Clinical outcomes of living donor liver transplantation for patients 65 years old or older with preserved performance status

What is the crux of successful living-donor liver transplantation for recipients aged 70 and beyond?

Aim

There is limited evidence regarding the feasibility of living-donor liver transplantation (LDLT) for patients aged over 70. The aims of this study were to assess postoperative outcomes in elderly recipients and to ascertain the potential feasibility and acceptability of LDLT.

Methods

Data were collected from 762 recipients, including 26 in the elderly group (aged ≥70) and 736 in the younger group (aged <70), and reviewed even by propensity score matching (PSM).

Results

No significant differences were observed in the frequency of postoperative complications between the two groups. Additionally, both groups exhibited a comparable 30-day mortality rate after LDLT (3.9% in both) and similar hospital stays (36 days vs. 40 days). The 1-, 3-, and 5-year graft survival rates in the elderly group were 92.0%, which was comparable to those in the younger group (p = 0.517), as confirmed by PSM. Notably, all donors for elderly patients were the children of the recipients, with an average age of 41.6 years, and grafts from donors aged ≥50 years were not utilized, signifying the use of high-quality grafts. Our inclusion criterion for elderly recipients was strictly defined as an ECOG-PS score of 0-2, which played a pivotal role in achieving favorable postoperative outcomes.

Conclusion

LDLT can be performed safely for elderly patients aged 70 years or older, provided they have a preserved PS and receive high-quality grafts from younger donors, inevitably all children of elderly recipients. This approach yields acceptable long-term outcomes. Consequently, age alone should not serve as an absolute contraindication for LDLT.

The impact of advanced patient age in liver transplantation: a European Liver Transplant Registry propensity-score matching study

BACKGROUND

The futility of liver transplantation in elderly recipients remains under debate in the HCV eradication era.

METHODS

The aim was to assess the effect of older age on outcome after liver transplantation. We used the ELTR to study the relationship between recipient age and post-transplant outcome. Young and elderly recipients were compared using a PSM method.

RESULTS

A total of 10,172 cases were analysed. Recipient age >65 years was identified as an independent risk factor associated with reduced patient survival (HR:1.42 95%CI:1.23-1.65,p < 0.001). After PSM, 2124 patients were matched, and the same association was found between elderly recipients and patient survival and graft survival (p < 0.001). As hepatocellular carcinoma and alcoholic cirrhosis were independent prognostic factors for patient and graft survival a propensity score-matching was performed for each. Patient and graft survival were significantly worse (p < 0.05) in the alcoholic cirrhosis elderly group. However, patient and graft survival in the hepatocellular carcinoma cohort were similar (p > 0.05) between groups.

CONCLUSION

Liver transplantation is an acceptable and safe curative option for elderly transplant candidates, with worse long-term outcomes compare to young candidates. The underlying liver disease for liver transplantation has a significant impact on the selection of elderly patients.

Clinical Outcomes of Liver Transplantation for Patients Over 60 Years Old: A Single-Center Experience

OBJECTIVES

Although advanced age is no longer considered an absolute contraindication for liver transplant, transplant in elderly patients with comorbid diseases remains debatable because of high risks with surgery. Here, we report patient outcomes in this population.

MATERIALS AND METHODS

We retrospectively reviewed medical records of 276 liver transplant recipients, grouped by age. Group 1 (≤59 years old) consisted of 247 recipients, and group 2 (≥60 years old) consisted of 29 recipients. Reviewed data included age, sex, cause of liver disease, presence of hepatocellular carcinoma, Child-Pugh and Model for End-Stage Liver Disease scores, survival, and posttransplant complications.

