Abstract
Background:
Chronic Kidney Disease (CKD) has become a significant global health issue, especially among the aging population. Renal transplantation is considered the most effective treatment for end-stage renal disease (ESRD), yet disparities exist in its accessibility and outcomes across different regions.
Objectives:
This study aimed to compare the perspectives and outcomes of renal transplantation in adult and geriatric patients with CKD in Europe and Indonesia, highlighting differences in healthcare systems, patient management, and socio-cultural considerations.
Methods:
A literature review was conducted using PubMed, ScienceDirect, and Google Scholar, focusing on publications from the last 10 years. Studies involving adult and elderly CKD patients undergoing renal transplantation in both Europe and Indonesia were analyzed for themes related to access, outcomes, quality of life, and post-transplant management.
Results:
European countries generally demonstrated more structured transplantation programs, better post-operative care, and higher graft survival rates due to strong infrastructure and funding. In contrast, Indonesian patients faced challenges such as limited donor availability, economic constraints, and lower awareness about transplantation. Geriatric patients in both regions exhibited more complications post-transplantation compared to younger adults, but still benefited in terms of survival and quality of life.
Discussion:
Disparities between Europe and Indonesia in renal transplantation stem from differences in healthcare access, government support, and patient education. Cultural and ethical issues also influence organ donation rates. Despite challenges, renal transplantation remains a viable option for geriatric patients, especially with proper selection and monitoring.
Conclusion:
While renal transplantation offers improved outcomes for CKD patients globally, substantial disparities remain between regions. Efforts to enhance transplantation programs in developing countries like Indonesia are crucial, especially in addressing the needs of the aging population.
Keywords: Chronic Kidney Disease, Renal Transplantation, Geriatric, Europe, Indonesia
1. BACKGROUND
Kidney transplantation is indicated for end-stage renal disease (ESRD), which is considered the preferred treatment modality (1). The history of kidney transplantation dates back to 1939, when Yurii Voronoy in Russia attempted the first human transplant using a deceased donor kidney, though the transplant was unsuccessful. A milestone was reached in 1953 when Jean Hamburger temporarily restored kidney function in a 16-year-old boy using a graft from his mother. The first successful long-term kidney transplant was achieved by Joseph Murray in monozygotic twins, with the graft surviving for eight years (2). Despite global advancements, only about 10% of patients requiring kidney transplantation receive it. Contributing factors include a shortage of organ donors, limited transplantation experts, inadequate infrastructure, religious concerns, and patient hesitancy, especially in low- and middle-income countries (3).
Kidney transplantation offers significantly better outcomes for ESRD patients compared to dialysis. Quality of life indicators improve notably post-transplantation, with more pronounced benefits seen in patients previously on hemodialysis rather than peritoneal dialysis (4). Furthermore, transplant recipients demonstrate better survival rates and, when using living donors or low Kidney Donor Profile Index (KDPI) deceased donors, the procedure proves more cost-effective than dialysis (5). Even high KDPI or incompatible donors can still be cost-effective, emphasizing the importance of optimizing factors influencing graft survival, such as immunosuppressive strategies (6).
2. OBJECTIVE
This review aims to analyze global perspectives on kidney transplantation in ESRD patients, with a specific focus on comparing adult and geriatric populations in Europe and Indonesia.
3. MATERIAL AND METHODS
This study employs a systematic review approach to explore global perspectives on patients with chronic kidney disease (CKD) who have undergone renal transplantation in Europe and Indonesia, focusing on adult and geriatric populations. The systematic review method was chosen as it allows for the comprehensive collection and analysis of data from various relevant studies, providing more robust conclusions on the topic. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we integrated findings from articles published between 2022 and 2025. The primary focus of this study is to compare the conditions of CKD patients undergoing renal transplantation in these two geographical regions, taking into account patient characteristics in both adult and geriatric groups.
Studies included in this review must meet the following inclusion criteria: publications indexed in PubMed, Cochrane, or Q1 medical journals; articles published between 2022 and 2025; studies involving CKD patients who have undergone renal transplantation in Europe or Indonesia; and studies reporting data on adult and geriatric patients, specifically regarding transplantation outcomes, complications, and post-transplant quality of life. Studies that are excluded from the review are those that are not directly related to renal transplantation in CKD patients, those involving populations other than adults or geriatrics, and those that are not available in full text or accessible via PubMed, Cochrane, or international reputable journals. Additionally, studies published in languages other than English or Indonesian are excluded.
