[What is the best immunosuppression for the elderly kidney transplantation patient?].
The proportion of elderly patients (>60 years) awaiting kidney transplantation has increased over the last few years. In this population, the risk of death is higher in the 4 months after transplantation. On the other hand, with the immune system's decrease in reactivity with age, the risk of acute rejection is lower. The choice of immunosuppressor treatment should take these particularities into account as well as the donor characteristics. Induction seems desirable, to secondarily lighten immunosuppression while reducing the initial risk of acute rejection. Induction using an interleukin-2 receptor antagonist, which incurs a lesser risk of infection, is probably preferable. Lightening immunosuppression could involve minimizing or stopping anticalcineurins or even replacing them from the beginning, but the advantages of these strategies has not been validated in the older patient. Similarly, therapeutic alternatives such as azathioprine or mycophenolate mofetil have not been fully tested in this population. The proliferation signal inhibitors could be useful because they reduce the risk of posttransplantation cancer. Finally, the innocuousness of stopping corticosteroids early to reduce the risk of metabolic and cardiovascular complications has not yet been demonstrated. Therefore, the receiver's age does not seem to determine a specific strategy, even if the strategy used for patients at low immunological risk is adopted most often. Prospective, randomized studies, which are more reliable, are therefore necessary so that guidelines can be established for the choice of immunosuppressor treatment in elderly patients.
Ladrière
M
M
Service de Néphrologie, CHU de Nancy, Vandoeuvre-les-Nancy, France. m.ladriere@chu-nancy.fr
D000305:Adrenal Cortex Hormones / Q000627:therapeutic use; D000368:Aged; D000369:Aged, 80 and over; D000375:Aging / Q000276:immunology; D065095:Calcineurin Inhibitors; D006084:Graft Rejection / Q000517:prevention & control; D006801:Humans; D007165:Immunosuppression Therapy / Q000379:methods*; D007166:Immunosuppressive Agents / Q000009:adverse effects / Q000145:classification / Q000627:therapeutic use; D016030:Kidney Transplantation / Q000276:immunology*; D008875:Middle Aged; D015375:Receptors, Interleukin-2 / Q000037:antagonists & inhibitors
D000305:Adrenal Cortex Hormones; D065095:Calcineurin Inhibitors; D007166:Immunosuppressive Agents; D015375:Receptors, Interleukin-2