An old virtue to improve senior programs.

Over the past decades, there have been significant demographic changes in patients awaiting deceased donor kidney transplants, with the largest increases in the > or = 65 year-age group. Because most allograft failures in older recipients are the result of death with a functioning graft, the transplant community has adopted the position that older donor kidneys, with reduced half-lives, often can provide suitable, lifelong function for an elderly recipient. Since 1999, the Eurotransplant Senior Program (ESP) allocates kidneys from donors > or = 65 years, without prospective matching for HLA antigens, to local transplant candidates > or = 65 years. The rationale behind this policy was to expedite the change of the elderly to receive a transplant and to reduce cold ischemia time to prevent ischemic injury and hereby delayed graft function and the increased risk of rejection. Two issues have been identified with the use of old donor kidneys. First, there is an increased incidence of acute interstitial rejection, compared with kidneys from younger donors and secondly, once a rejection episode occurs, the ability to mount a tissue repair process seems impaired. Especially in the elderly, avoiding acute rejection must be balanced against the greater risk of excessive immunosuppression, putting these recipients at higher risk of infection and malignancy. Combined matching for age as well as HLA-DR antigens may further improve the results of Senior Programs.