The Viability Of Liver Transplantation In Patients Age 70 And Older: An Updated Review

Abstract

Presenter: Krishnaraj Mahendraraj MD | Cedars-Sinai Medical Center Background: Liver transplantation in the elderly has been regarded with caution due to lower survival and increased morbidity. In this study, postoperative outcomes of orthotopic liver transplantation (OLT) in patients age 70 and older are compared to younger cohorts to assess its safety and efficacy. Methods: Data on 55,267 OLT recipients were abstracted from the Scientific Registry of Transplant Recipients (SRTR) over a 10 year period (2007-2017). Three age-based subgroups were created: elderly (age 70 and over), middle-age (age 50-69), and young (age 18-49). Pediatric recipients (age < 18) were excluded. Standard statistical analysis was performed using donor and recipient data to compare indications, mortality and graft survival. Results: There were 1,622 elderly OLT patients (2.9%), compared to 40,271 middle-age patients (72.9%) and 13,374 young patients (24.2%). Significantly fewer elderly patients had a BMI>30 compared to other groups (26.6% vs. 37.2% and 33.4%, p<0.01). The median MELD-Na score of elderly patients was significantly lower (18.4 vs. 21.6 and 27.2, p<0.01), with 63.8% elderly patients being MELD < 20. Most elderly patients received OLT for hepatocellular carcinoma (HCC)-exception status (665 patients; 41%). Fewer elderly patients were Status 1. They had a significantly lower pretransplant INR and bilirubin, and higher albumin. Elderly patients spend a significantly longer time on the waitlist, and tended to receive organs from older age donors. Elderly patients received organs from donors with higher rates of diabetes, hypertension, history of malignancy and macrosteatosis. Elderly patients also received a higher proportion of DCD and ECD organs. Elderly patients had lower overall survival (66.15% vs. 71.4% and 71.7%) and lower graft survival (68.4% vs. 73.9% and 75.7%), p<0.01. There were more graft complications observed in the elderly including hepatic artery thrombosis, infection, primary non-function, primary graft failure and vascular thrombosis, but these were not statistically significant. Elderly patients had a significantly lower 6-month (6.9%) and 1-year (8.7%) rejection rate compared to other groups (12% and 14%, respectively). Kaplan-Meier survival analysis of 5-year graft survival was 3.98 years in the elderly compared to 4.03 years in middle-age and 4.76 years in young recipients, p<0.001. There was no significant difference between survival estimates of elderly patients with HCC vs. non-HCC. Conclusion: Elderly OLT recipients tended to be in a better state of health at the time of transplant, and tended to wait longer for donor organs with more marginal characteristics. Despite having a significantly lower overall and graft survival rate, this difference (less than 5%) was not clinically significant. These Results suggest that OLT is a safe and viable treatment for the elderly, even when using marginal donor organs.