Kidney Transplantation in the Elderly: Necessity and Considerations

As global aging accelerates, the prevalence of chronic diseases, including hypertension and diabetes mellitus, is increasing, leading to a growing number of elderly patients with end-stage kidney disease (ESKD). In South Korea, between 2003 and 2023, the proportion of ESKD patients aged 65 and older more than doubled from 24.5% to 57.2%. Consequently, the number of elderly patients considered for kidney transplantation is rising. However, transplantation among individuals in this population remains limited due to a lack of standardized selection criteria and concerns regarding post-transplant outcomes. In this review, we address three major considerations with respect kidney transplantation for elderly patients: post-transplant clinical outcomes, appropriate evaluation criteria for transplant eligibility, and equitable access to transplantation. Despite early postoperative risks, the findings of previous studies have revealed improvements in long-term survival and quality of life among carefully selected elderly transplant recipients. Given that chronological age alone is an insufficient predictor of transplant outcomes, physiological assessments, including those for frailty, sarcopenia, and cognitive function, are increasingly being emphasized, and tools such as the Comprehensive Geriatric Assessment and predictive models such as K-EPTS are being developed to provide better guidance for decision-making. Notably, however, disparities in transplant access persist, thereby highlighting the necessity for policy efforts to enhance awareness and streamline allocation systems. In this regard, programs such as the Eurotransplant Senior Program and the KDPI-based allocation in the US serve as good models. Our finding in this review indicate that kidney transplantation can be a viable treatment option for elderly ESKD patients, provided that individualized assessments and equitable allocation policies are implemented.