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Lerosey L, Ksiasek E, Abrahamowicz M, Antoine C, Dharancy S, Dumortier J, Doussot A, Di Martino V, Houssel-Debry P, Conti F, Francoz C, Pageaux GP, Salame E, Faitot F, Coilly A, Hardwigsen J, Decaens T, Chermak F, Muscari F, Anty R, Duvoux C, Abergel A, Minello A, Mouillot T, Binquet C, Latournerie M. Recipient age influences survival after liver transplant: Results of the French national cohort 2007-2017. Liver Int 2024; 44:1396-1408. [PMID: 38451069 DOI: 10.1111/liv.15867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 01/11/2024] [Accepted: 01/31/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND In recent years, age at liver transplantation (LT) has markedly increased. In the context of organ shortage, we investigated the impact of recipient age on post-transplantation mortality. METHODS All adult patients who received a first LT between 2007 and 2017 were included in this cross-sectional study. Recipients' characteristics at the time of listing, donor and surgery data, post-operative complications and follow-up of vital status were retrieved from the national transplantation database. The impact of age on 5-year overall mortality post-LT was estimated using a flexible multivariable parametric model which was also used to estimate the association between age and 10-year net survival, accounting for expected age- and sex-related mortality. RESULTS Among the 7610 patients, 21.4% were aged 60-65 years, and 15.7% over 65. With increasing age, comorbidities increased but severity of liver disease decreased. Older recipient age was associated with decreased observed survival at 5 years after LT (p < .001), with a significant effect particularly during the first 2 years. The linear increase in the risk of death associated with age does not allow any definition of an age's threshold for LT (p = .832). Other covariates associated with an increased risk of 5-year death were dialysis and mechanical ventilation at transplant, transfusion during LT, hepatocellular carcinoma and donor age. Ten-year flexible net survival analysis confirmed these results. CONCLUSION Although there was a selection process for older recipients, increasing age at LT was associated with an increased risk of death, particularly in the first years after LT.
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Affiliation(s)
- Lea Lerosey
- Service d'Hépato-gastro-entérologie, CHU Dijon-Bourgogne, Dijon, France
| | - Elea Ksiasek
- CHU Dijon Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
| | - Michal Abrahamowicz
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Corinne Antoine
- Agence de Biomédecine, Direction Prélèvement Greffe Organes-Tissus, Saint-Denis, France
| | - Sébastien Dharancy
- Service des maladies de l'appareil digestif, CHRU de Lille, Lille, France
- Université Lille 2 and Inserm U795, Lille, France
| | - Jérôme Dumortier
- Service d'Hépa-gastroentérologie, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Alexandre Doussot
- Service de Chirurgie Hépato-biliaire, Hôpital Jean Minjoz, Besançon, France
| | | | | | - Filomena Conti
- Service d'Hépatologie, Hôpital Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Claire Francoz
- Service d'hépatologie, Hôpital Beaujon, Assistance Publique des Hôpitaux de Paris, Paris, France
| | | | - Ephrem Salame
- Service de chirurgie digestive et transplantation hépatique, CHU Tours, Tours, France
| | | | - Audrey Coilly
- Service d'Hépatologie, Hôpital Paul Brousse, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Jean Hardwigsen
- Service de chirurgie digestive et transplantation hépatique, CHU Marseille, Marseille, France
| | - Thomas Decaens
- Service d'hépato-gastroentérologie, CHU Grenoble, Grenoble, France
| | - Faiza Chermak
- Service d'Hépato-gastro-entérologie, CHU Bordeaux, Bordeaux, France
| | - Fabrice Muscari
- Service Chirurgie Hépato-Bilio-Pancréatique et Transplantation, CHU Toulouse, Toulouse, France
| | | | | | - Armand Abergel
- Hépatologie, CHU de Clermont Ferrand, Clermont-Ferrand, France
| | - Anne Minello
- Service d'Hépato-gastro-entérologie, CHU Dijon-Bourgogne, Dijon, France
| | - Thomas Mouillot
- Service d'Hépato-gastro-entérologie, CHU Dijon-Bourgogne, Dijon, France
| | - Christine Binquet
- CHU Dijon Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
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Wang M, Shui AM, Ruck J, King E, Rahimi R, Kappus M, Volk ML, Ganger DR, Ladner DP, Duarte-Rojo A, Huang CY, Verna EC, Lai JC. The liver frailty index is a predictor of healthcare utilization after liver transplantation in older adults. Clin Transplant 2024; 38:e15219. [PMID: 38064281 PMCID: PMC11042074 DOI: 10.1111/ctr.15219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 11/15/2023] [Accepted: 11/26/2023] [Indexed: 01/31/2024]
Abstract
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.
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Affiliation(s)
- Melinda Wang
- Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Amy M. Shui
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA
| | - Jessica Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth King
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Robert Rahimi
- Division of Gastroenterology and Hepatology, Department of Medicine, Baylor Scott and White Health, Dallas, Texas, USA
| | - Matthew Kappus
- Division of Gastroenterology, Department of Medicine, Duke University Hospital, Durham, North Carolina, USA
| | - Michael L. Volk
- Division of Gastroenterology and Nutrition, Department of Medicine, Loma Linda University, Loma Linda, California, USA
| | - Daniel R. Ganger
- Division of Gastroenterology and Nutrition, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Daniela P. Ladner
- Division of Organ Transplantation, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Andres Duarte-Rojo
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA
| | - Elizabeth C. Verna
- Center for Liver Division of Digestive and Liver Diseases, Diseases and Transplantation, Columbia University Medical Center, New York, New York, USA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
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Wang R, Katz D, Lin HM, Ouyang Y, Gal J, Suresh S, Labgaa I, Tabrizian P, Demaria S, Zerillo J, Smith NK. A Retrospective Study of the Role of Perioperative Serum Albumin and the Albumin-Bilirubin Grade in Predicting Post-Liver Transplant Length of Stay. Semin Cardiothorac Vasc Anesth 2023; 27:16-24. [PMID: 36408595 DOI: 10.1177/10892532221141138] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Serum albumin's association with liver transplant outcomes has been investigated with mixed findings. This study aimed to evaluate perioperative albumin level, independently and as part of the albumin-bilirubin (ALBI) grade, as a predictor of post-liver transplant hospital and intensive care unit (ICU) length of stay (LOS). METHODS Adult liver-only transplant recipients at our institution from September 2011 to May 2019 were included in this retrospective study. Repeat transplants were excluded. Demographic, laboratory, and hospital course data were extracted from an institutional data warehouse. Negative binomial regression was used to assess the association of LOS with ALBI grade, age, BMI, ASA score, Elixhauser comorbidity index, MELD-Na, warm ischemia time, units of platelets and cryoprecipitate transfused, and preoperative serum albumin. RESULTS Six hundred and sixty-three liver transplant recipients met inclusion criteria. The median preoperative serum albumin was 3.1 [2.6-3.6] g/dL. The median postoperative ICU and hospital LOS were 3.8 [2.4-6.8] and 12 [8-20] days, respectively. Preoperative serum albumin predicted hospital but not ICU LOS (ratio .9 [95% confidence interval (CI) .84-.99], P = .03, hospital LOS vs ratio .92 [95% CI 0.84-1.02], P = .10, ICU LOS). For patients with MELD-Na ≤ 20, ALBI grade-3 predicted longer hospital and ICU LOS (ratio 1.40 [95% CI 1.18-1.66], P < .001, hospital LOS vs ratio 1.62 [95% CI 1.32-1.99], P < .001, ICU LOS). These associations were not significant for patients with MELD-Na > 20. CONCLUSIONS Serum albumin predicted post-liver transplant hospital LOS. ALBI grade-3 predicted increased hospital and ICU LOS in low MELD-Na recipients.
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Affiliation(s)
- Ryan Wang
- Department of Anesthesiology, Perioperative and Pain Medicine, 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Daniel Katz
- Department of Anesthesiology, Perioperative and Pain Medicine, 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hung-Mo Lin
- Department of Population Health Science and Policy, 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yuxia Ouyang
- Department of Population Health Science and Policy, 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jonathan Gal
- Department of Anesthesiology, Perioperative and Pain Medicine, 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sumanth Suresh
- Department of Surgery, 12298SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Ismail Labgaa
- Department of Visceral Surgery, 30635Lausanne University Hospital, Lausanne, Switzerland
| | - Parissa Tabrizian
- Recanati/Miller Transplant Institute, 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel Demaria
- Department of Anesthesiology, Perioperative and Pain Medicine, 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jeron Zerillo
- Department of Anesthesiology and Critical Care Medicine, 5803Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Natalie K Smith
- Department of Anesthesiology, Perioperative and Pain Medicine, 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Melandro F, Lai Q, Ghinolfi D, Manzia TM, Spoletini G, Rossi M, Agnes S, Tisone G, De Simone P. Outcome of liver transplantation in elderly patients: an Italian multicenter case-control study. Updates Surg 2023; 75:541-552. [PMID: 36814042 DOI: 10.1007/s13304-023-01448-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 02/03/2023] [Indexed: 02/24/2023]
Abstract
Despite the controversial results of liver transplantation (LT) in elderly recipients, the proportion of patients continues to increase. This study investigated the outcome of LT in elderly patients (≥ 65 years) in an Italian, multicenter cohort. Between January 2014 and December 2019, 693 eligible patients were transplanted, and two groups were compared: recipients ≥ 65 years (n = 174, 25.1%) versus 50-59 years (n = 519, 74.9%). Confounders were balanced using a stabilized inverse probability therapy weighting (IPTW). Elderly patients showed more frequent early allograft dysfunction (23.9 versus 16.8%, p = 0.04). Control patients had longer posttransplant hospital stays (median: 14 versus 13 days; p = 0.02), while no difference was observed for posttransplant complications (p = 0.20). At multivariable analysis, recipient age ≥ 65 years was an independent risk factor for patient death (HR 1.76; p = 0.002) and graft loss (HR 1.63; p = 0.005). The 3-month, 1-year, and 5-year patient survival rates were 82.6, 79.8, and 66.4% versus 91.1, 88.5, and 82.0% in the elderly and control group, respectively (log-rank p = 0.001). The 3-month, 1-year, and 5-year graft survival rates were 81.5, 78.7, and 66.0% versus 90.2, 87.2, and 79.9% in the elderly and control group, respectively (log-rank p = 0.003). Elderly patients with CIT > 420 min showed 3-month, 1-year, and 5-year patient survival rates of 75.7%, 72.8%, and 58.5% versus 90.4%, 86.5%, and 79.4% for controls (log-rank p = 0.001). LT in elderly (≥ 65 years) recipients provides favorable results, but inferior to those achieved in younger patients (50-59), especially when CIT > 7 h. Containment of cold ischemia time seems pivotal for favorable outcomes in this class of patients.
