Older patients receiving vintage organs

Lisa Priest

April 10, 2006

After spending three years on dialysis, Frank Yaffa hadn't even come close to receiving a kidney transplant. So when his doctor suggested he could obtain two organs quicker than one, it sounded too good to pass up.

There was a catch: The organs might come from a donor who was old, a middle-aged diabetic or someone with high blood pressure. Knowing little about the donor, the retired salesman, then 71, underwent a double-kidney transplant at Toronto General Hospital last year.

"If you want to wait for a perfect match, it can take eight to 10 years," said Mr. Yaffa, now 72, of Richmond Hill, north of Toronto. "They gave me two kidneys that may not be perfect, but the two worked as well or better than one."

Although it might sound like the transplant version of a scratch 'n dent sale, doctors say these less-than-ideal organs work well in older patients. The kidneys might be slightly scarred and have less function than their younger counterparts, but they do the job.

Today, hospitals in Ontario, Quebec and Alberta have expanded their pool of potential kidney donors to include seniors, diabetics, stroke victims and people who have suffered the damaging effects of high blood pressure. Hospitals in other provinces are also using older donors on a case-by-case basis, although not necessarily as part of an official program.

"My grandfather is 92 years old; he is still farming; he is still driving a car," transplant surgeon Serdar Yilmaz, medical director of the Southern Alberta Transplant Program, said in a telephone interview from Calgary. "If he dies, I would use his organs."

This past winter, Toronto-based St. Michael's Hospital transplanted kidneys from an 80-year-old into two recipients -- something nephrologist Jeffrey Zaltzman, director of the hospital's renal-transplant program, said he wouldn't have thought possible five years ago.

"Not every 80-year-old kidney is a bad one," Dr. Zaltzman said.

His hospital has been gathering a list of patients 60 or older who would accept such an organ under these "extended-donor" criteria; he expects the program at St. Mike's to be running collaboratively next month with Toronto General Hospital's program.

But doctors aren't stopping at kidneys; old livers also are being used. So, too, are hearts from donors in their 50s and very rarely, from donors aged 60 or older.

Dr. Vivek Rao, Toronto General Hospital's surgical director of cardiac transplantation, has in some cases, performed cardiac bypass surgery on hearts to whip them into shape for transplant.

"Many of our patients would simply die waiting for that perfect heart to arrive," Dr. Rao said in a telephone interview from Toronto.

With the improved use of seatbelts and helmets, the number of young donors has decreased.

As of Dec. 31, 2004, 2,872 people were waiting for kidneys in Canada. In that same year, 55 patients died in the kidney queue, according to Canadian Institute for Health Information figures.

The median waiting-time for a kidney transplant in Canada, tracked from the moment the patient was put on the list, was 3.08 years in 2004, according to Canadian Institute for Health Information. However, it can vary dramatically by province and hospital. Some patients in Toronto, for example, can wait as long as 11 years.

That is longer than some older patients can last. And it has forced doctors to take a harder look at grandparents, diabetics and stroke victims as potential kidney donors.

"We started doing it because we were very sad to see kidneys going into the basket," said Dr. Isabelle Houde, medical director of the transplant unit at Laval University in Quebec City.

Anthony Jevnikar, director of transplant nephrology at London Health Sciences Centre, a hospital that uses extended donor criteria for kidney transplants, put it this way: "I would like to give everybody perfect kidneys. The reality is that's never going to happen."

And, it seems, not every one requires ideal kidneys.

A retrospective study looked at 109,127 patients receiving dialysis in the United States and added to the kidney waiting list from Jan. 1, 1995, to Dec. 31, 2002, and followed up through July 31, 2004. It found those who accepted an expanded-donor-criteria kidney had a 17-per-cent long-term lower risk of dying, compared with those who remained on dialysis or eventually received an ideal organ.

Patients who experienced the greatest survival benefits were those over 40 and patients who would wait more than 44 months for an ideal kidney. For patients younger than 40, there was no significant advantage to accepting a less-than-ideal kidney, according to that Journal of the American Medical Association study, published in December, 2005.

"If you are young and healthy, it's probably better to wait for a better-quality donor," said Dr. Greg Knoll, medical director of renal transplantation at the Ottawa Hospital.

In Canada, the Toronto General Hospital has had the most experience with expanded-donor-criteria transplants; it has used 97 donors who met such criteria for transplant over the past seven years. The mean age of donors was 63.5.

Its success is impressive: the five-year survival rate using expanded-donor-criteria kidneys is 70 per cent, compared with recipients of organs from ideal donors, who have an 82-per-cent survival over the same time period, Dr. Knoll said.

"It's really about balancing the disadvantages of waiting with the disadvantages of an extended-donor-criteria list," said Dr. Edward Cole, director of the division of nephrology and kidney transplantation at Toronto General Hospital. "The truth is we're helping both groups of people."

One of the first patients to receive such kidneys was Fay Saikkonen. She underwent a double-kidney transplant using extended donor criteria in 1997 at Toronto General.

"After I found out they were from an older lady, I didn't feel any different," the 65-year-old said in a telephone interview from Toronto. ". . . Life has been great, fantastic. I've never looked back. I think that everybody should think of signing that donor card."

Margaret Keresteci, manager of clinical registries for the Canadian Institute for Health Information, said 220 people 65 or older donated organs from 2001 to 2004. Of those, 12 were 80 or older. However, most donors -- some 3,228 in the same time period -- were 64 or younger.

"Over time, we're seeing older donors; I would call it a trend," Ms. Keresteci said in a telephone interview from Toronto. "As recipients are older and are getting dialysis, we're also seeing a bigger need for donor organs."

The United States, in particular, has used very old organs.

The oldest liver donor was 92 when the transplant was performed in 2004; the oldest lung donor was 75 in 2003; the oldest kidney donor was 84 when it was done last year, said Annie Moore, spokeswoman for the United Network for Organ Sharing, which administers the only organ procurement and transplantation network in the United States.

"If we make assumptions, then the system never gets challenged," Dr. Dan Zuege, medical director of the southern Alberta Human Organ Procurement and Exchange program said in a telephone interview from Calgary. "The concept of marginal donors would never be in existence if we just said, 'We're only going to look at people under 50.' "

Kimberly Young, chief executive of the Edmonton-based Canadian Council for Donation and Transplantation, said some people believe age is a reason not to donate.

"People say to me, 'You wouldn't want my organs because I am 60,' " Ms. Young said in a telephone interview from Ottawa. "People have these assumptions that as they age, their organs are not transplantable, but that's not just so."

In fact, even if kidney function is 50 to 60 per cent of normal, the organs can be used, typically transplanted as a pair into one patient. Kidneys with greater than 60-per-cent function are placed in two different patients, said Dr. Cole of Toronto General Hospital.

For Mr. Yaffa, whose kidneys were damaged because of a silent infection he had in childhood, it proved to be a great tradeoff. He was able to get off dialysis, and he now feels free and healthy.

"My kidney could have been from a very old person," Mr. Yaffa said. "I'm so grateful -- it's like being born again."

Copyright © 2006 GlobeandMail.com.

This article posted May 13, 2006.