Hello again and welcome to this lecture. We have learned that transplantation is the preferred option for a patient with end-stage renal failure. Is this also the case in elderly patients? And how relevant is the population of elderly with end-stage renal disease? What percentage of new patients enter renal replacement therapy is actually older then 65 years of age? Are these elderly also placed on the waiting list for transplantation? If not, why not? Is it safe to transplant this vulnerable population? And is there a survival benefit attached to this procedure as you compare it to dialysis? Can we improve the outcome parameters in these patients that actually receive a transplant? This lecture will try to answer these questions. With over 50% of new patients entering renal replacement therapy, nowadays being older than 65 years, the elderly actually represent the fastest growing population with chronic or end-stage renal disease. And substantial data provide evidence that kidney transplantation is both safe and successful. Survival with a transplant has been shown to exceed, or even double survival as compared to dialysis also in the elderly and those over the age of 70 years. But do the elderly actually get equal access to the waiting list for transplantation? Well, apparently not, since about only 10% of these elderly are eventually placed on the list. And retrospective studies have indicated that about 50% of not referred patients had no contraindication to transplantation, at least not according to published guidelines. Age matching for the elderly was introduced to expedite the chance for the elderly to receive a timely graft. And the figure shows that the increase in percentage of kidney transplant in patients over the age of 65 increased with the introduction of Eurotransplant Senior Program in the late 90s. So what are the potential reasons for this discrepancy? The most straightforward explanation is that many end-stage renal disease patients over the age of 70 or 75 years simply refuse the option or are just considered to be too old to receive a kidney transplant. In addition, elderly patients more often carry serious co-morbid conditions that prevent placement on the waiting list. So this is adding biological to chronological age. Last but not least, there is the critical issue of waiting time while on the active transplant list. With waiting times now approaching five years, patients with end-stage renal disease, on average, face a 50% chance of dying before a deceased donor kidney is offered for transplantation. Thus, elderly transplant candidates currently represent a stringent selection of the fastest growing subpopulation of patients with end-stage renal failure. What about these elderly who actually received a kidney transplant? Is graft loss a composite of patient death and return to dialysis primarily determined by patient death in these elderly? Apparently it is, and the main causes of mortality include infections early after the transplantation, and later on cardiovascular disease and malignancy. The inferior graft survival or excess death rate in the elderly indicated in this graph by the red line, can be best explained by at least two key issues. First, kidney transplants from older donors result in higher acute rejection rates, regardless of the age of the recipient. Especially in the elderly, additional treatment with high does steroids or depleting antibodies will significantly add to the observed higher infectious cause mortality rates. What have we learned about transplanting elderly end-stage renal disease patients? Outcome in this vulnerable population is best served by preferred allocation combining age and HLA-matching criteria. So why age matching? Well, graft survival is better if older kidneys are allocated to elder recipients. Independent of recipient age, the kidneys from older donors result in higher rejection rates. And as a consequence, graft survival is better if old kidneys are allocated to older recipients who are more likely to have a senescent immune system. This is also the main reason to include HLA-DR matching. Reducing the need for acute rejection treatment may reduce excess infectious disease morbidity and mortality. This will also better preserve the already inferior baseline function of these older kidneys. So what are the take home lessons about transplanting the elderly? Over 50% of new patients entering renal replacement therapy is nowadays older than 65 years of age. Only a relative small percentage, however, is actually placed on an active waiting list for a transplant. Kidney transplantation is however also safe and successful in these patients. And outcome is determined mainly by patient death and caused by infections. Factors to optimize outcome include age matching with HLA-DR matching. And in the following lecture, we will further focus on the actual transplant procedure itself.