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Affiliation(s)
- Fabio Melandro
- Sapienza University of Rome, AOU Umberto I Policlinico of Rome, Rome, Italy.
| | - Quirino Lai
- Sapienza University of Rome, AOU Umberto I Policlinico of Rome, Rome, Italy
| | - Davide Ghinolfi
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Via Paradisa 2, 56124, Pisa, Italy
| | - Tommaso Maria Manzia
- Hepatobiliary Surgery and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, Rome, Italy
| | - Gabriele Spoletini
- General Surgery and Liver Transplantation, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Massimo Rossi
- Sapienza University of Rome, AOU Umberto I Policlinico of Rome, Rome, Italy
| | - Salvatore Agnes
- General Surgery and Liver Transplantation, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giuseppe Tisone
- Hepatobiliary Surgery and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, Rome, Italy
| | - Paolo De Simone
- Department of Surgical, Medical, Biochemical Pathology and Intensive Care, University of Pisa, Pisa, Italy
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5
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Effect of Age on Liver Transplantation Recipient Outcomes: Two Centers' Experience. Transplant Proc 2023; 55:140-146. [PMID: 36526468 DOI: 10.1016/j.transproceed.2022.10.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 10/18/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Liver diseases epidemiology has changed with advances in perioperative care. Transplantation at large centers is favorable among older and younger recipients. Local limitations on transplantation for recipients older than 65 years were cancelled in 2014. This study evaluates the effects of age on the transplantation outcome of Israeli patients in the era after removal of the limitations on recipient age. METHODS This retrospective analysis examined prospective data on patients older than 18 years who underwent liver or liver-kidney transplantation between 2014 and 2019 at 2 transplantation centers. Patients were divided into 4 age groups (group 1: ≤59 years; group 2: 60-64 years; group 3: 65-69 years; and group 4: ≥70 years). Each group's associations of pretransplantation factors with outcome and survival were examined. RESULTS Two hundred sixty-one recipients underwent 269 transplantations (mean age: 53 ± 12.61 y). There were 181 male (67.8%) and 88 female recipients (67.28%). Overall, 207 patients (79.6%) survived ≥12 months. One-year survival rates were 82.9%, 73.2%, 71.4%, and 93.8% for groups 1 to 4, respectively (not statistically significant; P = .11). One-year graft survival was similar between groups. More patients with chronic obstructive pulmonary disease, diabetes mellitus, or ischemic heart disease tended to survive <12 months. Cardiovascular complication was more common in older groups and affected survival. CONCLUSION Patient age alone should not be used to deny access to transplantation, which could benefit older nonfrail individuals. However, risk factors such as male sex, chronic obstructive pulmonary disease, ischemic heart disease, diabetes mellitus, and concomitant kidney-liver transplantation should be carefully considered.
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Wong LL, Lee LY, Karasaki K, Ogihara M, Tran C. Management of hepatocellular carcinoma in patients who are 70 years or older. Surg Open Sci 2022; 10:53-58. [PMID: 35993004 PMCID: PMC9386461 DOI: 10.1016/j.sopen.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 07/18/2022] [Indexed: 11/30/2022] Open
Abstract
Background Although liver transplantation has been done successfully in elderly patients with hepatocellular carcinoma, these are likely well-selected patients. This study uses a large database of patients with hepatocellular carcinoma to explore treatment and potential candidacy for liver transplantation in the elderly. Methods Retrospective review of 1,533 hepatocellular carcinoma cases identified 2 groups: 475 patients 70 years or older (70 +) and 1,058 patients < 70 years. Demographics, risk factors, tumor characteristics, treatments, and survival were compared. Three- and 5-year survival rates were determined, and logistic regression was used to identify factors predictive of 3-year survival. Results Patients 70 + were more likely to have metabolic factors and less likely to have viral hepatitis, cirrhosis, hepatocellular carcinoma found with surveillance (21.7% vs 28.4%, P = .005), and hepatocellular carcinoma within Milan criteria (37.3% vs 43.8%, P = .019). Model for End-stage Liver Disease score was similar, but patients 70 + had higher mean creatinine and lower mean bilirubin. Patients 70 + were equally likely to undergo liver resection but less likely to undergo liver transplantation (0.4% vs 10.2%, P < .001). Three- and 5-year survival rates were significantly worse in 70 +, and predictors of 3-year survival included hepatocellular carcinoma found with surveillance, meeting Milan criteria, and normal alpha fetoprotein. Discussion Elderly patients with hepatocellular carcinoma were less likely to undergo liver transplantation potentially due to metabolic factors and advanced disease. Although there is no age cutoff for liver transplantation, elderly patients should be given realistic expectations of liver transplantation candidacy. Continued surveillance for hepatocellular carcinoma in elderly patients may allow for earlier diagnosis and improved liver transplantation candidacy. Key Message Hepatocellular carcinoma in patients who are 70 years or older can be managed with liver transplantation in select cases, but more patients will be managed with liver resection and nonoperative therapies. Most patients with hepatocellular carcinoma who are older than 70 years will not undergo liver transplant. Older patients are more likely to have metabolic risk factors and comorbidities including diabetes, hypertension, hyperlipidemia, and nonalcoholic steatohepatitis. Older patients have similar Model for End-stage Liver Disease score as younger patients; their scores are based on having more renal dysfunction and a lower bilirubin. Older patients are less likely to have their hepatocellular carcinoma found with surveillance and are more likely to have cancer that is beyond Milan criteria which are generally used for transplant candidacy.
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Affiliation(s)
- Linda L. Wong
- Department of Surgery, University of Hawaii, John A. Burns School of Medicine, 1356 Lusitana St, 6th Floor, Honolulu, HI 96813
- Corresponding author at: 550 S Beretania St, Suite 403, Honolulu, Hawaii 96813. 808-523-5033 (business phone), 808-523-0166 (home phone); fax: 808-528-4940.
| | - Lung Yi Lee
- Department of Surgery, University of Hawaii, John A. Burns School of Medicine, 1356 Lusitana St, 6th Floor, Honolulu, HI 96813
| | - Kameko Karasaki
- Department of Surgery, University of Hawaii, John A. Burns School of Medicine, 1356 Lusitana St, 6th Floor, Honolulu, HI 96813
| | - Makoto Ogihara
- Department of Surgery, University of Hawaii, John A. Burns School of Medicine, 1356 Lusitana St, 6th Floor, Honolulu, HI 96813
| | - Chuong Tran
- Department of Medicine, University of Hawaii, John A. Burns School of Medicine, 1356 Lusitana St, 7th Floor, Honolulu, HI 96813
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Justo I, Marcacuzco A, García-Conde M, Caso O, Cobo C, Nutu A, Manrique A, Calvo J, García-Sesma A, Rivas C, Loinaz C, Jiménez-Romero C. Liver Transplantation in Sexagenarian Patients Using Grafts From Uncontrolled Circulatory Death Versus Grafts From Brain Death Donation. Transplant Proc 2022; 54:1839-1846. [PMID: 35909015 DOI: 10.1016/j.transproceed.2022.05.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 05/09/2022] [Accepted: 05/11/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND An increased number of older recipients underwent liver transplantation in recent years, and consequently needing to obtain more liver grafts. In order to increase this pool, in 2006, we initiated the use of livers from uncontrolled circulatory death (uDCD). We analyzed the use of uDCD livers in sexagenarian recipients and their effect on overall survival. METHODS A retrospective and comparative study was performed among 4 groups according to recipient age (less or greater than 60 years) and donor type (donor brain death [DBD] or uDCD): Group A: DBD livers in recipients aged <60 years (n = 169); Group B: uDCD livers in recipients aged <60 years (n = 36); Group C: DBD livers in recipients aged >60 years (n = 96); and Group D: uDCD livers in recipients aged >60 years(n = 39). RESULTS Intraoperative transfusion, biliary complications, primary non-function, acute rejection, chronic renal dysfunction, retransplantation, and mortality during follow-up (cardiovascular diseases in 3 patients, hepatitis C virus recurrence in 4 patients, and de novo malignancies in 3 patients) were significantly higher, and 5-year patient and graft survival was significantly lower in sexagenarian recipients. Bilirubin and packed red blood cells transfusion were risk factors for patient survival, whereas hepatocelular carcinoma, creatinine, and packed red blood cells transfusion were risk factors for patient survival. Recipient age (<60 years) was confirmed as protective factor for patient and graft survival, whereas the use of uDCD was not a risk factor for patient or graft survival. CONCLUSIONS Use of a uDCD liver did not demonstrate as a risk factor for patient and graft survival, and recipient age (<60 years) was a protective factor for patient and graft survival.