RESULTS

In both groups, most patients (n = 108) required liver transplant for hepatitis B virus. Mean age was 40 ± 12.3 and 63 ± 2.3 years in groups 1 and 2, respectively, with more men than women in both group 1 (71.7% vs 28.3%) and group 2 (75.9% vs 24.1%). No significant differences were shown between groups for patient characteristics, except group 1 had significantly higher Model for End-Stage Liver Disease score. Group 1 mean survival time was 10.2 ± 0.6 years, with patient survival rates at 1, 5, 10, and 15 years of 65.5%, 53%, 46.3%, and 40%, respectively. In group 2, respective results were 10.6 ± 1.3 years and 75.9%, 68.6%, 61%, and 48.8% (no significant difference vs group 1).

CONCLUSIONS

Liver transplant recipients >60 years of age had survival rates, acute rejection rates, and complications similar to younger recipients. Liver transplant should not be withheld from older recipients on the basis of age alone. However, comprehensive screening for comorbidities should be performed.

The impact of older age on long term survival in living donor liver transplantation: A propensity score matching analysis

BACKGROUND

Prevalence of the end-stage liver disease in the elderly patients indicating a liver transplantation (LT) has been increasing. There is no universally accepted upper age limit for LT candidates but the functional status of older patients is important in pre-LT evaluation. This study aimed to examine the impact of older age on survival after living donor liver transplantation (LDLT).

METHOD

A total of 171 LDLT recipients were assessed in two groups: age ≥65 and < 65. To eliminate selection bias propensity score matching (PSM) was performed, and 56 of 171 recipients were included in this study.

RESULTS

There were 20 recipients in the older group and 36 in the younger. The 1-, 3-, and 5-year survival rates were 65.0%, 60.0%, and 60.0% in group 1; 88.9%, 84.7%, and 71.4% in group 2, respectively. The 1-year survival was significantly lower in the older recipients; however, overall survival rates were similar between the groups. Of the 56 recipients, 15 (27%) deaths were observed in overall, and 11 (20%) in 1-year follow-up. The univariate regression analysis after PSM revealed that MELD score affected 1- year survival and the multivariate analysis revealed that age ≥65 years and MELD score were the predictors of 1-year survival.

CONCLUSION

At first sight, before PSM, survival appeared to be worse for older recipients. However, we have shown that there were confounding effects of clinical variables in the preliminary evaluation. After the elimination of this bias with PSM, This study highlights that older recipients have similar outcomes as youngers in LDLT for long-term survival.

Immunosuppression in liver and intestinal transplantation

Immunosuppression handling plays a key role in the early and long-term results of transplantation. The development of multiple immunosuppressive drugs led to numerous clincial trials searching to reach the ideal regimen. Due to heterogeneity of the studied patient cohorts and flaws in many, even randomized controlled, study designs, the answer still stands out. Nowadays triple-drug immunosuppression containing a calcineurin inhibitor (preferentially tacrolimus), an antimetabolite (using mycophenolate moffettil or Azathioprine) and short-term steroids with or without induction therapy (using anti-IL2 receptor blocker or anti-lymphocytic serum) is the preferred option in both liver and intestinal transplantation. This chapter aims, based on a critical review of the definitions of rejection, corticoresistant rejection and standard immunosuppression to give some reflections on how to reach an optimal immunosuppressive status and to conduct trials allowing to draw solid conclusions. Endpoints of future trials should not anymore focus on biopsy proven, acute and chronic, rejection but also on graft and patient survival. Correlation between early- and long-term biologic, immunologic and histopathologic findings will be fundamental to reach in much more patients the status of operational tolerance.

