Redefining Limits: Oldest Living Kidney Donor in India

Dear Editor, Kidney transplantation continues to be the treatment of choice for end-stage renal disease (ESRD). Due to the disparity in organ availability and demand, most patients have to remain dependent on dialysis or on the waiting list for an organ, and many even die while waiting for a suitable organ. To overcome this global organ shortage, various strategies are being devised and implemented. This includes the expansion of the donor pool by allowing the inclusion of elderly donors previously deemed unsuitable. The purpose of writing this letter is to acknowledge the feasibility and safety of accepting the elderly living kidney donors when carefully selected and evaluated. The presented case highlights that age alone should not be a contraindication to living donation and underscores the need to expand donor eligibility criteria. With appropriate medical evaluation and perioperative management, elderly donors constitute a valuable yet underutilized resource that has the potential to substantially expand the donor pool and enhance access to transplantation for patients with end-stage renal disease globally. Evidence suggests that in carefully selected older donors, nephrectomy carries minimal perioperative risk. Furthermore, a long-term follow-up studies indicate minimal impact on renal function, with little to no increased risk of chronic kidney disease or progression to ESRD compared to age-matched nondonors.[1] Literature shows evidence of elderly donors as one from Mumbai, India, an 81-year-old woman became the country’s oldest living kidney donor in November 2021 after donating a kidney to her son.[2] The oldest altruistic living organ donor was an 85-year-old woman in Britain, who donated a kidney to a stranger in 2014.[3] All these reported cases were uneventful, with no perioperative complications; demonstrating the feasibility, safety, and positive recipient outcomes even with octogenarian donors. Here, we present the case of an 84-year and 8-month-old male who voluntarily donated one of his kidney to his 59-year-old son. The recipient, a 59-year-old male, was a case of ESRD with a history of hypertension (HTN) and type 2 diabetes mellitus. He was on dialysis while waiting for a suitable organ for transplant. Given the urgency of the situation and the father’s strong determination, a thorough medical evaluation was conducted to the elderly man’s suitability as an organ donor. On December 19, 2024, he underwent live donor renal transplantation Immunosuppression with tacrolimus (TAC) and mycophenolatemofetil (MMF) was started preoperatively on day 2, along with broad-spectrum IV antibiotics and other supportive medications. Intraoperatively, methylprednisolone (500 mg) was administered, and anti-thymocyte globulin (ATG) 50 mg was given on the day of surgery, followed by additional ATG doses of 25 mg on post-operative day (POD) 1, 2, and 3. Postoperatively, he remained on triple-drug immunosuppression with TAC, MMF, and prednisolone. Renal allograft function demonstrated progressive recovery, as evidenced by a decline in serum creatinine levels from 3.09 mg/dL on POD 1, 1.72 mg/dL on POD 2, 1.25 mg/dL on POD 3, and a slight stabilization at 1.39 mg/dL on POD 4. The patient had an uneventful recovery, with no signs of rejection or complications. The donor an 84-year and 8-months-old male with a history of HTN, controlled on medication had undergone thorough preoperative assessments including an abdominal ultrasound, diethylenetriamine pentaacetic acid (DTPA) renal scan, renal function tests, and computed tomography (CT) angiography which showed no abnormalities. Routine preoperative blood tests showed satisfactory values (urea of 24 mg/dL and creatinine of 0.78 mg/dL). CT angiography confirmed well-preserved renal function. His isotopic glomerular filtration rate was 37.7 mL/min in the right kidney and 39.18 mL/min in the left kidney. The laparoscopic donor nephrectomy under general anesthesia was performed without any complications on the day of transplant surgery. Postoperatively, his stay was uneventful and he was discharged with stable hemodynamic parameters. Despite technical and immunosuppression advances, access to transplantation remains variable and insufficient to address global needs mainly due to the shortage of suitable donor kidneys. Living donation from the elderly donors reduces waiting times, minimizes dialysis exposure, and expands the donor pool, benefiting all transplant candidates. In addition, older living donor allografts demonstrate survival rates comparable to or better than deceased donor allografts, even with suboptimal human leukocyte antigen (HLA) matching.[4] Kidneys from live elderly donors might not last long as compared to younger living donors, but this also includes the risk of morbidity and mortality that are associated in waiting for a deceased donor transplant. This also adds up the economic burden on the patients due to the cost of hemodialysis and the complications of ESRD. This case also underscores the importance of raising awareness among healthcare professionals and the public that older individuals in good health can successfully donate, either in a directed or nondirected manner. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.