Data were sourced from three main databases: PubMed, Cochrane Library, and Q1 medical journals. The search strategy included keywords related to renal transplantation, CKD, adult and geriatric patients, as well as geographic regions in Europe and Indonesia. Examples of search terms used included “renal transplantation in CKD”, “chronic kidney disease adult”, “geriatrics kidney transplant”, “outcomes renal transplantation Europe”, “Indonesia kidney transplant patients”, “global perspectives on renal transplantation”, and “CKD management in Europe and Indonesia”. The search was conducted using Boolean operators (“AND”, “OR”) to refine or expand the results.
The literature search was conducted between January and February 2025 to ensure the inclusion of the most recent studies. Articles published after this period were not included in the analysis. The selection process was performed in stages. First, the titles and abstracts of articles were screened for relevance to the topic. Relevant articles were then downloaded and thoroughly reviewed by two independent assessors to ensure they met the methodological criteria and reporting quality. Discrepancies between assessors were resolved through discussion or consultation with an expert in research methodology.
The methodological quality of each study was assessed using appropriate risk-of-bias tools, such as the Cochrane risk-of-bias tool for experimental studies or the Newcastle-Ottawa Scale for observational studies. Each study was evaluated based on criteria such as research design, sampling methods, control for confounders, and data analysis techniques. Studies deemed to have a high risk of bias were excluded to ensure the validity of the systematic review’s results.
Data extraction focused on the following information: study identity (title, authors, publication year, country or region of research), participant characteristics (sample size, average age, sex distribution, health status, stage of CKD, and indications for renal transplantation), study methodology (research design, sample size, data collection methods, and analysis techniques), key outcomes (post-transplant quality of life, graft survival rates, post-transplant complications, differences between adult and geriatric groups, and comparisons between Europe and Indonesia), and study conclusions (main findings and their implications for patient care and transplantation policies).
After data extraction, a descriptive analysis was performed to summarize the main findings from each study. Differences in outcomes between studies conducted in Europe and Indonesia were analyzed qualitatively to determine whether there were significant regional variations in approaches to renal transplantation in CKD patients, particularly in adult and geriatric populations. This analysis considered factors such as healthcare systems, availability of medications, and transplantation policies in each region.
The results of this systematic review will be presented in tables and graphs that summarize study characteristics, key outcomes, and regional comparisons. The main findings will be summarized narratively to provide a deeper understanding of the conditions of CKD patients undergoing renal transplantation in both Europe and Indonesia, with a focus on adult and geriatric population
4. RESULTS
Study selection & characteristics
Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we conducted a comprehensive search across multiple databases, yielding 1,637 articles. After removing duplicates and applying our predefined inclusion and exclusion criteria, we narrowed this down to 225 titles for further consideration. Subsequently, we screened the abstracts of these 225 titles, selecting 62 for abstract and detailed evaluation. Of these, 10 studies were deemed appropriate for full-text review. However, only 8 of these studies were available in full-text format and were included in our final analysis. This selection process is visually represented in a PRISMA flow diagram, which details the number of records identified, included, and excluded at each stage, along with the reasons for exclusions. In our systematic review, we ultimately included eight studies that met our predefined criteria. These studies spanned two distinct regions, with five conducted in Europe and three in Indonesia, and most of them employed retrospective cohort designs. Collectively, the studies provided data on more than 61,000 renal transplant patients, offering a broad perspective on the subject.
Table 1. Study characteristics.
| No | Reference Study | Study Design | Country/Regions | Sample Size | Average Age | Sex Distribution | Data Collection Methods |
|---|---|---|---|---|---|---|---|
| 1 | Liu et al2023 | Retrospective study | Europe | 740 | NS | NS | Clinical records |
| 2 | Grosyeux. 2024 | Comparative study | Europe | 59 | 29 years (IQR, 16.0–46.0 | NS | Assessment of GFR using iohexol-based measurement |
| 3 | Hakeem. et al. 2024 | Retrospective cohort | United Kingdom | 12.000 | NS | NS | UK Transplant Registry analysis |
| 4 | Yunantoet al.2022 | Prospective Cohort | Indonesia | 33 | 44 | 24/9 | Clinical records |
| 5 | Hustrini et al. 2023 | Cross-sectional | Indonesia | 281 | 52 | NS | Clinical records |
| 6 | Situmorang et al. 2023 | Retrospective Cohort | Indonesia | 752 | 33 | 538/214 | Clinical records(single center) |
| 7 | Mageri et al. 2023 | Retrospective Cohort | Europe | 491 | 58 | 326/165 | Clinical records |
| 8 | Huijben et al2023 | Prospective Cohort | Europe | 28 159 | NS | NS | ERA registry |
Table 2. Outcome and characteristics of kidney transplant in CKD.
