The Elderly Patient

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來自 Universiteit Leiden 的課程

Clinical Kidney, Pancreas and Islet Transplantation

198 個評分

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Universiteit Leiden

Clinical Kidney, Pancreas and Islet Transplantation

198 個評分

Kidney transplantation is a major advance of modern medicine which provides high-quality of life for patients with end-stage renal disease. What used to be an experimental, risky, and very limited treatment option more than 50 years ago is now routinely performed in many countries worldwide. The number of renal transplants is expected to rise sharply in the next decade since the proportion of patients with end stage renal disease is increasing. Are you interested in clinical kidney, pancreas and islet transplantation? If you are a (bio) medical student or a health care professional who works in the (pre) clinical transplant field this might be the course for you. This course is also for anyone interested in the research and knowledge on clinical transplantation. The course will be taught by a multidisciplinary team of transplant professionals and will give you the state of the art updates. It is divided in 4 modules: 1) Before the transplant 2) The surgical procedures and the challenged patient, including the patient with diabetes 3) Early challenges 4) Late challenges after transplantation. The offered modules will include lectures, interactive patient cases, 3D movies, interviews with well-known experts and with patients and a donor, a serious game to increase knowledge of the field and of course an active forum. Become an expert and join us! The course is endorsed by The European Society of Organ Transplantation (ESOT), The International Society of Nephrology (ISN) and The Transplantation Society (TTS). This MOOC has been accredited for Continuing Medical Education (CME). Health care professionals who works in the (pre) clinical transplant field, other health care professionals and general practitioners can obtain CME credit at 'LUMC-Boerhaave CME' upon passing the course. For more information we like to refer to the "Additional introduction for obtaining CME credit" module in week 1 of the course For another interesting course on organ donation and transplantation, see Organ Donation: From Death to Life from Cape Town University https://www.coursera.org/learn/organ-donation

從本節課中

The Procedure and the Patient

Now you know the factors of importance before transplantation, including the immunological barriers and important aspects for patient selection, we can focus on challenged patient groups and on surgical procedures. What does a kidney, pancreas and islet transplantation surgical procedure look like? What is important? And what are the key aspects in elderly patients, patients with diabetes and immunological challenged patients. We have unique visulisations, 360 virtual reality videos and a game about a patient case. Advanced readings will invite you to look at the different subjects in more depth. At the end of the module there are interviews about a patient with diabetes and the transplant recipient and donor to illustrate the impact of life. You can discuss patient cases on the forum together with your peers. In the honors lesson you can apply knowledge about more in depth immunological, surgical and metabolic challenges and living kidney donation. Let’s start and we hope you will enjoy this module.

Immunological Challenged Patient: ABO Incompatible Transplants6:53

Immunological Challenged Patient: Highly Sensitized Patient6:00

The Diabetic Patient10:37

The Elderly Patient6:36

與講師見面

Marlies Reinders
Prof. Dr.
LUMC, Department of Nephrology and Transplantation
Frans Claas
Professor
LUMC, Department of Immunohaematology and Blood Transfusion
Cees van Kooten
Professor
LUMC, Department of Nephrology and Transplantation
Sebastiaan Heidt
Dr.
LUMC, Department of Immunohaematology and Blood Transfusion
Volkert Huurman
Dr.
LUMC, Department of Transplant Surgery
Hans de Fijter
Professor
LUMC, Department of Nephrology and Transplantation
Eelco de Koning
Professor
LUMC, Department of Nephrology and Transplantation and Endocrinology and Metabolism
Andre Baranski
Dr.
LUMC, Department of Transplant Surgery
Ton Rabelink
Professor
LUMC, Department of Nephrology and Transplantation
Aiko de Vries
Dr.
LUMC, Department of Nephrology and Transplantation
Jan Nico Bouwes Bavinck
Dr.
LUMC, Department of Dermatology
Leo Visser
Professor
LUMC, Department of Infectious Diseases
Ingeborg Bajema
Dr.
LUMC, Department of Pathology

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.

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