As Japan’s society ages, there is a concurrent increase in the aging of patients requiring renal replacement therapy. Additionally, the demographic of patients seeking kidney transplants is also becoming older. Elderly patients with renal failure often present with various comorbidities, and we should discuss the eligibility criteria for kidney transplantation. Nevertheless, even in advanced age, it is evident that undergoing a kidney transplant yields a better prognosis for patient survival compared to continuing dialysis. Therefore, unless there are specific contraindications, the option of kidney transplantation should not be excluded solely based on age. In this paper, we aim to provide an explanation of the indications for kidney transplantation in elderly patients, as well as discuss the post-transplant management. Our goal is to contemplate the improvement of outcomes in elderly kidney transplant recipients.

Japan is experiencing a super-aging society unlike any other in the world. More than half of the living donor kidney transplants carried out in Japan in 2021 were from donors over 60 years old. Many reports indicate that there is no difference in short-term graft survival rates between elderly and young donors. GFR declines with age, but the rate of decline is relatively slow in elderly Japanese people. When evaluating renal function in elderly patients, it is important to note that the discrepancy between serum creatinine levels and GFR is larger than in younger patients. Elderly people may have various comorbidities in addition to age-related decline in renal function, so multidisciplinary evaluation is necessary to determine donor eligibility. After kidney donation, it is necessary to monitor GFR, blood pressure, weight, and presence of proteinuria, as well as promote a healthy lifestyle such as exercise, diet, and smoking cessation, as well as cancer screening and cognitive function evaluation.

Kidney transplantation is the renal replacement therapy of choice for most of the patients with end-stage renal disease (ESRD). It improves quality of life and life expectancy, and imposes a lower financial burden on the healthcare system in comparison to dialysis. Every year more and more older patients are among those receiving transplanted kidneys.

However, new challenges in older kidney transplant recipients include frailty and sarcopenia. Frailty and sarcopenia are interrelated complex geriatric syndromes that are linked to aging, comorbidities, increased mortality, and graft failure post-transplantation.

Chronic kidney disease (CKD) and more importantly ESRD are characterized by multiple metabolic complications that contribute for the development of frailty and sarcopenia.

Similarly, frailty and sarcopenia are important risk factors related to graft function and mortality in kidney transplant recipients.

However, both frailty and sarcopenia are considered to be reversible.

Frail and sarcopenia in kidney transplant recipients respond well to multiprofessional interventions that focus on the patients’ positive frailty criteria, while kidney rehabilitation may improve frailty and sarcopenia. Prospective studies are still needed to evaluate the utility of formally measuring frailty and sarcopenia in the older candidates to renal transplantation as part of the transplant evaluation process.

The number of elderly patients with end-stage kidney disease (ESKD) is increasing due to the aging society. Renal replacement therapy includes dialysis and kidney transplantation, but elderly patients with ESKD may have physical, emotional, and social difficulties in making appropriate choices. Recently, new treatment options such as conservative kidney management have garnered attention all over the world.

Decision support for end-of-life care may be considered for elderly patients with ESKD. Shared Decision Making is also important for elderly patients with ESKD, and we describe what kind of decision support should be provided.

According to the statistical survey of the Japanese Society for Dialysis Therapy (JSDT) in 2022, the average age of dialysis patients in Japan was 69.87 years, and although the average age is getting older every year, the number of patients under 65 years of age has been decreasing since 2012, and the number of patients under 70 years of age has been decreasing since 2017. This means that the increase in the number of dialysis patients in Japan is due to the increase in the number of patients over 70 years of age. This is also evident in the age of initiation, with the average age of initiation patients in 2022 being 71.42 years, indicating that patients are getting older every year. In other words, the majority of dialysis patients we see in our daily practice are already elderly. Next, regarding the modality of dialysis therapy, if we consider only the elderly patients over 70 years old, 97.7% of the patients in the 2021 survey were HD and 2.3% were PD, showing a slight tendency toward HD (calculated from the 2021 data using the WADDA system of JSDT). The treatment of elderly dialysis patients requires the participation of various professionals in addition to dialysis specialists and dialysis staff, and it is important to make good use of the government to establish a comprehensive regional medical care system.

