- Design
- Target trial emulation using European registry data
- Population
- 64,036 waitlisted adults on dialysis in five European countries or regions, 2000-2019
- Primary outcome
- Five-year survival, transplantation vs continued dialysis
- Effect
- At age 75, ECD/DCD kidney 59% vs dialysis 55%; HR 0.97 (0.70-1.33)
This study used European Renal Association registry data from Catalonia, Denmark, France, Norway and the UK to emulate a trial of transplantation versus staying on dialysis. It included 64,036 waitlisted adults, of whom 39,244 received a first deceased donor kidney between 2000 and 2019.
Standard-criteria kidneys, from donors after brain death or circulatory death, were associated with better five-year survival than continued dialysis at every recipient age. The advantage of expanded-criteria kidneys shrank with age. At 75, five-year survival after an expanded-criteria kidney from a circulatory death donor was 59% against 55% on dialysis (HR 0.97, 95% CI 0.70 to 1.33), and early post-transplant mortality was three times higher.
Target trial emulation reduces but cannot remove the bias of observational data. The findings support an individual conversation about which kidney offer an older patient should accept, not a cut-off.
- Keep referring suitable older patients on dialysis for transplant assessment; standard-criteria kidneys benefited all ages.
- Discuss the type of donor kidney an older patient would accept before an offer arrives.
- Explain that an expanded-criteria kidney at 75 carries a higher early risk for an uncertain long-term gain.
- Weigh frailty and cardiovascular disease in the discussion; the result at 75 did not differ by diabetes or cardiovascular disease, and frailty was not analysed.
Why it matters
It challenges the assumption that transplantation always beats dialysis, whatever the kidney and whatever the age.
Don't overread it
This is registry data analysed to resemble a trial; it does not show that older patients should be refused transplantation.
The statistics, in plain English
A hazard ratio of 0.97 with an interval from 0.70 to 1.33 means the data cannot tell whether that transplant improves or worsens survival at 75. Older groups were smaller, which widens the uncertainty.
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