| No | Reference Study | Post-Transplant Quality of Life | Graft Survival Rates | Post-Transplant Complications | Health Status | Main Findings | Differences Between Adult and Geriatric Groups | Comparisons Between Europe and Indonesia | Implications |
|---|---|---|---|---|---|---|---|---|---|
| 1 | Liu et al2023 | N/A | Comparable 1-year patient survival and death-censored graft survival | Increased risk of DGF in AKI groups (34.1% pediatric, 38.5% adult | CKD patients | Pediatric AKI kidneys show superior recovery of allograft function compared to adult AKI kidneys | N/A | N/A | utilizing pediatric AKI donors to reduce waiting-list mortality. |
| 2 | Grosyeux. 2024 | N/A | N/A | N/A | Kidney transplant patients and non-kidney transplant patients | The EKFC equation showed less bias in estimating GFR compared to CKD-EPI/CKiD equations among kidney transplant patients. Renal transplant status significantly influenced estimation bias. | N/A | N/A | Accurate GFR estimation is crucial for managing kidney transplant patients, suggesting the need for tailored equations in clinical practice. |
| 3 | Hakeem. et al. 2024 | N/A | Significantly inferior long-term allograft outcomes for Asian and black donors compared to white donors | N/A | N/A | Asian and black donor-recipient pairs have poorer graft outcomes compared to white counterparts. Increased deceased donation among ethnic minorities could enhance the recipient pool and improve outcomes. | N/A | N/A | Need for refined approaches to increase organ donation from ethnic minorities to improve transplant outcomes. |
| 4 | Yunanto et al.2022 | overall quality of life is increased and remain stable during follow up months compared to pre-operative | N/A | N/A | CKD patients | Overall quality of life shown gain between pre-transplant and months post transplant | N/A | N/A | Kidney transplant subjectively increase the quality of life in patient with CKD, higher transplant volume is needed. |
| 5 | Hustrini et al. 2023 | N/A | N/A | N/A | N/A | Diabetes, Glomerulonephritis, and Hypertension are the most common etiologies patient developing CKD needed RRT in Indonesia | N/A | the leading cause of CKD almost similar with EU region. with diabetes being the most common | multi-discipline treatment is necessary to prevent Chronic kidney disease |
| 6 | Situmorang et al. 2023 | N/A | One-Year:Patient survival rate: 96%Graft survival rate 97% | The mortality rate is higher in the DGF group | Single Renal Artery vs Multiple Renal Artery | there is no difference in SRA vs MRA renal transplant method; the DGF group showed lower 1 year survival | N/A | the results (One-year graft survival, and patient survival) is consistent with Europe results | There is no difference between SRA and MRA in kidney transplants. dialysis time before patient undergo KT has no significant effect. |
| 7 | Mageri et al. 2023 | N/A | 3 year & 5 year graft survival rate (donor age)<60: 87% & 78%60-70: 85 & 76 %>70: 84 & 66 %graft loss: 57 (11.6%) | N/A | N/A | HLA-antibodies presence being the most significant predictor of graft loss compared to other factor | There is no significant difference in graft survival between age groups, very old donor had lower graft rejection rate but with lower graft function | N/A | kidney transplantation from very old donors seems to be a valid option. |
| 8 | Huijben et al2023 | N/A | 1, 2, and 5 years survivalPatient survival rate: 96.8%, 94.9%, 88.3%Graft survival rate 92.3%, 89.5%, 80.2% | N/A | Kidney transplant patients and Dialysis patient | Increased prevalence of the KT in the elderly groups (>65 years) in several regions, better transplant outcome over years. | Younger transplant recipient shown better results overall. older transplant shown better results recently | The incidence and graft survival rate is relevant to indonesia recent reports | although the improved outcomes. further increase in theprevalence of KRT means higher high-quality transplant rates are needed. |
Regarding patient demographics, while three of the studies did not specify age groups, the reported average age across the studies was approximately 43 years. In terms of gender distribution, only three studies provided detailed data; within these studies, males predominated, comprising about 69.5% of the study population.
5. DISCUSSION
The study by Yunanto et al. (2022) represents renal transplantation for chronic kidney disease (CKD) patients in Europe and Indonesia, presenting a complex picture that reflects both advancements and challenges in each region. In Indonesia, a study conducted at Cipto Mangunkusumo Hospital revealed significant improvements in the quality of life (QoL) for kidney transplant recipients, with median QoL scores increasing from 50% preoperatively to 90% one month post-surgery (7). This improvement underscores the effectiveness of kidney transplantation as a treatment for end-stage renal disease, offering patients enhanced physical and emotional well-being compared to those on dialysis. However, the study also highlighted systemic issues, such as limited access to transplantation services and financial burdens that disproportionately affect older adults and those from lower socio-economic backgrounds.