Propensity Score-Matched Analysis of Posttransplant Outcomes in Living Donor Liver Transplantation for Older Adult Recipients

The impact of increasing recipient age on morbidity and mortality following living donor liver transplantation (LDLT) remains controversial. The study aims to analyze the impact of recipient age on outcomes following LDLT. Data on adult LDLTs performed between November 2009 and February 2020 were retrieved from a prospectively maintained database. Patients were stratified into 2 groups based on recipient age: 18 to 65 years (younger adults) and >65 years (older adults). Propensity score matching (PSM) using nearest-neighbor matching was used to match each older recipient with up to 2 younger adult recipients using multiple preoperative parameters. Outcomes evaluated were duration of ventilation, need for reintubation, tracheostomy, intensive care unit (ICU) readmission, length of ICU and hospital stays, postoperative complications, reoperation within 90 days, and patient survival. A total of 801 adult LDLT recipients were included in the study; 751 (93.7%) were younger adults, and 50 (6.3%) were older adults. Older recipients were more likely to be diabetic (60.0% versus 39.7%) and hypertensive (44.0% versus 20.4%) with preexisting cardiac disease (28.0% versus 11.2%). However, their pretransplant Model for End-Stage Liver Disease score was significantly lower (14.5 versus 17.7), and they were more likely to receive a transplant because of hepatocellular carcinoma (38.0% versus 17.7%). Older recipients had longer durations of ventilation after LT both before (3.7 versus 1.9 days) and after PSM (4.0 versus 1.5 days). After PSM, the 30-day (13.0% versus 2.4%), 90-day (15.2% and 2.4%), and overall mortality rates (21.7% versus 7.1%) were significantly higher for older recipients when compared with younger recipients. There was no difference between the younger and older recipients with respect to other postoperative outcomes. This propensity score-matched study shows that the older LDLT recipients have higher 30-day, 90-day, 1-year, and 5-year mortality rates when compared with matched younger counterparts.

Outcomes of pancreas transplantation in older versus younger recipients: a comparative analysis

PURPOSE

The feasibility of pancreas transplantation (PT) in older recipients remains a matter of debate. We examined the influence of recipient age on PT outcomes and identified the prognostic factors for older recipients.

METHODS

We compared the outcomes of PT in recipients aged < 50 years (younger group; n = 285) with those in recipients aged ≥ 50 years (older group; n = 94). Prognostic factors in the older group were analyzed by a logistic regression model and the influence of recipient age on survival outcomes were analyzed using propensity score matching.

RESULTS

The patient survival rate was significantly worse in the older group (P < 0.001). Patient death from infection or/and multiple organ failure or cardiac/cerebrovascular events was also more frequent in the older group than in the younger group (P = 0.012 and P = 0.045, respectively). A longer duration of diabetes was an independent risk factor of 1-year mortality in the older group. In a propensity score-matched comparison, the older recipients (n = 77) had significantly poorer survival than the younger recipients (n = 77) (P = 0.026).

CONCLUSIONS

PT should be considered with appropriate caution, especially for older recipients with a long duration of diabetes.

Transplant of Elderly Patients: Is There an Upper Age Cutoff?

Increased life expectancy and advances in the care of chronic liver disease has increased the number of elderly patients needing liver transplant. Organ donation policies prioritize transplant to the sickest. There is an ongoing debate with regard to balancing the principles of equity and utility. Several hospitals have adopted center-specific policies and there has been an increased trend of transplant in elderly patients since 2002. Appropriate patient selection and long-term outcomes in the setting of limited organ availability pose several challenges. This article reviews the data and discusses the pros and cons of transplants in the elderly.

Expanding Indications for Liver Transplant: Tumor and Patient Factors

During the past few decades, liver transplant has developed from a high-mortality procedure to an almost routine procedure with good survival outcomes. The development of living donor liver transplant has increased the availability of liver grafts, and the scope of indications for liver transplant has been expanding ever since. The aim of this review is to provide an overview of such an expansion of scope. Various criteria have been proposed to expand the eligibility of patients with hepatocellular carcinoma exceeding the Milan criteria for liver transplant. Furthermore, liver transplant is increasingly performed as a treatment modality for cholangiocarcinoma, neuroendocrine liver metastasis and colorectal liver metastasis. The number of elderly patients receiving liver transplant is on the rise. Combined organ transplantation has also been adopted to treat patients with multiple organ failure. Going forward, further development of preoperative noninvasive predictors in tumor, patient and even donor factors is needed to identify patients at risk of poor outcomes and hence optimize patient management.