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Affiliation(s)
- Iago Justo
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, Instituto de Investigación (imas12), Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain.
| | - Alberto Marcacuzco
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, Instituto de Investigación (imas12), Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - María García-Conde
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, Instituto de Investigación (imas12), Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Oscar Caso
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, Instituto de Investigación (imas12), Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Cristina Cobo
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, Instituto de Investigación (imas12), Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Anisa Nutu
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, Instituto de Investigación (imas12), Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Alejandro Manrique
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, Instituto de Investigación (imas12), Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Jorge Calvo
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, Instituto de Investigación (imas12), Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Alvaro García-Sesma
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, Instituto de Investigación (imas12), Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Cristina Rivas
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, Instituto de Investigación (imas12), Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Carmelo Loinaz
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, Instituto de Investigación (imas12), Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Carlos Jiménez-Romero
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, Instituto de Investigación (imas12), Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
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Fernandes MR, Waisberg DR, Lima MRD, Rocha-Santos V, Martino RB, Pinheiro RS, Nacif LS, Ducatti L, Arantes RM, Santos JPC, Alvarez PSE, Silva NA, Dala Riva DF, Silva AM, Song AT, Lee AD, Haddad LB, Galvão FH, Andraus W, Carneiro-D'Albuquerque L. Septuagenarian Donors and Recipients in Deceased Donor Liver Transplantation: A Brazilian Single Center Experience and Literature Review. Transplant Proc 2022; 54:1329-1332. [PMID: 35690491 DOI: 10.1016/j.transproceed.2022.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 03/13/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The number of elderly patients who have end-stage liver disease and require liver transplantation has dramatically increased. On the other hand, liver grafts from elderly donors have been offered more frequently for transplantation. The present study aims to analyze the results of liver transplants performed with donors and recipients aged ≥70 years. METHODS We performed a single-center retrospective study of deceased donors liver transplants that involved recipients aged ≥7070 years or recipients who received grafts from donors aged ≥70 years from 2011 to 2021. A literature review on the results of liver transplantation in elderly recipients was also performed. RESULTS Thirty septuagenarian recipients were included; their overall 1- and 5-years survival was 80% and 76.6%, respectively. The prevalence of recipients aged ≥70 years in our department was 2.65%. Twenty recipients received grafts form septuagenarian donors; their overall 1- and 5-years survival was 75%. The prevalence of donors aged ≥70 years in our department was 1%. In the literature review, 17 articles were analyzed. The 5-years survival of recipients aged ≥70 years ranged from 47.1% to 78.5%. CONCLUSIONS Septuagenarian recipients and patients who received grafts from elderly brain-dead donors present adequate overall survival after liver transplantation. Optimized donor-recipient matching is paramount for achieving good outcomes. The combination of high-risk donors with septuagenarian recipients should be avoided as well as using grafts of elderly donors that present others risk factors. Thus, the age of the donor or recipient alone cannot be considered an absolute contraindication for liver transplantation.
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Affiliation(s)
- Michel Ribeiro Fernandes
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Daniel Reis Waisberg
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil.
| | - Marisa Rafaela Damasceno Lima
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Vinicius Rocha-Santos
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Rodrigo Bronze Martino
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Rafael Soares Pinheiro
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Lucas Souto Nacif
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Liliana Ducatti
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Rubens Macedo Arantes
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - João Paulo Costa Santos
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Paola Sofia Espinoza Alvarez
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Nataliê Almeida Silva
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Daniel Fernandes Dala Riva
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Amanda Maria Silva
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Alice Tung Song
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - André Dong Lee
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Luciana Bertocco Haddad
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Flávio Henrique Galvão
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Wellington Andraus
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Luiz Carneiro-D'Albuquerque
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
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9
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Akdur A, Karakaya E, Ayvazoglu Soy HE, Yarbug Karakayalı F, Moray G, Haberal M. Clinical Outcomes of Liver Transplantation for Patients Over 60 Years Old: A Single-Center Experience. EXP CLIN TRANSPLANT 2022; 20:31-38. [PMID: 35384805 DOI: 10.6002/ect.mesot2021.o14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Aydıncan Akdur
- From the Department of General Surgery, Division of Transplantation, Baskent University, Ankara, Turkey
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10
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Xiao J, Yong JN, Ng CH, Syn N, Lim WH, Tan DJH, Tan EY, Huang D, Wong RC, Chew NWS, Tan EXX, Noureddin M, Siddiqui MS, Muthiah MD. A Meta-Analysis and Systematic Review on the Global Prevalence, Risk Factors, and Outcomes of Coronary Artery Disease in Liver Transplantation Recipients. Liver Transpl 2022; 28:689-699. [PMID: 34626045 DOI: 10.1002/lt.26331] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/02/2021] [Accepted: 10/06/2021] [Indexed: 12/12/2022]
Abstract
The shift in the changing etiology of cirrhosis requiring liver transplantation (LT) has resulted in an increasing prevalence of coronary artery disease (CAD) that can potentially impact post-LT outcomes. This systematic review and meta-analysis evaluates the prevalence of CAD, risk factors, and outcomes of patients diagnosed with CAD before LT. MEDLINE and EMBASE were searched for articles describing CAD in pre-LT patients. Meta-analysis of proportions using the generalized linear mix model was conducted to analyze the pooled prevalence of CAD in pre-LT patients. Associated risk factors for CAD in pre-LT patients and outcomes were evaluated in conventional pairwise meta-analysis. A total of 39 studies were included. The pooled prevalence of patients diagnosed with CAD before LT was 15.9% (95% CI, 9.8%-24.7%). Age, male sex, diabetes mellitus, hypertension, hyperlipidemia, smoking, nonalcoholic steatohepatitis, hepatitis B virus, and hepatocellular carcinoma were significantly associated with CAD. Patients from high-income countries especially North America, Europe, and South America, with the associated risk factors were at increased risk for CAD before LT. CAD before LT was associated with an increased odds of overall mortality (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.4-1.4; P = 0.01) and cardiac-related mortality (OR, 1.2; 95% CI, 1.1-1.3; P = 0.03). A total of 48.7% of included articles considered the presence of cardiovascular risk factors for CAD screening. However, 10.3% of the studies screened for CAD in pre-LT patients via invasive coronary angiography only, without stress testing or risk stratification. This study demonstrates the high prevalence of CAD in pre-LT patients, associated risk factors, and outcomes. There is heterogeneity among guidelines and practice in screening for pre-LT CAD, and more studies are needed to establish consensus.
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Affiliation(s)
- Jieling Xiao
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Jie Ning Yong
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Wen Hui Lim
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - En Ying Tan
- Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Daniel Huang
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Raymond C Wong
- Department of Cardiology, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Nicholas W S Chew
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Department of Cardiology, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Eunice Xiang Xuan Tan
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Mazen Noureddin
- Cedars-Sinai Fatty Liver Program, Division of Digestive and Liver Diseases, Department of Medicine, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Mohammad Shadab Siddiqui
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Mark D Muthiah
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
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11
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Serper M, Asrani S, VanWagner L, Reese PP, Kim M, Wolf MS. Redefining Success After Liver Transplantation: From Mortality Toward Function and Fulfillment. Liver Transpl 2022; 28:304-313. [PMID: 34608746 DOI: 10.1002/lt.26325] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/31/2021] [Accepted: 09/29/2021] [Indexed: 01/13/2023]
Abstract
Liver transplantation (LT), the only cure for end-stage liver disease, is a lifesaving, costly, and limited resource. LT recipients (LTRs) are aging with an increasing burden of medical comorbidities. Patient and graft survival rates exceed 70% at 5 years; however, patient-centered health outcomes beyond survival have received relatively little attention. LTRs must have strong self-management skills to navigate health systems, adhere to clinical monitoring, and take complex, multidrug regimens. All of these tasks require formidable cognitive abilities for active learning and problem solving. Yet, LTRs are at higher risk for impaired cognition as a result of the high prevalence of pretransplant hepatic encephalopathy, multiple chronic conditions, alcohol use, physical frailty, sarcopenia, and older age. Cognitive impairment after transplant may persist and has been causally linked to poor self-management skills, worse physical function, and inferior health outcomes in other health care settings, yet its impact after LT is largely unknown. There is a need to study potentially modifiable, posttransplant targets including caregiver support, physical activity, sleep, and treatment adherence to inform future health system responses to promote the long-term health and well-being of LTRs. Prospective, longitudinal data collection that encompasses key sociodemographic, cognitive-behavioral, psychosocial, and medical factors is needed to improve risk prediction and better inform patient and caregiver expectations. Interventions with proactive monitoring, reducing medical complexity, and improved care coordination can be tailored to optimize posttransplant care. We propose a research agenda focused on understudied, potentially modifiable risk factors to improve the long-term health of LTRs. Our conceptual model accounts for cognitive function, caregiver and patient self-management skills, health behaviors, and patient-centered outcomes beyond mortality. We propose actionable health-system, patient, and caregiver-directed interventions to fill knowledge gaps and improve outcomes.
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Affiliation(s)
- Marina Serper
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | | | - Lisa VanWagner
- Division of Gastroenterology & Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.,Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.,Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Peter P Reese
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.,Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA.,Division of Renal Electrolyte and Hypertension, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Minjee Kim
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL.,Center for Circadian and Sleep Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.,Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Michael S Wolf
- Division of General Internal Medicine & Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
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12
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Avanaz A, Doğru V, Kisaoglu A, Yilmaz VT, Ünal DS, Demiryilmaz I, Dinc B, Adanir H, Aydinli B. The impact of older age on long term survival in living donor liver transplantation: A propensity score matching analysis. Asian J Surg 2021; 45:2239-2245. [PMID: 34955343 DOI: 10.1016/j.asjsur.2021.11.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/15/2021] [Accepted: 11/26/2021] [Indexed: 11/02/2022] Open
Abstract
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.