In contrast, European studies have demonstrated high success rates in kidney transplantation, particularly among pediatric and young adult populations (8). Research indicates that kidneys from deceased donors with acute kidney injury (AKI) can yield favorable outcomes, with comparable graft survival rates to those from non-AKI donors (8). This is particularly relevant as it expands the donor pool, addressing the critical shortage of available organs. For instance, a study in France found that the EKFC equation for estimating glomerular filtration rate (GFR) outperformed traditional methods, providing more accurate assessments for kidney transplant recipients (9). This advancement is crucial for optimizing post-transplant care and improving long-term outcomes.
Despite these advancements, disparities remain. In Europe, the integration of robust healthcare policies and support systems facilitates better post-transplant care, including mental health support and structured follow-up programs (9). Conversely, Indonesia’s fragmented healthcare system often lacks these essential services, which can adversely affect patient outcomes and QoL. Furthermore, the psychological impact of transplantation is often overlooked in Indonesia, where cultural factors may inhibit open discussions about mental health and emotional support (9). The need for tailored strategies to bridge these gaps is evident. Enhancing donor registries, improving patient education, and advocating for policy reforms are critical steps toward achieving equitable access to kidney transplantation in both regions. Future research should focus on longitudinal studies that assess the long-term impacts of transplantation on QoL and explore the socio-economic factors influencing access to care in both Europe and Indonesia.
A study analyzing data from the UK Transplant Registry highlighted that while Asian and Black patients constituted 12.4% and 6.7% of all deceased donor recipients, they represented only 1.6% and 1.2% of all deceased donors, respectively (10). Moreover, the outcomes of renal transplants differ significantly based on donor-recipient ethnicity combinations. For instance, graft survival rates were notably lower for Black donor-Black recipient pairs compared to those involving White donors, indicating that ethnic matching plays a crucial role in transplant success (10). This disparity is not merely a statistical anomaly; it reflects underlying health issues prevalent in these populations, such as higher rates of hypertension and diabetes, which can adversely affect transplant outcomes (10). In Indonesia, similar challenges are observed, where cultural beliefs and lack of awareness about organ donation contribute to the low rates of deceased donations. Efforts to promote organ donation within the Indonesian context must consider these cultural nuances to improve access for CKD patients. The integration of community education programs and partnerships with local health organizations could enhance awareness and acceptance of organ donation, thereby increasing the donor pool.
Figure 1. PRISMA flow diagram.
The following studies further illustrate these findings: Liu et al. reported that pediatric AKI kidneys exhibit superior recovery of allograft function compared to adult counterparts, offering significant implications for reducing waiting-list mortality (8). Grosyeux et al. demonstrated that the EKFC equation showed less bias in estimating GFR in transplant patients compared to CKD-EPI and CKiD equations (9). Hakeem et al. emphasized significantly poorer long-term outcomes for Asian and Black donor-recipient pairs, underscoring the need for greater representation of minority donors (10).
In Indonesia, the literature on kidney transplantation remains limited. Among available studies, Yunanto et al. remains the only investigation to assess QoL changes before and after transplantation, revealing substantial improvements in long-term well-being (7). Hustrini et al. explored the etiology of CKD among transplant recipients, identifying patterns similar to global trends (11). Meanwhile, Situmorang et al. provided survival data, showing one-year graft and patient survival rates of 97% and 96%, respectively, with no significant differences between patients with single renal artery (SRA) and multiple renal arteries (MRA), aligning Indonesian outcomes with those in Europe (12).
European data from Mageri et al. and Huijben et al. further contribute by profiling transplant recipients and analyzing the impact of age, noting that younger patients fare better, although improved surgical and postoperative care have boosted outcomes among older patients as well (13,14).
6. CONCLUSION
Kidney transplantation significantly improves survival and quality of life for patients with end-stage renal disease. While European countries have optimized outcomes through robust systems and innovations, Indonesia continues to face challenges related to access, infrastructure, and public awareness. Bridging this disparity requires targeted strategies—expanding donor registries, improving patient education, adopting accurate renal monitoring tools, and addressing socioeconomic barriers. Aligning global best practices with local health policy is essential to ensure equitable, high-quality transplant care across diverse settings.
Author’s contribution:
The all authors were involved in all steps of preparation this article, including final proofreading.
Conflicts of interest:
There are no conflicts of interest.
Financial support and sponsorship:
This research did not receive any specific grant from funding agencies in the public, commercial, or notfor-profit sectors.
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