Living Donor Liver Transplant in Patients Aged 60 Years or Older: Experience from a Large Volume Centre in India

BACKGROUND

With ageing population and higher prevalence of nonalcoholic steatohepatitis (NASH) and hepatocellular carcinoma (HCC) in older patients, more and more living donor liver transplants (LDLTs) are being considered in this group of patients as eligibility for deceased donor liver transplant is restricted to those aged 65 years and younger. However, the short- and long-term outcomes of this group have not been reported from India, which does not have a robust national health scheme. The aim of this study was to provide guidelines for transplant in this group.

METHODS

All patients aged 60 years and older (group 1) who underwent LDLT in our centre between January 2006 and December 2017 were studied. A propensity score-matched group in 1:2 ratio was created with comparable sex and Model for End-Stage Liver Disease score (group 2). The 2 groups were compared for duration of hospital stay, surgical complications, hospital mortality and 1-, 3- and 5-year survival.

RESULTS

Group 1 consisted of 207 patients, and group 2 had 414 patients. The number of patients in group 1 gradually increased with time from 4 in 2006 to 33 in 2017 accounting for 15% of total cases. Group 1 had more patients with viral hepatitis, NASH and HCC, and they had a higher 30-day mortality due to cardiorespiratory complications. Although 1- and 3-year survival was similar, the 5-year survival was significantly lower in group 1.

CONCLUSION

Five-year survival was lower in the elderly group due to cardiorespiratory complications and recurrence of HCC. Outcomes in the elderly group can be improved with better patient selection and preventing HCC recurrence.

Recipient Age for Liver Transplantation: Should It Be Limited? A Propensity Score Matching Analysis of a Large European Series

BACKGROUND AND AIMS

The demand for older patients not to be denied access to liver transplantation (LT) has intensified as the European population continues to live longer and maintains better health.

AIM

This study aims to ascertain the impact of recipient age on the post-LT survival in 2 well-balanced populations at Vall d'Hebron University Hospital.

METHODS

From January 1990 to December 2016, LT recipients (young group: 50-65 years of age; elderly group: >65 years of age) were compared by means of a propensity score matching (PSM) method.

RESULTS

Prior to PSM, graft survival and patient survival were worse for the elderly group (P < .001). In 1126 LT recipients, a caliper width of 0.01 was used based on the donor (age, sex, cause of donor death, and donor intensive care unit stay) and recipient covariates (sex, body mass index, indication for LT, intraoperative blood transfusion, cardiovascular risk factors, and Model for End-Stage Liver Disease [MELD]-Era). After PSM, 206 patients were matched; 1-, 5-, and 10-year patient survival rates were 77%, 63%, and 52% vs 80%, 64%, and 45% (P = .50) for young vs elderly recipients, respectively. Similar graft survival rates were observed in both groups (P = .42).

CONCLUSIONS

Advanced age alone should not exclude patients from LT.

Effect of the clinical course of acute-on-chronic liver failure prior to liver transplantation on post-transplant survival

BACKGROUND & AIMS

Patients with acute-on-chronic liver failure (ACLF) can be listed for liver transplantation (LT) because LT is the only curative treatment option. We evaluated whether the clinical course of ACLF, particularly ACLF-3, between the time of listing and LT affects 1-year post-transplant survival.

METHODS

We identified patients from the United Network for Organ Sharing database who were transplanted within 28 days of listing and categorized them by ACLF grade at waitlist registration and LT, according to the EASL-CLIF definition.