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Affiliation(s)
- Ali Avanaz
- Department of Organ Transplantation, Akdeniz University School of Medicine, Antalya, Turkey.
| | - Volkan Doğru
- Department of General Surgery, Akdeniz University School of Medicine, Antalya, Turkey
| | - Abdullah Kisaoglu
- Department of Organ Transplantation, Akdeniz University School of Medicine, Antalya, Turkey
| | - Vural Taner Yilmaz
- Department of Organ Transplantation, Akdeniz University School of Medicine, Antalya, Turkey
| | - Demet Sarıdemir Ünal
- Department of General Surgery, Akdeniz University School of Medicine, Antalya, Turkey
| | - Ismail Demiryilmaz
- Department of Organ Transplantation, Akdeniz University School of Medicine, Antalya, Turkey
| | - Bora Dinc
- Department of Anesthesiology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Haydar Adanir
- Department of Gastroenterology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Bulent Aydinli
- Department of Organ Transplantation, Akdeniz University School of Medicine, Antalya, Turkey
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13
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Kleb C, Faisal MS, Quintini C, Miller CM, Menon KVN, Modaresi Esfeh J. Factors predicting futility of liver transplant in elderly recipients: A single-center experience. World J Transplant 2021; 11:421-431. [PMID: 34722171 PMCID: PMC8529943 DOI: 10.5500/wjt.v11.i10.421] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/19/2021] [Accepted: 09/19/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND As the population of the United States ages, there has been an increasing number of elderly patients with cirrhosis listed for transplant. Previous studies have shown variable results in terms of the relative survival benefit for elderly liver transplant (LT) recipients. There may be factors that are associated with a poor post-transplant outcome which may help determine which elderly patients should and should not be listed for LT.
AIM To identify factors associated with futility of transplant in elderly patients.
METHODS This was a retrospective study of all patients above the age of 45 who underwent liver transplantation at our tertiary care center between January 2010 and March 2020 (n = 1019). “Elderly” was defined as all patients aged 65 years and older. Futile outcome was defined as death within 90 d of transplant. Logistic regression analysis was performed to determine what variables, if any were associated with futile outcome in elderly patients. Secondary outcomes such as one year mortality and discharge to facility (such as skilled nursing facility or long-term acute care hospital) were analyzed in the entire sample, compared across three age groups (45-54, 55-64, and 65 + years).
RESULTS There was a total of 260 elderly patients who received LT in the designated time period. A total of 20 patients met the definition of “futile” outcome. The mean Model of End-Stage Liver Disease scores in the futile and non-futile group were not significantly different (21.78 in the futile group vs 19.66 in the “non-futile” group). Of the variables tested, only congestive heart failure was found to have a statistically significant association with futile outcome in LT recipients over the age of 65 (P = 0.001). Of these patients, all had diastolic heart failure with normal ejection fraction and at least grade I diastolic dysfunction as measured on echocardiogram. Patients aged 65 years and older were more likely to have the outcomes of death within 1 year of LT [hazard ratio: 1.937, confidence interval (CI): 1.24-3.02, P = 0.003] and discharge to facility (odds ratio: 1.94, CI: 1.4-2.8, P < 0.001) compared to patients in younger age groups.
CONCLUSION Diastolic heart failure in the elderly may be a predictor of futility post liver transplant in elderly patients. Elderly LT recipients may have worse outcomes as compared to younger patients.
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Affiliation(s)
- Cerise Kleb
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Muhammad Salman Faisal
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Cristiano Quintini
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Charles M Miller
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - K V Narayanan Menon
- Department of Gastroenterology & Hepatology, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Jamak Modaresi Esfeh
- Department of Gastroenterology & Hepatology, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
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14
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Schlegel A, Foley DP, Savier E, Flores Carvalho M, De Carlis L, Heaton N, Taner CB. Recommendations for Donor and Recipient Selection and Risk Prediction: Working Group Report From the ILTS Consensus Conference in DCD Liver Transplantation. Transplantation 2021; 105:1892-1903. [PMID: 34416750 DOI: 10.1097/tp.0000000000003825] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Although the utilization of donation after circulatory death donors (DCDs) for liver transplantation (LT) has increased steadily, much controversy remains, and no common acceptance criteria exist with regard to donor and recipient risk factors and prediction models. A consensus conference was organized by International Liver Transplantation Society on January 31, 2020, in Venice, Italy, to review the current clinical practice worldwide regarding DCD-LT and to develop internationally accepted guidelines. The format of the conference was based on the grade system. International experts in this field were allocated to 6 working groups and prepared evidence-based recommendations to answer-specific questions considering the currently available literature. Working group members and conference attendees served as jury to edit and confirm the final recommendations presented at the end of the conference by each working group separately. This report presents the final statements and recommendations provided by working group 2, covering the entire spectrum of donor and recipient risk factors and prediction models in DCD-LT.
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Affiliation(s)
- Andrea Schlegel
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, United Kingdom
- Hepatobiliary Unit, Department of Clinical and Experimental Medicine, University of Florence, AOU Careggi, Florence, Italy
| | - David P Foley
- University of Wisconsin School of Medicine and Public Health, William S. Middleton VA Medical Center, Madison, WI
| | - Eric Savier
- Department of Hepatobiliary Surgery and Liver Transplantation, Sorbonne Université Pitié-Salpêtrière Hospital, Paris, France
| | - Mauricio Flores Carvalho
- Hepatobiliary Unit, Department of Clinical and Experimental Medicine, University of Florence, AOU Careggi, Florence, Italy
| | - Luciano De Carlis
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Nigel Heaton
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
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15
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Eng NAM, Arjunan V, Prabhakar V, Mannalithara A, Ghaziani T, Ahmed A, Kwo P, Nguyen M, Melcher ML, Busuttil RW, Florman SS, Haydel B, Ruiz RM, Klintmalm GB, Lee DD, Taner CB, Hoteit MA, Verna EC, Halazun KJ, Tevar AD, Humar A, Chapman WC, Vachharajani N, Aucejo F, Nydam TL, Markmann JF, Mobley C, Ghobrial M, Langnas AN, Carney CA, Berumen J, Schnickel GT, Sudan DL, Hong JC, Rana A, Jones CM, Fishbein TM, Agopian V, Dhanasekaran R. Posttransplant Outcomes in Older Patients With Hepatocellular Carcinoma Are Driven by Non-Hepatocellular Carcinoma Factors. Liver Transpl 2021; 27:684-698. [PMID: 33306254 PMCID: PMC8140549 DOI: 10.1002/lt.25974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/13/2020] [Accepted: 11/05/2020] [Indexed: 01/10/2023]
Abstract
The incidence of hepatocellular carcinoma (HCC) is growing in the United States, especially among the elderly. Older patients are increasingly receiving transplants as a result of HCC, but the impact of advancing age on long-term posttransplant outcomes is not clear. To study this, we used data from the US Multicenter HCC Transplant Consortium of 4980 patients. We divided the patients into 4 groups by age at transplantation: 18 to 64 years (n = 4001), 65 to 69 years (n = 683), 70 to 74 years (n = 252), and ≥75 years (n = 44). There were no differences in HCC tumor stage, type of bridging locoregional therapy, or explant residual tumor between the groups. Older age was confirmed to be an independent and significant predictor of overall survival even after adjusting for demographic, etiologic, and cancer-related factors on multivariable analysis. A dose-response effect of age on survival was observed, with every 5-year increase in age older than 50 years resulting in an absolute increase of 8.3% in the mortality rate. Competing risk analysis revealed that older patients experienced higher rates of non-HCC-related mortality (P = 0.004), and not HCC-related death (P = 0.24). To delineate the precise cause of death, we further analyzed a single-center cohort of patients who received a transplant as a result of HCC (n = 302). Patients older than 65 years had a higher incidence of de novo cancer (18.1% versus 7.6%; P = 0.006) after transplantation and higher overall cancer-related mortality (14.3% versus 6.6%; P = 0.03). Even carefully selected elderly patients with HCC have significantly worse posttransplant survival rates, which are mostly driven by non-HCC-related causes. Minimizing immunosuppression and closer surveillance for de novo cancers can potentially improve the outcomes in elderly patients who received a transplant as a result of HCC.
