NASH Liver Transplantation Within the Elderly: Age-specific Cohort Differences in Transplant Trends and Outcomes in NASH, HCV and ALD

Abstract

Introduction: Although elderly liver transplant (LT) recipients have shown to have inferior outcomes to younger recipients, optimizing recipient selection may minimalize this discrepancy. LT trends and outcomes in the elderly within the three leading indications for LT, chronic hepatitis C (HCV), alcoholic liver disease (ALD) and non-alcoholic steatohepatitis (NASH) have yet to be defined. Methods: Using the United Network for Organ Sharing database, we analyzed LT trends and post-LT survival in an elderly age-specific (age > 65) cohort with a diagnosis of HCV, ALD or NASH from 2005-2014. Additionally, we compared demographic data (age, gender and ethnicity), Model End-Stage Liver Disease (MELD) score and hepatocellular carcinoma (HCC) within LT recipients < 65 years and > 65 years. Kaplan-Meir survival methods were performed to determine long-term (5-year LT) survival. Results: Overall from 2005-2014, there were 28,872 LT recipients secondary to HCV, ALD and NASH. Elderly LT recipients constituted 3,954 (13.0%) of LT. The proportion of elderly LT recipients was highest in NASH (n=1185, 26.7%), ALD (n=1076, 13.2%) and HCV (n=1693, 9.5%). Within this decade the number of elderly LT performed increased 8.6% annually. Compared to NASH LT recipients < 65, elderly NASH LT recipients had a significantly (p < 0.05) higher prevalence of non-Hispanic Whites (87.9% to 72.7%) and HCC (22.2% to 10.4%) and a lower mean MELD at LT excluding HCC cases (20.9 to 23.2) (Table). Although elderly LT recipients had a higher prevalence of HCC than their younger counterparts within all three etiologies, elderly LT recipients without HCC were transplanted at a lower acuity of illness or MELD score (Table). Compared to the younger cohorts, elderly LT had a significantly (p < 0.01) lower survival rate with the largest disparity seen in elderly NASH LT (< 65, 85.2%; > 65, 76.8%, p < 0.01) (Table). Within the elderly LT recipients, 5-year post LT survival rate was similar amongst NASH and ALD (NASH 76.8%, ALD 76.0%, HCV 71.7%, p = 0.03). Overall, elderly ALD LT recipients had higher long-term post-LT survival than NASH and HCV (Figure). Conclusion: The number of elderly LT recipients continues to rise, particularly within the elderly NASH LT population. Although elderly NASH LT recipients demonstrated a higher 5-year post-transplant survival compared to HCV, the large age-specific survival disparity within NASH necessitate further analysis to improve recipient selection.Figure 1Figure 2