RESULTS

A total of 3,636 patients listed with ACLF-3 underwent LT within 28 days. Among those transplanted, 892 (24.5%) recovered to no ACLF or ACLF grade 1 or 2 (ACLF 0-2) and 2,744 (75.5%) had ACLF-3 at transplantation. One-year survival was 82.0% among those transplanted with ACLF-3 vs. 88.2% among those improving to ACLF 0-2 (p <0.001). Conversely, the survival of patients listed with ACLF 0-2 who progressed to ACLF-3 at LT (n = 2,265) was significantly lower than that of recipients who remained at ACLF 0-2 (n = 17,631) at the time of LT (83.8% vs. 90.2%, p <0.001). Cox modeling demonstrated that recovery from ACLF-3 to ACLF 0-2 at LT was associated with reduced 1-year mortality after transplantation (hazard ratio0.65; 95% CI 0.53-0.78). Improvement in circulatory failure, brain failure, and removal from mechanical ventilation were also associated with reduced post-LT mortality. Among patients >60 years of age, 1-year survival was significantly higher among those who improved from ACLF-3 to ACLF 0-2 than among those who did not.

CONCLUSIONS

Improvement from ACLF-3 at listing to ACLF 0-2 at transplantation enhances post-LT survival, particularly in those who recovered from circulatory or brain failure, or were removed from the mechanical ventilator. The beneficial effect of improved ACLF on post-LT survival was also observed among patients >60 years of age.

LAY SUMMARY

Liver transplantation (LT) for patients with acute-on-chronic liver failure grade 3 (ACLF-3) significantly improves survival, but 1-year survival probability after LT remains lower than the expected outcomes for transplant centers. Our study reveals that among patients transplanted within 28 days of waitlist registration, improvement of ACLF-3 at listing to a lower grade of ACLF at transplantation significantly enhances post-transplant survival, even among patients aged 60 years or older. Subgroup analysis further demonstrates that improvement in circulatory failure, brain failure, or removal from mechanical ventilation have the strongest impact on post-transplant survival.

Is the treatment outcome of hepatocellular carcinoma inferior in elderly patients?

In view of the increasing life expectancy in different parts of the world, a larger proportion of elderly patients with hepatocellular carcinoma (HCC) requiring oncological treatment is expected. The clinicopathological characteristics of HCC in elderly patients and in younger patients are different. Elderly patients, in general, also have more comorbidities. Evaluation of the efficacy of different HCC treatment options in elderly patients is necessary to optimize treatment outcomes for them. Treatment modalities for HCC include hepatectomy, liver transplantation, radiofrequency ablation, transarterial chemoembolization, and molecular-targeted therapy with sorafenib. In this review, current evidence on the risks and outcomes of the different HCC treatments for elderly patients are discussed. According to data in the literature, elderly patients and younger patients benefited similarly from HCC treatments. More clinical data are needed for the determination of selecting criteria on elderly HCC patients to maximize their chance of getting the most appropriate and effective treatments. As such, further studies evaluating the outcomes of different HCC treatment modalities in elderly patients are warranted.

Survival Outcomes After Liver Transplantation in Elderly Patients: A Single-Center Retrospective Analysis

AIM

This study aims to evaluate survival rates in elderly patients after liver transplantation (LT) and to analyze the factors associated with mortality.

PATIENTS AND METHODS

Our study includes 535 patients over the age of 18 who had undergone LT in our clinic between June 2004 and January 2018. Data were collected prospectively and scanned retrospectively. Data concerning the patients' age, sex, LT indication, Child-Turcotte-Pugh score, Model for End-Stage Liver Disease score, presence of hepatocellular cancer (HCC), coexisting disease, LT types, and post-transplant survival were investigated. The patients were grouped under 2 categories (18-59 years of age and 60 years of age and over) and were compared in terms of their characteristics. In patients aged 60 and over, the causes of mortality and related factors were investigated.

RESULTS

The study included 535 patients, 458 (85.6%) of whom were between 18 and 59 years of age and 77 (14.4%) were over 60 years of age. The median follow-up period was 86.7 (1 to 247) months. The elderly group's survival rate was significantly lower than that of the younger group (P = .002). In elderly patients, survival rates of 1, 3, 5, and 10 years were 67.4%, 56.4%, 53.8%, and 46.1%, respectively.