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Affiliation(s)
| | - Vinodhini Arjunan
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA
| | | | - Ajitha Mannalithara
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA
| | - Tara Ghaziani
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA
| | - Paul Kwo
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA
| | - Mindie Nguyen
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA
| | - Marc L. Melcher
- Department: Surgery - Multi-Organ Transplantation, Stanford University, Stanford, CA
| | - Ronald W. Busuttil
- Dumont-UCLA (University of California, Los Angeles) Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Sander S. Florman
- Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY
| | - Brandy Haydel
- Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY
| | - Richard M. Ruiz
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Goran B. Klintmalm
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - David D. Lee
- Department of Transplantation, Mayo Clinic, Jacksonville, FL
| | - C. Burcin Taner
- Department of Transplantation, Mayo Clinic, Jacksonville, FL
| | - Maarouf A. Hoteit
- Division of Gastroenterology and Hepatology, Penn Transplant Institute, University of Pennsylvania
| | | | | | - Amit D. Tevar
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Abhinav Humar
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - William C. Chapman
- Section of Transplantation, Department of Surgery, Washington University in St. Louis, St. Louis, MO
| | - Neeta Vachharajani
- Section of Transplantation, Department of Surgery, Washington University in St. Louis, St. Louis, MO
| | | | - Trevor L. Nydam
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Denver, CO
| | - James F. Markmann
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Constance Mobley
- Sherrie & Alan Conover Center for Liver Disease & Transplantation, Houston Methodist Hospital, Houston, TX
| | - Mark Ghobrial
- Sherrie & Alan Conover Center for Liver Disease & Transplantation, Houston Methodist Hospital, Houston, TX
| | - Alan N. Langnas
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Carol A. Carney
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Jennifer Berumen
- Division of Transplantation and Hepatobiliary Surgery, Department of Surgery, University of California, San Diego, San Diego, CA
| | - Gabriel T. Schnickel
- Division of Transplantation and Hepatobiliary Surgery, Department of Surgery, University of California, San Diego, San Diego, CA
| | - Debra L. Sudan
- Department of Surgery, Duke University Medical Center; Durham, NC
| | - Johnny C. Hong
- Division of Transplant Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Abbas Rana
- Department of Surgery, Baylor College of Medicine, Houston, TX
| | | | - Thomas M. Fishbein
- Section of Hepatobiliary and Transplant Surgery, University of Louisville School of Medicine, Louisville, KY,Medstar Georgetown Transplant Institute, Georgetown University, Washington, District of Columbia
| | - Vatche Agopian
- Dumont-UCLA (University of California, Los Angeles) Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
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16
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Park JY, Choi YJ, Ri HS, Lee JM, Son HJ, Lee YS, Ryu JH, Yang KH. Impact of age on the incidence of complications after liver transplantation: A single-center retrospective study. Braz J Anesthesiol 2021; 71:387-394. [PMID: 33762194 PMCID: PMC9373325 DOI: 10.1016/j.bjane.2021.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 01/31/2021] [Accepted: 02/06/2021] [Indexed: 11/29/2022] Open
Abstract
Background and objective Advances in surgical technique, postoperative management, and immunosuppressive therapy have led to a steady increase in the number of patients undergoing organ transplantation. This study aimed to compare the incidence of postoperative complications between young and elderly patients undergoing liver transplantation (LT) at a single university hospital. Method The medical records of 253 patients who underwent LT between January 2010 and July 2017 were retrospectively reviewed. The patients were divided into two groups: those younger than 65 years (group Y, n = 231) and those older than 65 years (group O, n = 22). Data on patient demographics, perioperative management, and postoperative complications were collected. Results The patients’ baseline characteristics, including underlying diseases and the Model for End-Stage Liver Disease scores, were not different between groups. Preoperative laboratory findings were not significantly different between the two groups, except for hemoglobin level. The total amounts of infused fluid and packed red blood cells were higher in group O than in group Y. The postoperative plasma creatinine level was higher in group O than in group Y; however, the incidence of postoperative complications was not considerably different between the two groups. In addition, there was no difference in the survival rate after LT depending on age. Conclusion With the development of medical technology, LT in elderly patients is not an operation to be avoided, and the prognosis is expected to improve. Therefore, continuous efforts to understand the disease characteristics and physical differences in elderly patients who require LT are essential.
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Affiliation(s)
- Ju Yeon Park
- Daedong Hospital, Department of Anesthesiology and Pain Medicine, Busan, Republic of Korea; Pusan National University Yangsan Hospital, Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Republic of Korea
| | - Yoon Ji Choi
- Korea University Ansan Hospital, Department of Anesthesia and Pain Medicine, Ansan, Korea.
| | - Hyun-Su Ri
- Pusan National University Yangsan Hospital, Department of Anesthesia and Pain Medicine, Yangsan, Republic of Korea
| | - Jung Min Lee
- Korea University Ansan Hospital, Department of Anesthesia and Pain Medicine, Ansan, Korea
| | - Hyo Jung Son
- National Police Hospital, Department of Anesthesiology and Pain Medicine, Seoul, Korea
| | - Yoon Sook Lee
- Korea University Ansan Hospital, Department of Anesthesia and Pain Medicine, Ansan, Korea
| | - Je Ho Ryu
- Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Yangsan, Republic of Korea
| | - Kwang Ho Yang
- Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Yangsan, Republic of Korea
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17
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Rodríguez-Perálvarez M, Gómez-Bravo MÁ, Sánchez-Antolín G, De la Rosa G, Bilbao I, Colmenero J. Expanding Indications of Liver Transplantation in Spain: Consensus Statement and Recommendations by the Spanish Society of Liver Transplantation. Transplantation 2021; 105:602-607. [PMID: 32345868 DOI: 10.1097/tp.0000000000003281] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The number of patients awaiting liver transplantation (LT) in Spain has halved from 2015 to 2019 due to the reduction of candidates with hepatitis C and the successful implementation of nonheart beating donation programs across the country. The Spanish Society for Liver Transplantation has committed to take advantage of this situation by developing consensus around potential areas to expand the current indications for LT. The consensus group was composed of 6 coordinators and 23 expert delegates, each one representing an LT institution in Spain. METHODS A modified Delphi approach was used to identify areas to expand indications for LT and to build consensus around paramount aspects, such as inclusion criteria and waitlist prioritization within each area. The scientific evidence and strength of recommendations were assessed by the "Grading of Recommendations Assessment, Development, and Evaluation" system. RESULTS The consensus process resulted in the identification of 7 potential areas to expand criteria in LT: recipient's age, hepatocellular carcinoma, alcoholic hepatitis, acute-on-chronic liver failure, hilar and intrahepatic cholangiocarcinoma, and unresectable liver metastases of colorectal cancer. CONCLUSIONS We present the main recommendations issued for each topic, together with their core supporting evidence. These recommendations may allow for expanding criteria for LT homogenously in Spain and may provide a guidance to other countries/institutions facing a similar scenario.
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Affiliation(s)
- Manuel Rodríguez-Perálvarez
- Department of Hepatology and Liver Transplantation, Hospital Universitario Reina Sofía, IMIBIC, CIBERehd, Córdoba, Spain
| | - Miguel Ángel Gómez-Bravo
- Department of Abdominal Surgery and Transplantation, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Gloria Sánchez-Antolín
- Department of Hepatology and Liver Transplantation, Hospital Universitario Rio Hortega, Valladolid, Spain
| | | | - Itxarone Bilbao
- Department of Liver Transplantation, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Jordi Colmenero
- Department of Hepatology and Liver Transplantation, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
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18
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Abstract
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.
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Affiliation(s)
- Claudia Cottone
- Department of Internal Medicine at Northwestern Medicine McHenry Hospital, Rosalind Franklin University of Medicine and Science, 4309 West Medical Center Drive, McHenry, IL 60050, USA.
| | - Nathalie A Pena Polanco
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, 1120 Northwest 14th Street, Suite 1105, Miami, FL 33136, USA
| | - Kalyan Ram Bhamidimarri
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, 1120 Northwest 14th Street, Suite 1144, Miami, FL 33136, USA
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19
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Abele JT, Raubenheimer M, Bain VG, Wandzilak G, AlHulaimi N, Coulden R, deKemp RA, Klein R, Williams RG, Warshawski RS, Lalonde LD. Quantitative blood flow evaluation of vasodilation-stress compared with dobutamine-stress in patients with end-stage liver disease using 82Rb PET/CT. J Nucl Cardiol 2020; 27:2048-2059. [PMID: 30456495 DOI: 10.1007/s12350-018-01516-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 10/19/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Our aim was to determine if end-stage liver disease (ESLD) is associated with an attenuated response to vasodilator-stress or dobutamine-stress using 82Rb-PET MPI with blood flow quantification. METHODS AND RESULTS Pre-liver transplant patients who had a normal dipyridamole-stress (n = 27) or dobutamine-stress (n = 26) 82Rb PET/CT MPI study with no identifiable coronary artery calcium were identified retrospectively and compared to a prospectively identified low-risk of liver disease dipyridamole-stress control group (n = 20). The dipyridamole-stress liver disease group had a lower myocardial flow reserve (MFR) (1.89 ± 0.79) than the control group (2.79 ± 0.96, P < .05). The dobutamine-stress group had a higher MFR than both other groups (3.69 ± 1.49, P < .05). A moderate negative correlation between MELD score and MFR was demonstrated for the dipyridamole-stress liver disease group (r = - 0.473, P < .05). This correlation was not observed for the dobutamine-stress liver disease group (r = - 0.253, P = .21). The liver failure group as a whole (n = 53) had a higher resting myocardial blood flow (0.97 ± 0.33 mL/min/g) than the control group (0.82 ± 0.26, P < .05). CONCLUSION Dipyridamole demonstrates an attenuated vasodilatory response in ESLD patients compared to a non-ESLD control group related to higher resting blood flow and comparatively reduced stress blood flow. Dobutamine does not demonstrate this effect implying it may be the preferred pharmacologic MPI stress agent for ESLD patients.
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Affiliation(s)
- Jonathan T Abele
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada.
- Department of Radiology and Diagnostic Imaging, 2A2.42 Walter C MacKenzie Health Sciences Centre, University of Alberta, 8440 - 112 Street NW, Edmonton, Alberta, T6G 2B7, Canada.
| | - Monique Raubenheimer
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Vincent G Bain
- Liver Unit, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Greg Wandzilak
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
| | - Naji AlHulaimi
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Richard Coulden
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
| | - Robert A deKemp
- Division of Cardiology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ran Klein
- Division of Nuclear Medicine, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Randall G Williams
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Robert S Warshawski
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
| | - Lucille D Lalonde
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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20
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Schindler TH, Leucker T. Revival of an old stressor: Dobutamine-stimulation for PET myocardial perfusion imaging in patients with end-stage liver disease? J Nucl Cardiol 2020; 27:2060-2062. [PMID: 30515744 DOI: 10.1007/s12350-018-01543-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 11/20/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Thomas H Schindler
- Division of Nuclear Medicine, Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway, St. Louis, MO, 63110, USA.
| | - Thorsten Leucker
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
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21
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Abstract
BACKGROUND Despite the increasing prevalence of end-stage liver disease in older adults, there is no consensus to determine suitability for liver transplantation (LT) in the elderly. Disparities in LT access exist, with a disproportionately lower percentage of African Americans (AAs) receiving LT. Understanding waitlist outcomes in older adults, specifically AAs, will identify opportunities to improve LT access for this vulnerable population. METHODS All adult, liver-only white and AA LT waitlist candidates (January 1, 2003 to October 1, 2015) were identified in the Scientific Registry of Transplant Recipients. Age and race categories were defined: younger white (age <60 years), younger AA, older white (age, ≥60 years), and older AA. Outcomes were delisting, transplantation, and mortality and were modeled using Fine and Gray competing risks. RESULTS Among 101 805 candidates, 58.4% underwent transplantation, 14.7% died while listed, and 21.4% were delisted. Among those delisted, 36.1% died, whereas 7.4% were subsequently relisted. Both older AAs and older whites were more likely than younger whites to be delisted and to die after delisting. Older whites had higher incidence of waitlist mortality than younger whites (subdistribution hazard ratio, 1.07; 95% confidence interval, 1.01-1.13). All AAs and older whites had decreased incidence of LT, compared with younger whites. CONCLUSIONS Both older age and AA race were associated with decreased cumulative incidence of transplantation. Independent of race, older candidates had increased incidences of delisting and mortality after delisting than younger whites. Our findings support the need for interventions to ensure medical suitability for LT among older adults and to address disparities in LT access for AAs.
