Organ donors -- and recipients -- are aging

At 84 years old, Juan Guano would seem an unlikely candidate for a kidney transplant.

But consider this: The kidney he received was 69.

Until recently, that kidney would not have been eligible for use in a transplant, because of the age of the deceased donor. But this summer, surgeons at Northwestern Memorial Hospital transplanted it in Guano, making him among the nation's oldest organ recipients.

His surgery illustrates two intersecting trends in transplant medicine: People 60 and older represent the fastest-growing age group on transplant waiting lists, and kidneys increasingly are being accepted from older people and donors who had health problems before they died.

Organs from these "expanded-criteria donors," which otherwise would be discarded, can give patients like Guano a new lease on life. Guano, a grandfather of five and great-grandfather of six, beams as he recalls being summoned to the hospital on Father's Day for surgery. The octogenarian had undergone six years of dialysis after his kidneys failed.

"I was surprised; I was shocked," Guano said in Spanish as he relaxed in the sunny living room of his art-filled home, surrounded by three of his four children. "I still can't believe it."

Some experts have expressed ethical concerns about using less-than-perfect kidneys for transplants, stressing the need for full disclosure to the recipients.

"The primary reason (for using these kidneys) is to try to get the most out of the existing organs to save lives, but another factor is that transplantation is lucrative," said Arthur Caplan, director of the Center for Bioethics at University of Pennsylvania.

"We have a lot of programs doing transplants, clearly more than the supply of organs justify," he added. "That means people want to save lives but they also push hard to try to use organs of somewhat questionable quality. ... Even an 84-year-old needs to know that (surgeons) are talking about a kidney that they had reservations about."

More than 16,000 kidney transplants were performed nationwide last year, and the current waiting list for kidneys stands at about 81,000. The use of expanded-criteria kidneys has increased about 30 percent since 2002 and now accounts for about 11 percent of all kidney transplants.

Guano got his kidney through Northwestern's Hispanic Transplant Program. Dr. Juan Carlos Caicedo, the program's director, said that of the almost 3,000 kidney transplants performed by Northwestern since 1988, 188 came from donors 65 or older.

"Part of our informed consent process -- and it's very thorough -- is to explain to every patient all the risks and benefits, and they have the last one word," Caicedo said. "They can decide if they want it or if they don't want it."

Patients who accept an expanded-criteria kidney have a shorter wait for an organ and are less likely to die than patients on dialysis.

A recent study published in the Clinical Journal of the American Society of Nephrology found that about half of kidney transplant candidates older than 60 will die before getting a deceased-donor kidney. The risk of dying before transplant was even higher for African-Americans, diabetic patients, those 70 or older and those with blood type B or O.

The down-side of taking an expanded-criteria kidney instead of a standard kidney is a higher risk of organ rejection and death.

"What we are trying to do is have the best match between donor and recipient," Caicedo said. "We don't want to transplant kidneys from young donors into old people or vice versa. We want the match to have the best outcome, making sure the patient and the kidney have the longest survival. In this case, we were able to use an expanded-criteria kidney that probably would not be good for a 20-year-old. And we used a kidney that in many cases would have been thrown away or not used."

The kidney Guano received had been offered to others, who turned it down. Not knowing how much longer he'd have to wait if he said no, Guano recalls telling the doctors: "Yes, I want to take it."

Between 1988 and the end of June, nine people 86 or older got kidney transplants from a deceased donor in the U.S.; two received kidneys from living donors. Still waiting are about 150 people between 81 and 85, and about a dozen people 86 or older.

The transplant waiting list is aging because people are living longer and developing diseases like diabetes and hypertension that lead to chronic disease and eventually end-stage organ failure, said Dr. John Friedewald, vice chairman of the kidney allocation committee of United Network for Organ Sharing, which oversees the nation's transplant system.

But the donor pool is much younger, he said, creating a mismatch.

There is no automatic age cutoff on the waiting list for a kidney. Transplant centers decide whom to add to the list and which donor organs to accept, and the criteria they use vary, said Dr. Robert Higgins, president of UNOS and chairman of heart transplantation at Rush University Medical Center.

Guano's daughter Sonia said several Chicago hospitals had turned him away, but his family kept searching.

Older people typically have more risk factors that can complicate surgery, including hypertension, diabetes, obesity and arteriosclerosis. But they generally are not ruled out for transplant solely on the basis of age.

"You could be a young 65 or you can be an old 25-year-old," Caicedo said. "Sometimes you have a 65- to 70-year-old patient who is very young in spirit and attitude and they can have multiple medical problems, but they are motivated. ... Mental attitude is so important here. It's not the chronological age."

Guano went home two days after the transplant. Two days later, he was back to working on his series of 12 Christian-inspired sculptures called "Los Hijos del Sol," or "Children of the Sun." A retired furniture factory worker and accomplished sculptor, he emigrated to the U.S. from Ecuador 33 years ago and became a citizen about a dozen years ago.

On a recent day, Guano chatted about his active life as he carried a clay model of a sculpture to his simply adorned living room, decorated with lace curtains, family photos, several Santa Claus figures and a small Ecuadorean flag. He was animated as he spoke of his desire to exhibit his art and one day meet his donor's family.

High blood pressure destroyed his original kidneys. But Guano was in otherwise good health before the transplant. Caicedo said a transplant offered him a better quality of life than dialysis, and possibly a longer life.

"He was in great shape," Caicedo said. "He could live five, 10 years more."

Medicare, which paid for Guano's surgery, covers transplant costs if the patient is over 65, including anti-rejection medications.

Higgins said Northwestern should be applauded for using expanded-criteria kidneys to expand the donor pool.

"In the long run, we know for any patient a transplant is better than staying on dialysis," he said. "The question that arises in a cost-constrained environment is how health care expenditures should be utilized in situations like this. That's a larger question that I think lies in the medical and regulatory community and on the policy development side, and it's not a simple answer."
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