensely thankful to the Surgery and Nephrology nursing team, anesthesiologists, and the laboratory at the Pauls Stradins Clinical University hospital for their invaluable support. Prof. Justinas Besusparis, MD, PhD, kindly provided the biopsy result.

Statement of Ethics

This retrospective review of patient data did not require ethical approval in accordance with local guidelines. Written informed consent was obtained from the patient for publication of the details of their medical case and any accompanying images.

Conflict of Interest Statement

The authors have no conflicts of interest to declare.

Funding Sources

No funding was received to assist with the preparation of this manuscript.

Author Contributions

D.K. and I.Z. takes responsibility for the content of the manuscript, including the data and analysis. D.K. was a major contributor in writing the manuscript. V.K., J.J., V.M., V.S., A.P., and I.Z. were involved in preparation of the draft manuscript, and critical revision, and approval of the final manuscript. J.J. and V.S. performed the kidney transplantation surgery. All authors read and approved the final manuscript.

Funding Statement

No funding was received to assist with the preparation of this manuscript.

Data Availability Statement

All data underlying the results are available as part of the article or upon request from the corresponding author. The data that support the findings of this study are not publicly available due to their containing information that could compromise the privacy of research participants but are available from the corresponding author D.K.