Age-adapted immunosuppression may be warranted for older kidney transplant recipients but post-transplant risks stratified by age in the contemporary era of immunosuppression are lacking.

We undertook a retrospective single-centre analysis of 1140 consecutive patients receiving kidney-alone allografts, with median follow-up 4.4 years’ post-transplantation, undertaken at a single-centre between January 2007 and January 2015. All patients received standardized immunosuppression. Descriptive analyses were stratified by age groups (age: <60, n=918; age: 60–64, n=111; age: 65–69, n=82; age: ≥70, n=29). Incidence of death, kidney allograft rejection, function/loss and immunosuppression-related complications was analyzed across age groups. For Cox regression analysis, older kidney transplant recipients were classified as age≥60 (n=222).

Kidney transplant recipients had increased risk for cardiac events, cerebrovascular accidents, cancer and CMV viraemia with increasing age. Rejection rates were similar but kidney transplant recipients with increasing age were significantly less likely to develop anti-HLA antibodies. Older kidney transplant recipients progressively had worse patient survival and overall graft survival, but equivalent death-censored graft survival. In Cox regression analysis, age≥60 was a strong independent risk factor for mortality in addition to preexisting diabetes, development of post-transplant cancer and development of rejection.

Older kidney transplant recipients have increased risk for immunosuppression-related complications (contributing to increased mortality) but rejection rates and death-censored graft losses are similar. Clinical trials for age-adapted immunosuppression are warranted for older adults but require balancing risks for cancer and rejection to achieve optimal long-term clinical outcomes.