Clinical Characteristics Associated With Posttransplant Survival Among Adults 70 Years Old or Older Undergoing Liver Transplantation

Association between protein-energy malnutrition and healthcare use among adult patients after liver transplantation: A retrospective cohort study

BACKGROUND

Protein-energy malnutrition is associated with poor surgical outcomes in liver transplant patients, but its impact on healthcare use has not been precisely characterized. We sought to quantify the burden of protein-energy malnutrition in hospitalized patients undergoing liver transplantation.

METHODS

Current Procedural Terminology codes were used to identify United States hospitalizations between 2011 and 2018 for liver transplantation using the Nationwide Inpatient Sample. Patients <18 years old were excluded. Protein-energy malnutrition was identified by International Classification of Diseases Ninth and Tenth Revision codes. Multivariable regression was used to determine associations between protein-energy malnutrition and hospital outcomes, including hospital length of stay and hospital charges/costs.

RESULTS

Of 9856 hospitalizations, 2835 (29%) had protein-energy malnutrition. Patients with protein-energy malnutrition had greater comorbidity burden and in-hospital acuity (eg, dialysis, sepsis, vasopressors, or mechanical ventilation). The adjusted median difference of protein-energy malnutrition vs no protein-energy malnutrition for length of stay was 6.4 days (95% CI, 5.6-7.1; P < 0.001), for hospital charges was $108,063 (95% CI, $93,172-$122,953; P < 0.001), and for hospital costs was $23,636 (95% CI, $20,390-$26,882; P < 0.001).

CONCLUSION

Among patients undergoing liver transplantation, protein-energy malnutrition was associated with increased length of stay and hospital charges/costs. The additional cost of protein-energy malnutrition to liver transplantation programs was $23,636 per protein-energy malnutrition hospitalization. Our data justify the development of and investment in personnel and programs dedicated to reversing-or even preventing-protein-energy malnutrition in patients awaiting liver transplantation.

Simultaneous Liver and Kidney Transplantation in Patients Aged 70 y and Older: Proceed With Caution

Background

The number of elderly patients aged 70 y and older with liver and kidney failure is increasing, mainly because of increasing prevalence of metabolic dysfunction-associated steatohepatitis. At present, limited data are available on the outcomes of elderly patients who fit the criteria for dual organ transplantation since the implementation of the simultaneous liver and kidney (SLK) allocation policy.

Methods

We performed a retrospective analysis of the Organ Procurement and Transplantation Network database of adults aged 18 y and older undergoing SLK and kidney transplantation only from August 11, 2017, to December 31, 2022. We examined patient and graft survivals and compared the outcomes of the recipients aged 70 y and older undergoing SLK transplantation to those who received kidney transplant alone and kidney after liver transplant.

Results

During the study period, there has been a significant rise in the number of patients aged 70 y and older undergoing SLK transplantation, with 6 patients undergoing SLK transplantation in 2017 and 63 in 2021. Patients aged 70 y and older had significantly lower survival with 82.9% at 1 y and 66.5% at 3 y compared with 89.3% and 78.8% in the 50-69 y age group and 93.2% and 88.6% in the 18-49 y age group, respectively. Overall, kidney allograft survival was significantly lower in the 70 y and older group, with 80.9% at 1 y and 66.4% at 3 y compared with 91.1% and 75.5%, respectively, in those undergoing kidney transplant alone. There was no difference in kidney allograft survival in those undergoing SLK and kidney after liver transplantation.

Conclusions

Although the outcomes are inferior in recipients of SLK transplant aged 70 y and older, chronologic age should not preclude them from undergoing transplantation. Kidney transplantation after liver transplantation could be considered to avoid futile transplants.

The liver frailty index is a predictor of healthcare utilization after liver transplantation in older adults

BACKGROUND

Older adults have higher healthcare utilization after liver transplantation (LT), yet objective risk stratification tools in this population are lacking. We evaluated the Liver Frailty Index (LFI) as one potential tool.

METHODS

Ambulatory LT candidates ≥65 years without hepatocellular carcinoma (HCC) who underwent LT from 1/2012 to 6/2022 at 8 U.S. centers were included. Estimates of the difference in median using quantile regression were used to assess the adjusted association between LFI and hospitalized days within 90 days post-LT.

RESULTS

Of 131 LT recipients, median (interquartile range [IQR]) (1st -3rd quartiles) age was 68 years (66-70); median pre-LT MELD-Na was 19 (15-24). Median LFI was 4.1 (3.6-4.7); 27% were frail (LFI≥4.5). Median hospitalized days within 90 days post-LT was 11 (7-20). Compared with non-frail patients, frail patients were hospitalized for a median of 5 days longer post-LT (95% CI .30-9.7, p = .04). Each .5 unit increase in pre-LT LFI was associated with an increase of 1.16 days (95%CI .42-2.69, p = .02) in hospitalized days post-LT.

CONCLUSION

Among older adults undergoing LT, frailty was associated with more hospitalized days within 90 days after LT. The LFI can identify older adults who might benefit from pre-LT or early post-LT programs which may reduce post-LT healthcare utilization, such as early rehabilitation or post-hospital discharge programs.