Ismail N, Hakim R M, Helderman J H
Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN.
Am J Kidney Dis. 1994 Jan;23(1):1-15. doi: 10.1016/s0272-6386(12)80805-5.
The United States end-stage renal disease (ESRD) population is growing progressively older. As a percentage of the overall ESRD population, the number of patients 65 years of age and older approached 40% by 1989. However, the percentage of ESRD patients with a functioning transplant was only 2.7% in this age group. Success of transplantation in geriatric ESRD patients over the last decade is due to improved patient selection as well as the use of cyclosporine A and lower doses of corticosteroids, with the achievement of 1-year patient and graft survival rates of 85% and 75%, respectively. For patients older than 60 or 65 years, the 5-year "functional" graft survival is 55% to 60%. Although overall results are excellent, the management of transplantation in the elderly requires an understanding of pharmacology, immunology, and physiology peculiar to this age group. Since the elderly have a degree of immune incompetence, they require less aggressive immunotherapy. Elderly patients have decreased hepatic enzyme activity, especially the P450 system, and therefore require a lower cyclosporine dose. Although elderly patients experience less rejection episodes than younger patients, graft loss in the elderly transplant recipient is due mainly to patient death. Most common causes of death in the elderly transplant recipient are cardiovascular disease and infection related to peaks of immunosuppression. Shortage of cadaver kidneys and limited life expectancy of the geriatric ESRD patient make allocation of cadaver kidneys to patients over 70 years (and even 65 years) a controversial issue and an ethical dilemma. Use of elderly cadaver donors (over 55 to 60 years) is associated with inferior success rates and is not an optimal solution to shortage of cadaver kidneys.
美国终末期肾病（ESRD）患者群体的年龄越来越大。到1989年，65岁及以上的患者人数占ESRD患者总数的比例接近40%。然而，该年龄组中具有功能正常移植肾的ESRD患者比例仅为2.7%。过去十年中，老年ESRD患者移植手术的成功得益于患者选择标准的改进以及环孢素A和较低剂量皮质类固醇的使用，患者和移植肾1年生存率分别达到了85%和75%。对于60岁或65岁以上的患者，移植肾5年“功能”生存率为55%至60%。尽管总体结果良好，但老年患者的移植管理需要了解该年龄组特有的药理学、免疫学和生理学知识。由于老年人存在一定程度的免疫功能不全，他们需要的免疫治疗强度较低。老年患者肝酶活性降低，尤其是P450系统，因此需要较低剂量的环孢素。尽管老年患者发生排斥反应的次数比年轻患者少，但老年移植受者的移植肾丢失主要是由于患者死亡。老年移植受者最常见的死亡原因是心血管疾病和与免疫抑制高峰相关的感染。尸体肾短缺以及老年ESRD患者预期寿命有限，使得将尸体肾分配给70岁以上（甚至65岁以上）的患者成为一个有争议的问题和伦理困境。使用老年尸体供者（55至60岁以上）的成功率较低，并非解决尸体肾短缺的最佳办法。