CONCLUSION

In elderly patients, factors that increase post-LT mortality require thorough consideration. Equally important is the physiological status of the candidates for transplantation. Correct patient selection in the preoperative stage and good postoperative care can provide successful survival results in elderly patients.

Age and liver transplantation

The average age of liver transplant donors and recipients has increased over the years. Independent of the cause of liver disease, older candidates have more comorbidities, higher waitlist mortality and higher post-transplant mortality than younger patients. However, transplant benefit may be similar in older and younger recipients, provided older recipients are carefully selected. The cohort of elderly patients transplanted decades ago is also increasingly raising issues concerning long-term exposure to immunosuppression and aging of the transplanted liver. Excellent results can be achieved with elderly donors and there is virtually no upper age limit for donors after brain death liver transplantation. The issue is how to optimise selection, procurement and matching to ensure good results with elderly donors. The impact of old donor age is more pronounced in younger recipients and patients with a high model for end-stage liver disease score. Age matching between the donor and the recipient should be incorporated into allocation policies with a multistep approach. However, age matching may vary depending on the objectives of different allocation policies. In addition, age matching must be revisited in the era of direct-acting antivirals. More restrictive limits have been adopted in donation after circulatory death. Perfusion machines which are currently under investigation may help expand these limits. In living donor liver transplantation, donor age limit is essentially guided by morbidity related to procurement. In this review we summarise changing trends in recipient and donor age. We discuss the implications of older age donors and recipients. We also consider different options for age matching in liver transplantation that could improve outcomes.

Liver transplantation in elderly patients: a systematic review and first meta-analysis

BACKGROUND

Elderly recipients are frequently discussed by the scientific community but objective indication for this parameter has been provided. The aim of this study was to synthesize the available evidence on liver transplantation for elderly patients to assess graft and patient survival.

METHODS

A literature search of the Medline, EMBASE, and Scopus databases was carried out from January 2000 to August 2018. Clinical studies comparing the outcomes of liver transplantation in adult younger (<65 years) and elderly (>65 years) populations were analyzed. The primary outcomes were patient mortality and graft loss rates. This review was registered (Number CRD42017058261) as required in the international prospective register for systematic review protocols (PROSPERO).

RESULTS

Twenty-two studies were included involving a total of 242,487 patients (elderly: 23,660 and young: 218,827) were included in this study. In the meta-analysis, the elderly group had patient mortality (hazard ratio [HR]: 1.26; 95% confidence interval [CI]: 0.97-1.63; P = 0.09; I2 = 48%) and graft (HR: 1.09; 95% CI: 0.81-1.47; P = 0.59; I2 = 12%) loss rates comparable to those in the young group.

CONCLUSIONS

Elderly patients have similar long-term survival and graft loss rates as young patients. Liver transplantation is an acceptable and safe curative option for elderly transplant candidates.

Recipient Age and Mortality After Liver Transplantation: A Population-based Cohort Study

BACKGROUND

The feasibility of liver transplantation (LT) in elderly recipients remains a topic of debate.

METHODS

This cohort study evaluated the impact of recipient's age on LT outcome between January 2007 and May 2016 covered by the Korean National Health Insurance system (n = 9415). Multilevel regression models were used to determine the impact of recipient's age on in-hospital and long-term mortality after LT.

RESULTS

All patients had a first LT, with 2473 transplanted with liver from deceased donors (DD) and 6942 from living donors. The mean age was 52.2 ± 9.0 years. Most LT were performed on patients in their 50s (n = 4290, 45.6%) and 0.9% (n = 84) of the LT was performed on patients older 70 years. The overall in-hospital mortality was 6.3%, and the 3-year mortality was 11.3%. The in-hospital mortality included, 13.5% associated with DDLT and 3.7% involved living donor LT. When compared with that for patients aged 51 to 55 years, the risk of death among recipients older than 70 years was about fourfold higher after adjusting for baseline liver disease (odds ratio, 4.1; 95% confidence interval, 2.21-7.58), and was nearly threefold higher after adjusting for baseline liver disease and perioperative complications (odds ratio, 2.92; 95% confidence interval, 1.37-6.24). Also, the cost of LT increased significantly with age.

