Photo Credit: SvetaZi
Liver transplants from older donors can be effective for septuagenarian candidates and are associated with lower mortality and shorter time to transplant.
“The utilization of carefully selected livers from older donors can be an effective option for septuagenarian liver transplant candidates, which is associated with a decrease in waitlist mortality, shortens time to transplant, increases organ utilization, without compromising the one-year and five-year outcomes,” Kenji Okumura, MD, and colleagues wrote in the Journal of Liver Transplantation.
Dr. Okumura and colleagues used United Network of Organ Sharing data to assess outcomes in 2,797 septuagenarians who received deceased-donor liver transplants. The 1,487 (53.2%) donors who were younger than 50 (DON<50) had a median age of 34, and the 1,310 (46.8 %) donors who were 50 or older (DON≥50) had a median age of 60.
Post-transplant survivals for donors younger than 50 years vs. 50 and older were similar: DON<50 (89.3%) vs. DON≥50 (88.3%) at one year, and DON<50 (41.4%) vs. DON≥50 (42.8%) at five years.
In multivariable analysis, donor age of at least 50 years was not associated with increased mortality after liver transplant.
The leading causes of death in recipients with younger and older donors were comparable: malignancy (18.7 %), infection including COVID-19 (18.7 %), and cardiovascular disease (14%). Donor age >60 years did not affect mortality.
Physician’s Weekly (PW) talked about the study with three transplant surgeons: Dr. Okumura, lead study author, and Ben E. Biesterveld, MD and Paul J Gaglio, MD, FACP, AGAF, FAASLD, who were not involved in the study.
PW: For clinicians, what are the most important findings?
Dr. Biesterveld: This study shows that we can use grafts from donors over 50 years old with comparable outcomes to using livers from young donors.
Dr. Gaglio: Post-transplant survival in individuals who receive a liver transplant from an older donor is quite good, particularly in older recipients. Appropriate donor-recipient matching optimizes outcomes. However, the current organ allocation and distribution system, which prioritizes transplantation in the most ill patients, makes this difficult. It was previously thought that post-transplant outcomes with livers from older donors were inferior; however, it is becoming increasingly apparent that careful selection of organs from older donors provides acceptable outcomes.
Did the results surprise you?
Dr. Okumura: We were pleasantly surprised by the results, as they validate the approach of utilizing older donor livers for older liver transplant candidates.
Why was it necessary to do this study?
Dr. Okumura: Despite suitable organ function, based on the chronological age and probable longevity of organs from older donors, the transplant community has considered these organs to be “marginal” and has hesitated to use them for transplantation, especially for younger candidates. Similarly, as older candidates wait longer on the waitlist, they have a higher chance of becoming ineligible for transplant due to various medical complications or death. Demonstrating the safety of various interventions to help expand the donor pool is needed to help advance the field of transplantation.
Dr. Gaglio: Many more patients are waiting for a liver transplant than organs are available. Previously, livers from older donors were considered unacceptable due to concerns related to poor post-transplant outcomes. However, using appropriately selected livers from older donors will allow liver transplantation in more patients.
How might the findings impact older donors and patients?
Dr. Okumura: Our findings offer a clear pathway to be adopted by transplant centers worldwide and lead to the improvement of liver transplant outcomes in older recipients.
Dr. Biesterveld: This study nicely shows that over 10 years, the number of transplants done for older recipients has been rising and has been done safely. Hopefully, we can continue to expand access to transplant for this age group.
Dr. Gaglio: Data from this study and previous research indicate that using well-selected livers from older donors is acceptable to increase the utilization of these grafts and provide increased access to transplantation, particularly in older recipients.
What future research would you like to see?
Dr. Okumura: The main unanswered question is how old both donors and recipients are. Are there any objective modalities that may help define age in terms of functionality and quality of life besides chronological age? As this strategy becomes more common, long-term outcomes (>5-10 years) and potential complications associated with an “older liver” will need to be defined.
Dr. Biesterveld: It would be interesting to know how even older donor livers perform in older recipients.
Dr. Gaglio: The most common indication for liver transplantation in this study was hepatitis C. This is no longer the most common indication, as alcohol-associated liver disease and MASLD (metabolic dysfunction-associated steatotic liver disease) are the most common indications.
The long-term outcomes in a recipient of an older liver who then re-develops MASLD or liver fat in their new liver post-transplant are unclear. In addition, this study’s results may have been affected by the COVID-19 pandemic, as some study patients succumbed to this infection post-transplant. We now have therapies and vaccines for this infection, so survival rates may improve.
Is there anything else you’d like to mention?
Dr. Okumura: Please consider referring your patients with liver disease to transplant centers early. As the field advances, age and many other conditions that were considered absolute contraindications for liver transplant may no longer be obstacles to care. A personalized approach to transplant, where the right donor is matched with the right recipient, offers the best chance for short-term and long-term transplant outcomes.
Dr. Biesterveld: The transplant community is safely transplanting older patients with end-stage liver disease, and these patients should be referred for transplant evaluation. Considering the impact of normothermic regional perfusion and ex vivo perfusion strategies on donor quality is important. The adoption of these technologies has exploded in recent years (mainly after the time of this study). They have allowed us to utilize even more livers for transplant. I think they will have a remarkable impact on our ability to safely transplant even more complex recipients, including the elderly. This is another area for future research.
Dr. Gaglio: Screening for liver fibrosis in all patients with liver disease using non-invasive lab tests, such as the aspartate aminotransferase to platelet ratio index (APRI) and fibrosis-4 (FIB-4) and non-invasive radiologic tests (eg, FibroScan or ultrasound with elastography), is important as patients with advanced fibrosis (F2 or greater) need to be appropriately treated to prevent complications and progression of liver disease. This practice is critical in patients with metabolic syndrome who develop MASLD, which is rapidly becoming the most common indication for liver transplantation.
