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A major analysis presented at the 62nd European Renal Association (ERA) Congress has found that the survival benefit of kidney transplantation over dialysis does not universally extend to older and high-risk patients who receive organs from expanded criteria donors. The findings, based on registry data from over 64,000 individuals, challenge the long-held belief that transplantation always offers a clear advantage over dialysis, particularly for the most vulnerable patient groups.
Key Findings from the ERA Registry
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The study analyzed data from adults wait-listed for a first deceased donor kidney transplant between 2000 and 2019 in several European countries.
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Patients were grouped by donor type: standard-criteria donors (younger, healthier) and expanded-criteria donors (older, with more comorbidities or higher risk factors).
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Five-year survival rates were substantially higher for recipients of standard-criteria donor kidneys compared to those who remained on dialysis, regardless of recipient age.
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However, for expanded-criteria donor kidneys, the survival benefit decreased sharply with increasing recipient age and comorbidities.
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Among patients aged 75 and older, five-year survival after receiving an expanded-criteria donor kidney was 57–58%, only marginally better than the 54% survival rate for those who remained on dialysis.
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Recipients with diabetes or cardiovascular disease saw similar patterns: standard-criteria donor transplants offered a survival advantage, but this benefit diminished with expanded-criteria donors as age increased.
Risks and Considerations
A significant factor was the increased early post-transplant mortality observed in older patients receiving expanded-criteria kidneys. Mortality risk spiked in the first 10 months post-transplant, nearly equaling the risk of remaining on dialysis by the five-year mark.
Study presenter Dr. Rachel Hellemans emphasized the importance of considering both patient and donor quality in transplant decisions. She noted that while transplantation remains the optimal treatment for many with kidney failure, the shortage of suitable donor organs has led to increased use of less-than-ideal donors. This shift, combined with improved survival rates on dialysis, raises critical questions about where the true survival benefit of transplantation lies for different patient groups.
Implications for Clinical Practice
Vianda Stel, PhD, director of the ERA Registry, highlighted that these findings equip clinicians to have more nuanced discussions with patients about the risks and benefits of transplantation, especially when the expected survival advantage is marginal. The data suggest that for the oldest or highest-risk patients, particularly those likely to receive expanded-criteria or circulatory-death donor kidneys, the survival benefit of transplantation plateaus.
Dr. Christoph Wanner, head of Nephrology at the University of Würzburg, suggested that these results could prompt a reevaluation of current transplant waiting lists, potentially prioritizing organs for patients most likely to benefit and reducing wait times1.
Ongoing Debate and Need for Further Research
Some experts, such as Dr. Daniel W. Coyne from Washington University, have noted that these findings differ from current practices and perceptions in the United States, calling for similar analyses using U.S. data.
“The message is not ‘don’t transplant older people,’ but rather ‘be open about uncertainty when the numbers say benefit may be marginal.'”
— Vianda Stel, PhD, ERA Registry Director
Disclaimer:
This news article summarizes findings from a recent analysis presented at the ERA Congress 2025 and is intended for informational purposes only. The study’s conclusions may not apply to every individual case, and treatment decisions should always be made in consultation with qualified healthcare professionals. The research discussed is based on registry data and may have limitations, including potential confounding factors and the evolving nature of transplantation science1.