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22
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Shah VH, Rao MK. Changing Landscape of Solid Organ Transplantation for Older Adults: Trends and Post-Transplant Age-Related Outcomes. CURRENT TRANSPLANTATION REPORTS 2020. [DOI: 10.1007/s40472-020-00275-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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23
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Abstract
The aging of the population, the increased prevalence of chronic liver diseases in elderly and the need to broaden the list of potential liver donors enjoin us to better understand what is an aged liver. In this review, we provide a brief introduction to cellular senescence, revisit the main morphological and functional modifications of the liver induced by aging, particularly concerning metabolism, immune response and regeneration, and try to elude some of the signalling pathways responsible for these modifications. Finally, we discuss the clinical consequences of aging on chronic liver diseases and the implications of older age for donors and recipients in liver transplantation.
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24
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Liver transplantation at safety net hospitals: Potentially vulnerable patients with noninferior outcomes. Surgery 2019; 166:1135-1141. [DOI: 10.1016/j.surg.2019.06.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 05/28/2019] [Accepted: 06/10/2019] [Indexed: 12/29/2022]
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25
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Kalra A, Kriss M, Francis P, Norvell JP. CON: Patients of Advanced Age Should Not Routinely Undergo Liver Transplantation. Clin Liver Dis (Hoboken) 2019; 14:70-73. [PMID: 31508224 PMCID: PMC6726411 DOI: 10.1002/cld.818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 02/20/2019] [Indexed: 02/04/2023] Open
Affiliation(s)
- Avash Kalra
- Division of Gastroenterology and HepatologyUniversity of Colorado School of MedicineAuroraCO
| | - Michael Kriss
- Division of Gastroenterology and HepatologyUniversity of Colorado School of MedicineAuroraCO
| | - Prashanth Francis
- Division of Gastroenterology and HepatologyUniversity of Colorado School of MedicineAuroraCO
| | - J. P. Norvell
- Division of Gastroenterology and HepatologyUniversity of Colorado School of MedicineAuroraCO
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26
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Egeli T, Unek T, Agalar C, Ozbilgin M, Derici S, Cevlik AD, Akarsu M, Ellidokuz H, Astarcioglu I. Survival Outcomes After Liver Transplantation in Elderly Patients: A Single-Center Retrospective Analysis. Transplant Proc 2019; 51:1143-1146. [PMID: 31101188 DOI: 10.1016/j.transproceed.2019.01.090] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 01/21/2019] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- T Egeli
- Hepatopancreaticobiliary Surgery and Liver Transplantation Unit, Department of General Surgery, Dokuz Eylul University School of Medicine, Izmir, Turkey.
| | - T Unek
- Hepatopancreaticobiliary Surgery and Liver Transplantation Unit, Department of General Surgery, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - C Agalar
- Hepatopancreaticobiliary Surgery and Liver Transplantation Unit, Department of General Surgery, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - M Ozbilgin
- Hepatopancreaticobiliary Surgery and Liver Transplantation Unit, Department of General Surgery, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - S Derici
- Hepatopancreaticobiliary Surgery and Liver Transplantation Unit, Department of General Surgery, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - A D Cevlik
- Hepatopancreaticobiliary Surgery and Liver Transplantation Unit, Department of General Surgery, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - M Akarsu
- Division of Gastroenterology, Department of Internal Medicine, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - H Ellidokuz
- Department of Preventive Oncology, Institute of Oncology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - I Astarcioglu
- Hepatopancreaticobiliary Surgery and Liver Transplantation Unit, Department of General Surgery, Dokuz Eylul University School of Medicine, Izmir, Turkey
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27
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Abstract
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.
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28
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Haugen CE, Holscher CM, Garonzik-Wang J, Pozo M, Warsame F, McAdams-DeMarco M, Segev DL. National Trends in Liver Transplantation in Older Adults. J Am Geriatr Soc 2018; 66:2321-2326. [PMID: 30325004 PMCID: PMC6289760 DOI: 10.1111/jgs.15583] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 07/27/2018] [Accepted: 07/31/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To explore trends in liver transplantation (LT) and outcomes for older recipients for evaluation, counseling, and appropriate referral of this vulnerable group of older adults. DESIGN Prospective national cohort study. SETTING Scientific Registry of Transplant Recipients (January 1, 2003-December 31, 2016). PARTICIPANTS Older (aged ≥ 65) deceased donor liver-only transplant recipients (n=8,627). MEASUREMENTS We evaluated temporal changes in recipient, donor, and transplant characteristics and post-LT length of stay (LOS), acute rejection, graft loss, and mortality using logistic regression and Cox proportional hazards. RESULTS LT in older adults almost quadrupled, from 263 in 2003 (9.5% of total LTs that year) to 1,144 in 2016 (20.7% of total LTs). Recent recipients were more likely to be female and African American and have a higher body mass index and Model for End-Stage Liver Disease score. Hepatitis C, nonalcoholic steatohepatitis, and hepatocellular carcinoma were the most common indications for LT in recent recipients. Odds of LOS longer than 2 weeks decreased 34% from 2003-06 to 2013-16 (adjusted odds ratio (aOR)=0.66, 95% confidence interval (CI)=0.57-0.76, P < .001), 1-year acute rejection decreased 30% (aOR=0.70, 95% CI=0.56-0.88, P = .002), all-cause graft loss decreased 54% (adjusted hazard ratio (aHR)=0.46, 95% CI=0.40-0.52, P < .001), and mortality decreased 57% (aHR=0.43, 95% CI=0.38-0.49, P < .001). CONCLUSION Despite the substantial increase in the number of older adults undergoing LT and the severity of their condition, LOS, rejection, graft loss, and mortality have significantly decreased over time. These trends can help guide appropriate LT referral and counseling in older adults with end-stage liver disease. J Am Geriatr Soc 66:2321-2326, 2018.
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Affiliation(s)
- Christine E Haugen
- Department of Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Courtenay M Holscher
- Department of Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | - Marcos Pozo
- Department of Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Fatima Warsame
- Department of Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Mara McAdams-DeMarco
- Department of Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Dorry L Segev
- Department of Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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29
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Kollmann D, Maschke S, Rasoul-Rockenschaub S, Baron-Stefaniak J, Hofmann M, Silberhumer G, Györi GP, Soliman T, Berlakovich GA. Outcome after liver transplantation in elderly recipients (>65 years) - A single-center retrospective analysis. Dig Liver Dis 2018; 50:1049-1055. [PMID: 30017655 DOI: 10.1016/j.dld.2018.06.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 04/10/2018] [Accepted: 06/19/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Liver transplantation (LT) in elderly recipients is controversially discussed in the literature with only little data on long-term outcome available. We aimed to evaluate the safety and efficiency of LT in elderly recipients (>65 years). METHODS Between 1989-2016, 139 patients >65 years-old were listed for liver transplantation, and 76 (55%) were transplanted. Patient outcome and characteristics were evaluated separately for the time period before (1989-2004) and after (2005-2016) MELD-implementation. Post-transplant outcome was compared between the elderly cohort and LT-recipients aged 18-65 years (n = 1395). RESULTS Overall survival of patients >65 years was better in the MELD-era compared to the earlier period (1- and 5-year-survival: 73%, 60% vs. 69%, 37%, respectively; p = 0.055). The main differences between the two groups included higher recipient age (p = 0.001) and BMI (p = 0.001), higher donor age (p < 0.001), less need of intraoperative red blood cells (p = 0.008) and a lower number of postoperative rejections (p = 0.03) after 2004. Comparing the overall survival of patients transplanted in the MELD-era aged 18-65 years vs. >65 years displayed comparable 1- and 5 year-survival rates (81%, 68% vs. 73% and 60%, respectively, p = 0.558). CONCLUSION In the modern era, outcome of patients receiving LT with >65 years is comparable to <65 year-old patients. After careful evaluation, patients >65 years old should be considered for LT.