CONCLUSIONS

The data show that age remains an important risk factor for LT, suggesting that LT should be considered with caution in elderly recipients.

Living Donor Liver Transplantation for Patients Older Than Age 70 Years: A Single-Center Experience

Over the past two decades, the age of liver transplantation (LT) recipients has been increasing. We reviewed our experience with LT for patients aged ≥70 years (range: 70-78 years) and investigated the feasibility of performing LT, especially living donor LT (LDLT), for older patients. We retrospectively reviewed the medical records of 25 patients (15 LDLT recipients, 10 deceased donor LT recipients) aged ≥70 years who underwent LT from January 2000 to April 2016. Their perioperative morbidity rate was 28.0%, and the in-hospital mortality rate was 16.0%; these results were comparable to those of matched patients in their 60s (n = 73; morbidity, p = 0.726; mortality, p = 0.816). For patients in their 70s, the 1- and 5-year patient survival rates were 84.0% and 69.8%, and the 1- and 5-year graft survival rates were 83.5% and 75.1%, respectively. Comparisons of patient and graft survival rates between matched patients in their 60s and 70s showed no statistically significant differences (patient survival, p = 0.372; graft survival, p = 0.183). Our experience suggests that patients aged ≥70 years should not be excluded from LT, or even LDLT, based solely on age and implies that careful selection of recipients and donors as well as meticulous surgical technique are necessary for successful results.

Living Donor Liver Transplantation in Patients 70 Years or Older

INTRODUCTION

Previous published studies have shown that age is not a contraindication for deceased donor liver transplantation. The data about elderly recipient after living donor liver transplantation (LDLT) is unsatisfactory. The aim of this study was to evaluate the outcome of the LDLT with recipients aged 70 years or older.

PATIENTS AND METHODS

Between 2005 and 2013, 469 patients underwent LDLTs. The clinical characteristics, preoperative, intraoperative, and postoperative data, graft, and patients' survival of these patients were retrospectively analyzed. All recipients who were 70 years or older at the time of liver transplantation were indentified. The results were compared to the results of the patients younger than 70 years.

RESULTS

There were 12 patients (2%) 70 years or older. All patients received the right lobe of their donor in a standard technique. One patient died postoperatively because of pulmonary infection, and one patient died 6 months after the operation because of graft failure after cardiac infarction. The comorbidity score of these two patients were significantly higher compared to the other ten patients without any complications (8.5 vs. 4.6, P = 0.01). The 1-year and 3-year patient and graft survival was 84%. There were no significant differences in complications, hospital stay, perioperative mortality, or median survival compared to the younger group.

CONCLUSION

Although the number of the patients is small, our study emphasizes that LDLT of patients 70 years or older can be performed safely in patients without major comorbidities. Elderly patients with increased risk for postoperative complications should be excluded from LDLT.

Bundled strategies against infection after liver transplantation: Lessons from multidrug-resistant Pseudomonas aeruginosa

