Liver Transplantation With Livers From Octogenarians and a Nonagenarian

Post-transplant biliary complications using liver grafts from deceased donors older than 70 years: Retrospective case-control study

BACKGROUND

The shortage of liver grafts and subsequent waitlist mortality led us to expand the donor pool using liver grafts from older donors.

AIM

To determine the incidence, outcomes, and risk factors for biliary complications (BC) in liver transplantation (LT) using liver grafts from donors aged > 70 years.

METHODS

Between January 1994 and December 31, 2019, 297 LTs were performed using donors older than 70 years. After excluding 47 LT for several reasons, we divided 250 LTs into two groups, namely post-LT BC (n = 21) and without BC (n = 229). This retrospective case-control study compared both groups.

RESULTS

Choledocho-choledochostomy without T-tube was the most frequent technique (76.2% in the BC group vs 92.6% in the non-BC group). Twenty-one patients (8.4%) developed BC (13 anastomotic strictures, 7 biliary leakages, and 1 non-anastomotic biliary stricture). Nine patients underwent percutaneous balloon dilation and nine required a Roux-en-Y hepaticojejunostomy because of dilation failure. The incidence of post-LT complications (graft dysfunction, rejection, renal failure, and non-BC reoperations) was similar in both groups. There were no significant differences in the patient and graft survival between the groups. Moreover, only three deaths were attributed to BC. While female donors were protective factors for BC, donor cardiac arrest was a risk factor.

CONCLUSION

The incidence of BC was relatively low on using liver grafts > 70 years. It could be managed in most cases by percutaneous dilation or Roux-en-Y hepaticojejunostomy, without significant differences in the patient or graft survival between the groups.

Safe use of livers from deceased donors older than 70 years in recipients with HCV cirrhosis treated with direct-action antivirals. Retrospective cohort study

INTRODUCTION

There is controversy regarding the use of older grafts for liver transplantation (LT) in HCV-infected patients, but the introduction of direct-acting antivirals (DAA) can radically change that debate.

METHODS

The aim of this retrospective cohort study was to evaluate outcomes of the use of liver grafts from donors older than 70 years in recipients with HCV infection who underwent pre- or post-LT treatment with DAA. We compared two groups of patients who underwent LT using livers >70 years; the groups were defined according to antiviral therapy: non-DAA therapy group (n = 62; LT between May 1996 and December 2013), and DAA therapy group (n = 31; LT between January 2014 and December 2019).

RESULTS

Thirty (96.8%) patients of DAA therapy and nine (14.5%) of non-DAA therapy (21 patients underwent complete therapy with interferon-ribavirin) achieved sustained viral response (SVR). One, 3-, and 5-year patient survival were 83.9%, 67.7%, and 56.5% in the non-DAA group vs 93.5%, 88.4%, and 88.4% in the DAA group (P = 0.04); the 1-, 3-, and 5-year graft survival were 77.4%, 62.9%, and 51.6% in the non-DAA group vs. 88.6%, 83.7%, and 83.7% in the DAA group (P = 0.03). Multivariate analysis demonstrated donor female sex and DAA therapy as protective factors of graft survival.

CONCLUSIONS

Pre- or post-LT therapy with DAA in HCV-infected patients has achieved an almost overall SVR. The use of liver grafts >70 years in these patients treated with DAA was associated with significantly higher 5-year patient and graft survival in DAA group compared to non-DAA group. Thus, the introduction of DAA therapy has allowed the safe use of livers >70 years in HCV-positive recipients.

Minimizing Risk Associated With Older Liver Donors by Matching to Preferred Recipients: A National Registry and Validation Study

BACKGROUND

Allografts from older liver donors (OLDs), 70 years or older are often discarded for fear of inferior outcomes. We previously identified "preferred recipients" who did not suffer the higher risk of graft loss and mortality associated with OLDs. Preferred recipients were first-time, non-status 1 registrants older than 45 years, body mass index less than 35, indication other than hepatitis C, and cold ischemia time less than 8 hours.

METHODS

We assessed the validity of the preferred recipient construct in a larger, more recent cohort (38 891 patients, 2006-2013). We compared recipients of OLD grafts to recipients of average liver donors (ALDs, age = 40-69) and ideal liver donors (ILDs, age = 18-39) grafts using multilevel Cox regression adjusting for recipient and transplant factors.

RESULTS

The use of OLD grafts in preferred recipients has increased from 2006 to 2013 (P = 0.02). Preferred recipients Model for End-Stage Liver Disease scores ranged 6 to 40. Preferred recipients had similar 5-year all-cause graft loss (ACGL) with OLD versus ALD and ILD grafts (25.4% vs 24.5% and 21.6%). Conversely, nonpreferred recipients had higher 5-year ACGL with OLD versus ALD and ILD grafts (41.4% vs 32.9% and 25.6%). After adjustment, preferred recipients had similar graft loss with OLD versus ALD grafts (hazard ratio [HR], 0.921.081.27; P = 0.3) and ILD grafts (HR, 0.981.161.39, P = 0.09); however, nonpreferred recipients had higher ACGL risk with OLD grafts versus ALD (HR, 1.281.411.56, P < 0.001) and ILD grafts (HR, 1.501.671.86, P < 0.001). Similar trends are seen with mortality.

