Immunosuppression in the elderly renal allograft recipient: a systematic review.
The Elderly are the fastest growing part of kidney transplant recipients. The best immunosuppressive strategy is unknown.



We performed a systematic search of randomized controlled trials and observational studies focused on safety and efficacy of different immunosuppression strategies in elderly kidney recipients. Data extraction and risk of bias evaluation were systematically performed.



Ten studies were included: 2 randomized clinical trials and 8 observational. A marginal benefit was found for early renal function with delayed tacrolimus or complete tacrolimus avoidance using mycophenolate mofetil (MMF). Observational cohort studies looked at different antibody induction strategies, calcineurin-inhibitors based maintenance immunosuppression, calcineurin-inhibitor-free sirolimus-based therapy and use of MMF versus azathioprine. Treatment with interleukin-2 receptor antibody induction, calcineurin-inhibitor minimization with MMF and steroid minimization is advisable in the low immunologic risk elderly recipient, considering the increased risk of toxicities, infection and malignancies. In the high immunologic risk elderly recipient, taking into account the morbid consequences of acute rejection in the elderly, observational studies support antibody induction with depletive antibodies, calcineurin-inhibitor, MMF and steroids; calcineurin-inhibitor-minimization is not recommended.



There is very limited evidence for the benefits and harms of different immunosuppression strategies in the elderly. Most of the published literature are observational studies, and randomized controlled trials are urgently needed.
Department of Nephrology, Hospital Universitari Bellvitge, Barcelona, Spain.
Nuria
N
Montero
Red de Investigación Renal (Redinren) Instituto Carlos III, Madrid, Spain; Department of Nephrology, Hospital del Mar, Barcelona, Spain; Universitat Autonoma de Barcelona, Barcelona, Spain.
María José
MJ
Pérez-Sáez
Red de Investigación Renal (Redinren) Instituto Carlos III, Madrid, Spain; Department of Nephrology, Hospital del Mar, Barcelona, Spain; Universitat Autonoma de Barcelona, Barcelona, Spain. Electronic address: julpascual@gmail.com.
Julio
J
Pascual
Department of Nephrology, Antwerp University Hospital, Antwerp, Belgium.
Daniel
D
Abramowicz
Department of Nephrology Campus Charité Mitte, Berlin, Germany.
Klemens
K
Budde
Richard Bright Renal Unit, Bristol, UK.
Chris
C
Dudley
Service de Néphrologie, Univ Lille Nord de France, Lille, France.
Mark
M
Hazzan
Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Poland.
Marian
M
Klinger
Department of Nephrology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy.
Umberto
U
Maggiore
Department of Nephrology, Medical University of Vienna, Vienna, Austria.
Rainer
R
Oberbauer
Department of Nephrology, Hospital del Mar, Barcelona, Spain.
Julio
J
Pascual
Department of Nephrology P, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark.
Soren S
SS
Sorensen
Department of Nephrology, Transplant Centre, Prague, Czech Republic.
Ondrej
O
Viklicky
D000368:Aged; D065095:Calcineurin Inhibitors; D006084:Graft Rejection; D006801:Humans; D007165:Immunosuppression Therapy; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D016030:Kidney Transplantation; D016032:Randomized Controlled Trials as Topic
D065095:Calcineurin Inhibitors; D007166:Immunosuppressive Agents