As of December 31, 2022, a total of 11,261 liver transplants had been performed in 70 institutions in Japan. There were 804 deceased donor transplants (801 from heart-beating donors and 3 from non-heart-beating donors) and 10,457 living-donor transplants. The annual total of liver transplants in 2022 was 422. Deceased-donor transplants increased to 86 in 2022 from 60 in 2021. The most frequent indication was cholestatic disease, followed by hepatocellular disease and neoplastic disease. As for hepatocellular disease in 2022, alcoholic cirrhosis and non-alcoholic steatohepatitis were the most common. Patient survival following transplantation from heart-beating donors (801 transplants: 1-year 89.4%, 3-year 86.9%, 5-year 83.8%, 10-year 76.2%, 15-year 67.9%, 20-year 54.8%) was similar to that from living-donors (10,457 transplants: 1-year 85.9%, 3-year 82.2%, 5-year 79.7%, 10-year 74.7%, 15-year 69.7%, 20-year 64.9%, 25-year 61.6%, 30-year 58.6%). Graft survival was very much the same as patient survival (heart-beating donor: 1-year 88.9%, 3-year 86.2%, 5-year 83.2%, 10-year 75.6%, 15-year 67.2%, 20-year 54.3%; living-donor: 1-year 85.3%, 3-year 81.2%, 5-year 78.6%, 10-year 73.0%, 15-year 67.5%, 20-year 62.3%, 25-year 58.9%, 30-year 56.0%). Survival data are reported according to age and sex of recipient, indication, graft type, age and sex of donor, ABO-compatibility, and other factors. Cause of death of living liver donors is also reported.

【Objective】 The aim of this study was to investigate the efficacy and safety of intravenous immunoglobulin (IVIG)-based therapy for antibody-mediated rejection (AMR) in lung transplantation in Japan.

【Methods】 This retrospective observation study enrolled 48 patients, including 41 adults and 7 children, who underwent IVIG-based therapy for AMR in 4 lung transplant hospitals in Japan between April 2001 and March 2022.

【Results】 AMR was treated by IVIG alone in 18 patients or IVIG combined with other therapies, including, in particular, steroid pulse therapy, plasma exchange, and/or rituximab. The total dose of IVIG was 0.15 g/kg-8.82 g/kg (median: 1.71 g/kg). Donor-specific antibody (DSA) developed in 33 patients after lung transplantation. Following IVIG-based therapy, DSA titer decreased in all DSA to human leukocyte antigen (HLA) class I and 90% of DSA to HLA class II, and AMR was ameliorated in 41 patients (85.4%). The 6- and 12-month graft survival after IVIG-based therapy were 85.4% and 83.0%, respectively. The 6- and 12-month overall survival rates after IVIG-based therapy were 93.8% and 87.5%, respectively. Serious adverse events related directly to IVIG administration were not observed in this study.

【Conclusion】 IVIG-based therapy could be performed safely, could reduce circulating de novo DSA, and could improve AMR after lung transplantation.

We retrospectively surveyed the status of IVIg use in treatment for antibody-mediated rejection (AMR) in Japan between 2001 and 2022 for kidney, liver, pancreas, pancreatic islet. heart, lung, and intestine transplantation.

One hundred eighty-eight clinical departments responded. Of these, 54 clinical departments used IVIg for AMR. In addition, IVIg was administered to 17 in the kidney, 61 in the liver, 11 in the heart, 48 in the lung, 4 in the pancreas, and 3 in intestine.

We report on treatment details and IVIg dosage.

【Objective】 Suppression of rejection is important for maintaining graft function after heart transplantation. Antibody-mediated rejection (AMR), which is a type of rejection, is rare but may seriously damage graft function and lead to heart failure. Therefore, devising a therapeutic strategy for AMR suppression is an extremely important issue. We retrospectively conducted a survey on the actual usage of intravenous immunoglobulin (IVIg) for AMR at transplant facilities in Japan.

【Design and Methods】 In this study, we summarized 11 cases using IVIg for AMR.

【Results】 The average time of diagnosis of AMR was 41.1 months after transplantation, and cardiac dysfunction was observed in 7 patients (64%). As a therapeutic dose of IVIg, half of the doses were as low as 0.2 g/kg. Only 1 case was treated with IVIg alone, and in many cases it was used in combination with plasmapheresis therapy or steroid pulse therapy. As a result of AMR, 9 out of 11 cases (82%) could maintain graft function, while 2 cases lost it. As for changes in anti-HLA antibodies, it was often confirmed that mean fluorescence intensity was suppressed to about half at 6 months after IVIg.

【Conclusion】 It is important to develop standard treatment protocols including IVIg for AMR after heart transplantation.

The effects of pre- and post-renal transplant rehabilitation therapy in recipients with sarcopenia are unknown. In this report, we describe the effect of rehabilitation therapy in a renal transplant recipient with severe sarcopenia. The recipient, a woman in her forties, received living donor renal transplantation for chronic renal failure due to cyclosporine nephropathy. The recipient was diagnosed with severe sarcopenia, and decreased muscle strength, skeletal muscle mass, gait speed, and exercise tolerance before renal transplantation. The recipient also exhibited decreased physical function, general health and vitality, among QOL issues. We followed the recipient from 1 month pre-transplant to 2 months post-transplant while instructing her in rehabilitation exercise. As a result, the recipient had improved leg muscle strength, gait speed, exercise tolerance, and physical QOL compared to pre-transplant. We suggest that pre- and post-renal transplant rehabilitation therapy improved the recipient’s physical function and QOL.