CONCLUSIONS

Because preferred recipients comprise 43.3% (n = 2916) of the current waitlist and span the full range of Model for End-Stage Liver Disease scores, transplanted OLD allografts could be distributed without added risk of graft loss or mortality.

Liver Transplantation With Old Grafts: A Ten-Year Experience

BACKGROUND

The persistent scarcity of donors has prompted liver transplantation teams to find solutions for increasing graft availability. We report our experience of liver transplantations performed with grafts from older donors, specifically over 70 and 80 years old.

PATIENTS AND METHODS

We analyzed our prospectively maintained single-center database from January 1, 2005, to December 31, 2014, with 380 liver transplantations performed in 354 patients. Six groups were composed according to donor age: <40 (n = 84), 40 to 49 (n = 67), from 50 to 59 (n = 62), from 60 to 69 (n = 76), from 70 to 79 (n = 64), and ≥80 years (n = 27).

RESULTS

Donors <40 years of age had a lower body mass index, died more often from trauma, and more often had cardiac arrest and high transaminase levels. In contrast, older donors (≥70 years of age) died more often from stroke. Recipients of grafts from donors <50 years of age were more frequently infected by hepatitis C virus; recipients of oldest grafts more often had hepatocellular carcinoma. Cold ischemia time was the shortest in donors >80 years of age. Patient survival was not significantly different between the groups. In multivariate analysis, factors predicting graft loss were transaminase peak, retransplantation and cold ischemia time but not donor age.

CONCLUSIONS

Older donors >70 and >80 years of age could provide excellent liver grafts.

Deceased donor liver transplantation from donors with central nervous system malignancy: Experience of the Inonu University

OBJECTIVE

Liver transplantation from deceased donors with a central nervous system (CNS) malignancy has some risk of tumor transmission to the recipient. Though the risk is small, this group of donors is regarded as marginal. The use of marginal grafts may be an acceptable alternative practice in order to expand the donor pool in countries where there is a shortage of donated organs. The aim of this study was to examine and present the outcomes of liver transplantations performed using donors with a CNS tumor.

METHODS

Between March 2002 and July 2017, 1990 (deceased donor: n=399, 20%; living donor: n=1591, 80%) liver transplantations were performed at the center. Of the 399 deceased donors, 17 (4.2%) had a CNS tumor. The data of donors with a CNS tumor and of recipients who survived for more than 1 month (n=11) were retrospectively reviewed. Demographic data, the grade of the CNS tumor, tumor transmission to recipient data, and survival rates were analyzed.

RESULTS

Only 2 (18%) grafts were provided locally, 6 (54%) were offered to the transplantation center after all of the national centers had declined them, and 3 (37%) were made available to us by the national coordination center for patients with a documented notification of urgency. High-grade (grade III-IV) brain tumors were detected in 7 (64%) donors, while low-grade (grade I-II) tumors were found in 2 patients. The remaining 2 donors were not pathologically graded because the diagnosis was made radiologically. The 1-, 3-, and 5-year overall and tumor-free survival of the patients was estimated at 100%, 70%, and 45%, respectively.

CONCLUSION

A median survival of 40 months (range: 13-62 months) was achieved in recipients of grafts from a donor with a CNS tumor and no donor-related malignant transformation was observed.

Liver Transplantation Results by Donor Age

OBJECTIVE

The objective of this study was to compare liver transplantation outcomes as a function of donor age.

MATERIAL AND METHODS

We performed 212 liver transplantations between 2008 and 2014. We described a prospective cohort study and grouped the patients by liver donor age. We compared quantitative and categorical variables using statistical analysis.

RESULTS

No statistically significant differences were found among any graft age groups in gender (always more males), time on waiting list, age, height, Child Pugh Turcotte (CHILD) score, Model for End-stage Liver Disease (MELD) score, need for intraoperative blood products, or intensive care unit stay. The most frequent etiology of liver failure was alcohol. A brain-dead donor was the most frequent type in all groups. The whole graft was used except in 4 cases. No statistically significant differences were found among groups in the surgical technique, postreperfusion syndrome, arterial complications, biliary complications, venous complications, acute rejection, and retransplantation. The 3-year patient survival rate was 64% in the <60-year graft age group, 48% in the 60- to 69-year group, 64% in the 70- to 79-year group, and 40% in the ≥80-year group (P = .264). The 3-year graft survival rate was 62% in the <60-year graft age group, 47% in the 60- to 69-year group, 65% in the 70- to 79-year group, and 40% in the ≥80-year group (P = .295).

CONCLUSIONS

Given the need to increase the pool of liver donors, older donors should be considered as a source for liver transplantation, although careful selection is required.

Having a Healthy Birth With a 100-Year-Old Liver

In March 2008, a 19-year-old woman required emergency liver transplantation due to acute-on-chronic liver failure. No living donor candidate was available. A marginal deceased liver that had been rejected by all the other centers was offered. The liver belonged to a 93-year-old woman and contained a hydatid cyst. Because of low donation rates in our country, we chose to accept the 93-year-old liver. The postoperative early and late courses were fortunately uneventful. Five years after transplantation, the woman became pregnant and gave birth to a healthy female baby. Today, the ages of the baby, mother, and the transplanted liver are 1, 26, and 100 years, respectively. A nonagenarian liver with hydatid disease was able to sustain its viability in a younger woman after transplant and also helped her bring in a new life into the world.