Age, functional status, and survival benefit from kidney transplantation

描述(申请人提供)：肾移植是终末期肾病(ESRD)的最佳治疗方法，包括对老年ESRD患者，但捐赠肾脏的稀缺使人们将移植的兴趣集中在将移植分配给受益最大的个人。肾脏移植需求的增长和未得到满足的原因是终末期肾病在美国的患病率不断上升。从1995年到2005年，ESRD患病率增加了70%，65岁以上患者的上升速度更快。终末期肾病透析患者的死亡率显著上升。例如，65-69岁的透析患者的寿命只有普通人群同龄人的25%。与透析相比，肾移植能显著提高所有年龄段患者的存活率和生活质量。然而，与年轻受者相比，年龄较大的受者从肾移植中获得的寿命较短。因此，器官共享联合网络拥有先进的政策应用，随着患者年龄的增长，这些应用将减少接受肾移植的机会。总而言之，这些事实表明，政策制定者和临床医生迫切需要更准确地预测肾移植候选者和受者的死亡率，以优化器官的公平和有效利用。这笔赠款的中心前提是，功能状态将作为一种新的、准确的肾移植生存益处预测指标。最近来自老年医学的见解表明，更好的功能状态与更长的生存时间之间存在着很强的联系。功能状态可以捕捉糖尿病和血管疾病等并存疾病的累积影响。肾移植候选人在接受多年透析时经常经历高发病率，导致名单上的临时停用、永久移除、死亡或移植后存活率低。因此，我们将研究功能状态是否可以用来预测等待移植的终末期肾病患者之间在健康方面的重要差异。由于即使在健康人群中，功能状态也会随着年龄的增长而下降，我们还将检查功能状态的预测价值是否在不同的年龄层之间有所不同。我们建议对肾移植候选人和接受者进行一项回顾性队列研究，使用一种新的数据集，该数据集将来自器官共享联合网络和一家大型透析提供商的注册数据联系起来。这项研究将有以下具体目标：1)确定肾移植候选者和接受者的功能状态是否预示着存活；2)评估年龄如何影响肾移植候选者和接受者的功能状况与存活率的关系；以及3)确定功能状况是否预示着肾脏移植等待名单上的移除或失活。这项研究的结果有可能为与分配稀缺的移植肾脏资源相关的政策制定提供信息，并帮助终末期肾病患者及其医生了解肾移植对所有年龄段的个人的相对风险和好处。 公共卫生相关性：终末期肾病损害生活质量，降低存活率，在美国越来越常见，特别是在老年人中。肾移植为大多数终末期肾病患者提供了最佳的治疗方法，但可供移植的器官严重短缺，促使人们对为受益最大的患者提供肾移植产生了浓厚的兴趣。这项研究将采用一种新的方法，使用功能状态--一种衡量完成重要日常活动能力的指标--作为一种工具，预测哪些患者从肾移植中获得最大的生存好处。

DESCRIPTION (provided by applicant): Kidney transplantation is the optimal treatment for end-stage renal disease (ESRD), including for older patients with ESRD, but the scarcity of donated kidneys has focused interest on allocating transplants to the individuals who benefit the most. The growing and unmet need for kidney transplants is driven by the rising prevalence of ESRD in the United States. ESRD prevalence increased 70% from 1995 - 2005, with an even greater rate of rise among patients over 65 years old. Mortality for ESRD patients on dialysis is markedly elevated. For example, dialysis patients 65 - 69 years old live only 25% as long as individuals of the same age in the general population. Compared to dialysis, kidney transplantation leads to substantial improvements in survival and quality of life at all ages. However, older recipients gain fewer years of life from a kidney transplant compared to younger recipients. As a result, the United Network for Organ Sharing has advanced policy applications that would decrease access to kidney transplantation as patients get older. Collectively, these facts indicate that policy-makers and clinicians urgently need more accurate predictors of mortality among kidney transplant candidates and recipients to optimize the fair and efficient use of organs. The central premise of this grant is that functional status would act as a novel and accurate predictor of survival benefit from kidney transplantation. Recent insights from geriatric medicine reveal a strong relationship between better functional status and longer survival. Functional status can capture the cumulative impact of co-morbidities such as diabetes and vascular disease. Kidney transplant candidates often experience a high rate of morbidities while receiving years of dialysis, leading to temporary de-activation on the list, permanent removal, death, or poor survival after transplantation. Therefore, we will study whether functional status can be used to predict important differences in health between individuals with ESRD awaiting a transplant. Because functional status declines with aging even in healthy populations, we will also examine whether the predictive value of functional status differs between age strata. We propose a retrospective cohort study of kidney transplant candidates and recipients using a novel dataset that links registry data from the United Network for Organ Sharing and a large dialysis provider. The study will have the following specific aims: 1) To determine if functional status predicts survival among kidney transplant candidates and recipients; 2) To assess how age affects the relationship of functional status to survival among kidney transplant candidates and recipients; and 3) To determine if functional status predicts removal or inactivation on the waiting list for a kidney transplant. The results of this study have the potential to inform policy development related to allocating the scarce resource of transplanted kidneys, and to help patients with ESRD and their physicians understand the relative risks and benefits of kidney transplantation for individuals of all ages. PUBLIC HEALTH RELEVANCE: End-stage kidney disease impairs quality of life, decreases survival and is increasingly common in the United States, particularly among older adults. Kidney transplantation offers the optimal treatment for most patients with end-stage kidney disease, but a profound shortage of organs for transplantation has driven strong interest in providing kidney transplants to the patients who benefit the most. This study will take the novel approach of using functional status - a measure of the ability to complete important daily activities - as a tool to predict which patients derive the greatest survival benefit from a kidney transplant.