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Affiliation(s)
- Dagmar Kollmann
- Department of Surgery, Division of Transplantation, Medical University of Vienna, Vienna, Austria
| | - Svenja Maschke
- Department of Surgery, Division of Transplantation, Medical University of Vienna, Vienna, Austria
| | - Susanne Rasoul-Rockenschaub
- Department of Surgery, Division of Transplantation, Medical University of Vienna, Vienna, Austria; Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Joanna Baron-Stefaniak
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Michael Hofmann
- Department of Surgery, Division of Transplantation, Medical University of Vienna, Vienna, Austria
| | - Gerd Silberhumer
- Department of Surgery, Division of Transplantation, Medical University of Vienna, Vienna, Austria
| | - Georg P Györi
- Department of Surgery, Division of Transplantation, Medical University of Vienna, Vienna, Austria
| | - Thomas Soliman
- Department of Surgery, Division of Transplantation, Medical University of Vienna, Vienna, Austria.
| | - Gabriela A Berlakovich
- Department of Surgery, Division of Transplantation, Medical University of Vienna, Vienna, Austria
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30
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Singanayagam A, Bernal W. Transplantation for the Very Sick Patient—Donor and Recipient Factors. CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0197-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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31
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Abstract
INTRODUCTION Liver transplantation has emerged as a successful therapy for end-stage liver disease. However, cardiovascular mortality is the leading cause of fatality in the postoperative period. The aim of this study was to reveal the prevalence and identify risk factors of early cardiovascular events (CVEs). METHODS We performed a retrospective study of all consecutive patients who underwent a primary liver transplantation from 1986 to 2017 (n = 916). We investigated the occurrence of in-hospital CVEs, their predictors, and short- and long-term outcome. RESULTS The prevalence of CVEs was 11%. The adjusted analysis showed that higher age (OR 1.06, 95% CI 1.03-1.09), higher MELD score (OR 1.04, 95% CI 1.01-1.07 CI) and sinus tachycardia at time of screening (OR 3.12, 95% CI 1.45-6.72) were positive predictors for a CVE. Preoperative propranolol use showed a trend towards a higher risk of CVE (OR 1.66, 95% CI 1.00-2.77, p = 0.051). In a sub-analysis of patients where echocardiography data were available (n = 597), a larger left atrial diameter and a higher E/E' ratio were related to early CVEs. Ten-year survival in 30-day survivors was favourable (68.6%; 56.0% vs. 69.8% in the CVE+ vs. the CVE-group, respectively, p = 0.056). DISCUSSION In conclusion, besides known risk factors (age and MELD score), sinus tachycardia (related to the presence of acute liver failure and cirrhosis) was an independent predictor for CVE after liver transplantation.
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32
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Niazi SK, Schneekloth TD, Vasquez AR, Keaveny AP, Davis S, Picco M, Heckman MG, Diehl NN, Jowsey-Gregoire SG, Rummans TA, Burcin Taner C. Impact of psychiatric comorbidities on outcomes of elderly liver transplant recipients. J Psychosom Res 2018; 111:27-35. [PMID: 29935751 DOI: 10.1016/j.jpsychores.2018.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 05/09/2018] [Accepted: 05/10/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study evaluated the impact of psychiatric comorbidities in liver transplant (LT) recipients aged ≥65 years (elderly) on length of hospital-stay (LOS), death, and a composite outcome of graft loss or death. METHODS This retrospective study assessed impact of psychiatric comorbidities in 122 elderly LT recipients and a matched group of 122 LT recipients aged <65 years (younger). Associations were assessed using adjusted multivariable regression models. RESULTS Among elderly, median age at LT was 68 years, most were males (62%), white (85%) and 61.7% had a history of any psychiatric diagnosis. Among younger, median age was 55, most were males (67.2%), white (77.5%) and 61.5% had any psychiatric diagnosis. Median LOS was 8 days for both groups. Among elderly, after a median follow-up of 5 years, 25.4% died and 29.5% experienced graft loss or death. History of adjustment disorder, history of depression, past psychiatric medication use, and pain prior to LT were associated with an increased risk of death or the composite graft loss or death. Perioperative use of SSRIs and lack of sleeping medication use were associated with longer LOS. Among aged <65, after median follow-up of 4.7 years, 21 patients (17%) died and 25 (20%) experienced graft loss or death; history of depression, perioperative SSRIs or sleeping medications use was associated with increased mortality and graft-loss or death. CONCLUSION Six out of 10 patients among both elderly and younger cohorts had pre-LT psychiatric comorbidities, some of which adversely affected outcomes after LT.
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Affiliation(s)
- Shehzad K Niazi
- Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, FL, United States; Department of Transplantation, Mayo Clinic, Jacksonville, FL, United States.
| | - Terry D Schneekloth
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States; William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN, United States
| | - Adriana R Vasquez
- Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, FL, United States; Department of Transplantation, Mayo Clinic, Jacksonville, FL, United States
| | - Andrew P Keaveny
- Department of Transplantation, Mayo Clinic, Jacksonville, FL, United States
| | - Susan Davis
- Mayo Clinic, Jacksonville, FL, United States
| | | | - Michael G Heckman
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL, United States
| | - Nancy N Diehl
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL, United States
| | - Sheila G Jowsey-Gregoire
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States; William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN, United States
| | - Teresa A Rummans
- Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, FL, United States; Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - C Burcin Taner
- Department of Transplantation, Mayo Clinic, Jacksonville, FL, United States
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Takahashi K, Nagai S, Safwan M, Liang C, Ohkohchi N. Thrombocytopenia after liver transplantation: Should we care? World J Gastroenterol 2018; 24:1386-1397. [PMID: 29632420 PMCID: PMC5889819 DOI: 10.3748/wjg.v24.i13.1386] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 03/06/2018] [Accepted: 03/18/2018] [Indexed: 02/06/2023] Open
Abstract
Transient thrombocytopenia is a common phenomenon after liver transplantation. After liver transplantation (LT), platelet count decreases and reaches a nadir on postoperative days 3-5, with an average reduction in platelet counts of 60%; platelet count recovers to preoperative levels approximately two weeks after LT. The putative mechanisms include haemodilution, decreased platelet production, increased sequestration, medications, infections, thrombosis, or combination of these processes. However, the precise mechanisms remain unclear. The role of platelets in liver transplantation has been highlighted in recent years, and particular attention has been given to their effects beyond hemostasis and thrombosis. Previous studies have demonstrated that perioperative thrombocytopenia causes poor graft regeneration, increases the incidence of postoperative morbidity, and deteriorates the graft and decreases patient survival in both the short and long term after liver transplantation. Platelet therapies to increase perioperative platelet counts, such as thrombopoietin, thrombopoietin receptor agonist, platelet transfusion, splenectomy, and intravenous immunoglobulin treatment might have a potential for improving graft survival, however clinical trials are lacking. Further studies are warranted to detect direct evidence on whether thrombocytopenia is the cause or result of poor-graft function and postoperative complications, and to determine who needs platelet therapies in order to prevent postoperative complications and thus improve post-transplant outcomes.
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Affiliation(s)
- Kazuhiro Takahashi
- Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, University of Tsukuba, Tsukuba, Ibaraki 3058575, Japan
| | - Shunji Nagai
- Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, ML 48202, United States
| | - Mohamed Safwan
- Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, ML 48202, United States
| | - Chen Liang
- Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, University of Tsukuba, Tsukuba, Ibaraki 3058575, Japan
| | - Nobuhiro Ohkohchi
- Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, University of Tsukuba, Tsukuba, Ibaraki 3058575, Japan
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Elderly recipients of liver transplantation: impact of age and psychosocial variables on outcome. Curr Opin Organ Transplant 2018; 22:588-592. [PMID: 28914641 DOI: 10.1097/mot.0000000000000469] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW With expanding experience and success of liver transplantation, increasing numbers of elderly candidates await and undergo liver transplantation. There is accumulating evidence that graft survival and mortality does not appear to differ significantly between the young and carefully selected elderly liver transplantation recipients. Although existing evidence suggests that psychosocial factors impact outcomes after liver transplantation in general, no such information is available specifically for elderly (age ≥65 years) liver transplantation recipients. We conducted a broad medical literature review of outcome studies of elderly liver transplantation recipients. In this review article, we summarize the findings and comment on psychosocial variables included in these studies. RECENT FINDINGS Ten outcome studies have reported on the impact of age on the liver transplantation outcomes. There is increasing evidence of favorable outcomes in elderly liver transplantation recipients. Few of these studies include measures of quality of life, functional improvement and other psychosocial variables. SUMMARY Very limited information is available about the impact of psychosocial factors on outcomes in elderly liver transplantation recipients. This dearth of information represents a critical gap in our knowledge and has implications for optimal candidate selection and outcomes after liver transplantation.
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Halliday N, Westbrook RH. Liver transplantation: need, indications, patient selection and pre-transplant care. Br J Hosp Med (Lond) 2017; 78:252-259. [PMID: 28489446 DOI: 10.12968/hmed.2017.78.5.252] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Chronic or acute liver failure and primary liver cancers can be effectively managed with liver transplantation. The range of indications for liver transplantation is increasing but there is a mismatch between the numbers of available donations and current needs. Specific criteria for listing patients exist but, at minimum, the predicted mortality without transplantation must exceed that with transplantation, coupled with a 50% predicted 5-year survival following liver transplantation. The risk posed by liver disease must be weighed against the risk of liver transplantation, considering the patient's comorbidities, age, nutritional status and behavioural factors in a complex assessment process. This article reviews current UK practice in the selection and care of patients being assessed for liver transplantation.
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Affiliation(s)
- Neil Halliday
- Wellcome Clinical Research Fellow, Institute of Immunity and Transplantation, University College London, London NW3 2PF
| | - Rachel H Westbrook
- Consultant Hepatologist, Sheila Sherlock Liver Centre, Royal Free Hospital NHS Trust, London
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36
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Leven EA, Annunziato R, Helcer J, Lieber SR, Knight CS, Wlodarkiewicz C, Soriano RP, Florman SS, Schiano TD, Shemesh E. Medication adherence and rejection rates in older vs younger adult liver transplant recipients. Clin Transplant 2017; 31. [PMID: 28370346 DOI: 10.1111/ctr.12981] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2017] [Indexed: 12/31/2022]
Abstract
A growing number of older adults are undergoing liver transplantation (LT) in the United States. In some settings, it is thought that adherence declines with age. This retrospective study examined adherence and clinical outcomes in older vs younger adult LT recipients. Medical records of adult LT recipients from 2009 to 2012 from a single urban center were reviewed. The medication level variability index (MLVI) was the predefined primary outcome, with nonadherence defined as MLVI >2.5. The secondary outcome was incidence of rejection. Outcomes were evaluated starting 1 year post-LT until 2015. A total of 42 of 248 patients were ≥65 at transplant. Older adults had significantly better adherence than younger ones (65%≥65 were adherent vs 42% younger adults; chi-square two-tailed P=.02). Survival analyses of rejection between age groups censored by time since transplant showed no difference among the four age groups (χ2 =0.84, P=.84). Older age was not found to be a risk factor for reduced adherence or graft rejection in patients surviving at least 1 year post-LT.