Infection is a life-threatening complication after liver transplantation (LT). A recent outbreak of multidrug-resistant Pseudomonas aeruginosa triggered changes in our infection control measures. This study investigated the usefulness of our bundled interventions against postoperative infection after LT. This before-and-after analysis enrolled 130 patients who underwent living donor or deceased donor LT between January 2011 and October 2014. We initiated 3 measures after January 2013: (1) we required LT candidates to be able to walk independently; (2) we increased the hand hygiene compliance rate and contact precautions; and (3) we introduced procalcitonin (PCT) measurement for a more precise determination of empirical antimicrobial treatment. We compared factors affecting the emergence of drug-resistant microorganisms, such as the duration of antimicrobial and carbapenem therapy and hospital stay, and outcomes such as bacteremia and death from infection between before (n = 77) and after (n = 53) the LT suspension period. The utility of PCT measurement was also evaluated. Patients' backgrounds were not significantly different before and after the protocol revision. Incidence of bacteremia (44% versus 25%; P = 0.02), detection rate of multiple bacteria (18% versus 4%; P = 0.01), and deaths from infections (12% versus 2%; P =  0.04) significantly decreased after the protocol revision. Duration of antibiotic (42.3 versus 25.1 days; P =  0.002) and carbapenem administration (15.1 versus 5.2 days; P < 0.001) and the length of postoperative hospital stay (85.4 versus 63.5 days; P =  0.048) also decreased after the protocol revision. PCT mean values were significantly higher in the bacteremia group (10.10 ng/mL), compared with the uneventful group (0.65 ng/mL; P =  0.002) and rejection group (2.30 ng/mL; P =  0.02). One-year overall survival after LT significantly increased in the latter period (71% versus 94%; P =  0.001). In conclusion, the bundled interventions were useful in preventing infections and lengthening overall survival after LT.

Reappraisal of upper age limit for adult living-donor liver transplantation using right lobe grafts: an outcome analysis

BACKGROUND

Increasingly more elderly recipients are being evaluated for liver transplant nowadays. Reported outcomes of deceased donor liver transplant in elderly recipients have varied in different eras. Little was reported on the outcome of living donor liver transplant (LDLT) in elderly patients, and the upper age limit for consideration for LDLT is variable from center to center.

PATIENTS AND METHODS

We retrospectively reviewed our database for LDLT procedures performed for recipients 60 years of age or older. Procedures performed for retransplantation or left lobe liver transplants were excluded. Patients were divided into two groups: group A included recipients at least 60 and younger than 65 years old and group B included recipients at least 65 years old.

RESULTS

A total of 55 liver transplants were included in our study. Group A included 30 patients, whereas group B included 25 patients. There was a trend toward more vascular complications, more frequent rejections, and hepatitis B virus recurrence in younger patients. This was only significant for hepatitis B virus recurrence. However, there was a trend toward more biliary complications, incisional hernias, and longer ICU/hospital stay in older patients. None of the latter variables reached statistical significance. Older recipients had better patient survival, which was more evident at 3 and 5 years of follow-up. However, graft and disease-free survivals did not differ significantly between both groups.

CONCLUSION

LDLT using right lobe grafts for recipients aged 65 years or older is safe and feasible.

Lack of agreement for defining 'clinical suspicion of rejection' in liver transplantation: a model to select candidates for liver biopsy

The gold standard to diagnose acute cellular rejection (ACR) after liver transplantation (LT) is histological evaluation, but there is no consensus to select patients for liver biopsy. We aimed to evaluate the agreement among clinicians to select candidates for liver biopsy early after LT. From a protocol biopsy population (n = 690), we randomly selected 100 LT patients in whom the biopsy was taken 7-10 days after LT. The clinical information between LT and protocol biopsy was given to nine clinicians from three transplant centres who decided whether a liver biopsy was needed. The agreement among clinicians to select candidates for liver biopsy was poor: κ = 0.06-0.62, being κ < 0.40 in 76% of comparisons. The concordance between indication for liver biopsy and moderate-severe ACR in the protocol biopsy was κ < 0.30 in all cases. A multivariate model based on the product age-by-MELD (OR = 0.81; P = 0.013), delta eosinophils (OR = 1.5; P = 0.002) and mean tacrolimus trough concentrations <6 ng/ml within the prior 4 days (OR = 11.4; P = 0.047) had an AUROC = 0.84 to diagnose moderate-severe histological ACR. In conclusion, the agreement among clinicians to select patients for liver biopsy is very poor. If further validated the proposed model would provide an objective method to select candidates for liver biopsy after LT.