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general population of the same age is not striking. A Introduction Canadian study compared the patient survival of 284 transplant recipients above age 60 years with that of At the threshold of the millenium the industrial counthe sexand age-matched general population. The tries have to face the problem of an increasingly aged survival at 5 years was 75 and 88% respectively [6 ]. A population. Between 1900 and 1980 the life expectancy careful selection of the recipient, paying particular per person at age 65 has risen from 11.9 years to 16.4 attention to potential evidence of cardiovascular disyears. During the 1980s the number of people aged ease, could further reduce the risk. 75–79 increased by 28.8% and that of persons over the Even more encouraging are the data about graft age of 85 years by 52.4% [1]. It should be pointed out survival. An analysis of UNOS showed that the 5-year that not only has the life expectancy of older persons graft survival was similar in transplant recipients above improved, but also their general health status is subage 60 years and in those aged 0–60 years. Graft stantially better than in the past. The longevity revolusurvival declined in older patients after the 5th year tion will continue to increase in the future and will because of their high rate of death. However, the represent a major problem for politicians, economists, so-called functional graft survival, excluding death, and sociologists. was better for patients above age 60 years than for If the number of elderly persons in the general any other age group, mainly because of the lower population is progressively increasing, the number of number of grafts lost by rejection in the elderly group elderly uraemic patients requiring renal replacement [5]. Two factors may account for the low incidence of therapy has increased even more rapidly in recent rejection in elderly patients: (i) elderly patients are years, creating a true ‘elderly boom’ in dialysis units. usually more compliant than younger transplant recipiThe number of dialysis patients older than 65 years has more than doubled within 10 years in the US [2]. ents [7]; (ii) in the elderly the inflammatory and In Europe, more than 50% of new patients admitted immune responses are blunted. Particularly, producto dialysis in 1995 were older than 60 years; in Italy tion of IL-2, expression of IL-2 receptors, cellular and and in France, 35% of dialysis patients were older than immunological responses, and expression of HLA-DR 70 years [3]. antigens are attenuated [8]. Although many elderly patients on dialysis are frail Probably the most convincing data about the feasib[4], a consistent number of older patients are well ility of renal transplantation in the elderly are those rehabilitated and do not have comorbid conditions produced recently by the group of Rotterdam. that would be a contraindication to transplantation. Roodnat et al. [9] subdivided their population of Yet many centres are still reluctant to accept patients cyclosporin-treated cadaver renal graft recipients into older than 60–65 years as candidates for renal transthree comparably sized age groups (17–43 years, 44–55 plantation. Two main objections for transplanting years, and 56–75 years). Patients were transplanted older patients are generally advanced: (i) patient and between 1983 and 1997. Three time periods were graft survival is poor in the elderly; (ii) life-expectancy considered. In each of them the relative risk of graft for elderly patients is better on dialysis than with a failure, including death, remained stable. Assuming transplant. that the relative risk of graft failure was 1.0 in the period between 1983 and 1990, it decreased subsequently and was 0.49 in the period 1991–1993 and Patient and graft survival in older recipients 0.22 between 1994 and 1997. In each of these periods the older the age of the As expected, in renal transplant recipients as well as recipients the higher the risk of graft failure, but the in general population the more advanced the age the impact of age was considerably attenuated between shorter the life expectancy [5]. However, the difference the first and the third period. Because of the improving in survival between older transplant patients and the results, the risk of graft failure or death was similar for a 20-year-old recipient transplanted between 1983 Correspondence and offprint requests to: C. Ponticelli, Divisione di and 1990 and for a 70-year-old recipient transplanted Nefrologia e Dialisi, IRCCS Ospedale Maggiore, Via Commenda 15, I-20129 Milan, Italy. between 1991 and 1993, while it was halved for a

Should renal transplantation be offered to older patients?