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Affiliation(s)
- Emily A Leven
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rachel Annunziato
- Departments of Pediatrics and Psychiatry, Icahn School of Medicine at Mount Sinai, Fordham University, New York, NY, USA
| | - Jacqueline Helcer
- Departments of Pediatrics and Psychiatry, Icahn School of Medicine at Mount Sinai, Fordham University, New York, NY, USA
| | - Sarah R Lieber
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher S Knight
- Departments of Pediatrics and Psychiatry, Icahn School of Medicine at Mount Sinai, Fordham University, New York, NY, USA
| | | | - Rainier P Soriano
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sander S Florman
- Recanati Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Thomas D Schiano
- Intestinal Transplant Program, Recanati Miller Transplant Institute, Mount Sinai Hospital, New York, NY, USA
| | - Eyal Shemesh
- Division of Developmental Behavioral Pediatrics, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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37
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Abstract
Indications for liver transplant have been extended, and older and sicker patients are undergoing transplantation. Infectious, malignant, and cardiovascular diseases account for the most posttransplant deaths. Cirrhotic patients can develop heart disease through systemic diseases affecting the heart and the liver, cirrhosis-specific heart disease, or common cardiovascular. No single factor can predict posttransplant cardiovascular complications. Patients with history of cardiovascular disease, and specific abnormalities on echocardiography, electrocardiography, or serum markers of heart disease seem to be at increased risk of complications. Pretransplant cardiovascular evaluation is essential to detecting these risk factors so their effects can be mitigated through appropriate intervention.
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38
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Hernandez Burgos PM, Lopez Menendez F, Lopez-Candales A. Reduced right ventricular functional reserve: An important end point finding during dobutamine stress echocardiography testing for liver transplant evaluation. Int J Cardiol 2016; 210:122-4. [PMID: 26942329 DOI: 10.1016/j.ijcard.2016.02.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/14/2016] [Accepted: 02/20/2016] [Indexed: 11/26/2022]
Affiliation(s)
| | - Francisco Lopez Menendez
- Department of Medicine and Cardiovascular Health and Disease Division at the University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Angel Lopez-Candales
- Cardiovascular Medicine Division at the University of Puerto Rico School of Medicine, Medical Sciences Campus, San Juan, Puerto Rico
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39
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Su F, Yu L, Berry K, Liou IW, Landis CS, Rayhill SC, Reyes JD, Ioannou GN. Aging of Liver Transplant Registrants and Recipients: Trends and Impact on Waitlist Outcomes, Post-Transplantation Outcomes, and Transplant-Related Survival Benefit. Gastroenterology 2016; 150:441-53.e6; quiz e16. [PMID: 26522262 DOI: 10.1053/j.gastro.2015.10.043] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 09/30/2015] [Accepted: 10/21/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Epidemiologic factors have generated increased demand for liver transplantation among older patients. We aimed to describe trends in age among liver transplant registrants and recipients and the effect of age on waitlist and post-transplantation outcomes and on transplant-related survival benefit. METHODS We obtained data from the United Network for Organ Sharing on adults who were listed for liver transplantation (N = 122,606) or underwent liver transplantation (N = 60,820) from 2002 to 2014 in the United States. Competing risks analysis was used to model waitlist outcomes and Cox proportional hazards analysis to model post-transplantation survival. These models were also used to estimate 5-year transplant-related survival benefit for different age groups, calculated as the difference between waitlist and post-transplantation life expectancy. RESULTS Between 2002 and 2014, the mean age of liver transplant registrants increased from 51.2 to 55.7 years, with a more prominent increase in hepatitis C virus-positive (50.9-57.9 years) than hepatitis C virus-negative (51.3-54.3 years) registrants. The proportion of registrants aged ≥60 years increased from 19% to 41%. In hepatitis C virus-negative patients, aging trends were driven by increasing proportions of patients with hepatocellular carcinoma or nonalcoholic steatohepatitis. Among transplant registrants, increasing age was associated with increasing mortality before transplantation and decreasing likelihood of transplantation. Among transplant recipients, increasing age was associated with increasing post-transplantation mortality. There was little difference in 5-year transplant-related survival benefit between different age groups who had the same Model for End-Stage Liver Disease score. CONCLUSIONS Dramatic aging of liver transplant registrants and recipients occurred from 2002 to 2014, driven by aging of the hepatitis C virus-positive cohort and increased prevalence of nonalcoholic steatohepatitis and hepatocellular carcinoma. Increasing age does not affect transplant-related survival benefit substantially because age diminishes both post-transplantation survival and waitlist survival approximately equally.
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Affiliation(s)
- Feng Su
- Division of Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Lei Yu
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Iris W Liou
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington
| | - Charles S Landis
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington
| | - Stephen C Rayhill
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, Washington
| | - Jorge D Reyes
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, Washington
| | - George N Ioannou
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington.
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40
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Sutherland AI, IJzermans JNM, Forsythe JLR, Dor FJMF. Kidney and liver transplantation in the elderly. Br J Surg 2015; 103:e62-72. [PMID: 26662845 DOI: 10.1002/bjs.10064] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 10/27/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Transplant surgery is facing a shortage of deceased donor organs. In response, the criteria for organ donation have been extended, and an increasing number of organs from older donors are being used. For recipients, the benefits of transplantation are great, and the growing ageing population has led to increasing numbers of elderly patients being accepted for transplantation. METHODS The literature was reviewed to investigate the impact of age of donors and recipients in abdominal organ transplantation, and to highlight aspects of the fine balance in donor and recipient selection and screening, as well as allocation policies fair to young and old alike. RESULTS Overall, kidney and liver transplantation from older deceased donors have good outcomes, but are not as good as those from younger donors. Careful donor selection based on risk indices, and potentially biomarkers, special allocation schemes to match elderly donors with elderly recipients, and vigorous recipient selection, allows good outcomes with increasing age of both donors and recipients. The results of live kidney donation have been excellent for donor and recipient, and there is a trend towards inclusion of older donors. Future strategies, including personalized immunosuppression for older recipients as well as machine preservation and reconditioning of donor organs, are promising ways to improve the outcome of transplantation between older donors and older recipients. CONCLUSION Kidney and liver transplantation in the elderly is a clinical reality. Outcomes are good, but can be optimized by using strategies that modify donor risk factors and recipient co-morbidities, and personalized approaches to organ allocation and immunosuppression.
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Affiliation(s)
- A I Sutherland
- Division of Hepatopancreatobiliary and Transplant Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - J N M IJzermans
- Division of Hepatopancreatobiliary and Transplant Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - J L R Forsythe
- Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - F J M F Dor
- Division of Hepatopancreatobiliary and Transplant Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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41
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Wong RJ, Aguilar M, Gish RG, Cheung R, Ahmed A. The impact of pretransplant hepatic encephalopathy on survival following liver transplantation. Liver Transpl 2015; 21:873-80. [PMID: 25902933 DOI: 10.1002/lt.24153] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 04/05/2015] [Accepted: 04/13/2015] [Indexed: 01/13/2023]
Abstract
Hepatic encephalopathy (HE) is a surrogate marker of liver disease severity, and more severe HE is associated with higher mortality among patients with chronic liver disease. However, whether severity of HE at the time of liver transplantation (LT) directly impacts post-LT survival or whether this suspected mortality linkage is due to more severe liver disease and subsequently higher rates of post-LT infection is not well defined. Using population-based data from the 2003 to 2013 United Network for Organ Sharing registry, we evaluated the impact of HE at the time of LT on post-LT survival among adults in the United States. Survival was stratified by HE severity (none, grade 1-2, grade 3-4) and Model for End-Stage Liver Disease score and was evaluated using Kaplan-Meier methods and multivariate Cox proportional hazards models. From 2003 to 2013, 59,937 patients underwent LT (36.1%, no HE; 53.8%, grade 1-2 HE; 10.2%, grade 3-4 HE). Compared to no HE, patients with grade 3-4 HE had significantly lower overall post-LT survival (1-year, 82.5% versus 90.3%; P < 0.001; 5-year, 69.1% versus 74.4%; P < 0.001). On multivariate regression, grade 3-4 HE was independently associated with lower overall post-LT survival (HR, 1.27; 95% CI, 1.17-1.39; P < 0.001). However, the increased mortality associated with HE is observed primarily within the first year following LT and was a reflection of higher rates of infection-related deaths among patients with more severe HE. In conclusion, grade 3-4 HE at the time of LT is associated with lower post-LT survival, with a proposed direct or indirect association of more severe HE before LT with increased rates of post-LT infections. Increased awareness and vigilance toward treating HE before LT and more aggressive monitoring and treatment for infections in the perioperative setting may improve LT outcomes.
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Affiliation(s)
- Robert J Wong
- Division of Gastroenterology and Hepatology, Highland Hospital, Oakland, CA
| | - Maria Aguilar
- Department of Medicine, Alameda Health System, Highland Hospital, Oakland, CA
| | - Robert G Gish
- Hepatitis B Foundation, Doylestown, PA.,Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA
| | - Ramsey Cheung
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA.,Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA
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