Liver Transplantation Trends for Older Recipients: Regional and Ethnic Variations

Impact of Recipient Age at Liver Transplant on Long-term Outcomes

BACKGROUND

The age of a liver transplant (LT) candidate is one of many variables used in the transplant selection process. Most research about the age at transplant has used prespecified age ranges or categories in assessing associations with transplant outcomes. However, there is a lack of knowledge about the age at transplant and survival. This study aimed to examine associations of age at transplant as a continuous variable, in conjunction with other patient and disease-related factors, with patient and graft survival after LT.

METHODS

We used the Standard Transplant Analysis and Research data to identify LT recipients between January 2002 and June 2018. Cox regression models with a restricted cubic spline term for age examined associations with graft and patient survival after LT. We assessed the interactions of age with recipients' sex, race/ethnicity, region, indication for transplant, body mass index, model for end-stage liver disease score, diabetes, functional status at transplant, and donor risk index.

RESULTS

Age at the time of LT showed a nonlinear association with both graft and patient survival. Each demographic, clinical, transplant-related, and donor-related factor influenced these relationships differently.

CONCLUSIONS

Our results suggest that some older LT candidates may be better than some younger candidates and that clinicians should not exclusively use age to determine who receives LT.

Access to Liver Transplantation for Hepatocellular Carcinoma: Does Candidate Age Matter?

BACKGROUND

Liver transplantation (LT) offers an effective alternative treatment for unresectable hepatocellular carcinoma (HCC). Despite its growing acceptance and longer life expectancy rates, survival data in older patients are conflicting and consensus guidelines are lacking in terms of a cut-off age range for operations.

STUDY DESIGN

We explored our prospectively maintained institutional database to identify patients diagnosed with HCC between January 1, 2002 and December 31, 2019. Long-term oncologic outcomes were analyzed in patients undergoing LT or hepatic resection, with patient age considered as the primary variable.

RESULTS

In total, 1,629 patients with HCC were identified, of whom 700 were considered for curative operations (LT, n = 538; resection, n = 162). Patients older than 65 years were less likely to be considered for LT (p < 0.01), although there were no age-related differences in the de-listing rate among age groups (p = 0.90). Older patients had overall survival (OS) outcomes comparable with younger patients after LT (3-year OS: 85.5% vs 84%; 5-year OS: 73.9% vs 77%; p = 0.26). Long-term survival was lower in the group who underwent resection, however, older patients still demonstrated equivalent OS outcomes (3-year OS: 59% vs 64.8%; 5-year OS: 44.8% vs 49%; p = 0.13). There were no differences in the development of local or distant metastatic disease between groups.

CONCLUSIONS

Although older candidates were less likely to be considered for LT in the management of HCC, judicious matching can lead to OS data comparable with their younger counterparts. Previous age misconceptions need to be challenged without the concern of worse long-term oncologic outcomes after surgery.

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

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

Ethnic and Age Disparities in Outcomes Among Liver Transplant Waitlist Candidates

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.

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

BACKGROUND AND AIMS

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

Advanced age alone should not exclude patients from LT.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Liver transplantation in New Orleans: parity in a world of disparity?

BACKGROUND

Racial disparity in access to liver transplantation among African Americans (AA) compared to Caucasians (CA) has been well described. The aim of this investigation was to examine the presentation of AA liver transplant recipients in a socioeconomically challenged region.

METHODS

680 adult liver transplant candidates and 233 resultant recipients between 2007 and 2015 were analyzed using univariate and multivariate analyses to evaluate factors significant for transplantation.

RESULTS

Percentages of wait list patients transplanted were similar between CA and AA (34.9% vs. 32.2%, p = 0.5205). AA were younger (50.4 ± 1.8 vs. 56.3 ± 0.7 yrs, p = 0.0003) with higher average MELD scores (22.9 ± 1.6 vs. 19.4 ± 0.7, p = 0.0230). Overall patient mortality was similar (AA 22.7% vs. CA 26.3%, p = 0.5931). A multiple linear regression showed that male gender was strongly associated with transplantation.

CONCLUSIONS

Equal access to liver transplantation remains challenging for racial minorities. At our institution, AA were accepted and transplanted at an equivalent rate as CA despite a higher AA population, HCV rate and diagnosed HCC. AA were younger and sicker at the time of transplant, but overall had similar outcomes compared to CA. Our study highlights the need for studies to delineate the underpinnings of disparity in transplantation access.

Outcomes Between Elderly and Young Hepatocellular Carcinoma Living Donor Liver Transplantation Recipients: A Single-Center Experience

Although older age theoretically might be a negative risk factor for liver transplantation (LT) outcomes, age alone should not exclude a patient from waiting list. This study is to investigate the outcomes of elderly hepatocellular carcinoma (HCC) living donor liver transplantation (LDLT) recipients which meet Milan criteria.A retrospective study was performed in a single liver transplantation center. Demographic and clinical data of 110 HCC LDLT recipients from January 2004 to December 2012 were collected and analyzed, including 31 elderly recipients in group E (≥ 60 years) and 79 younger recipients in group Y (<60 years).Recipients' age between 2 groups were significantly different (65.4  ±  4.8 vs 49.9  ±  5.9, P = 0.000). There was no significant difference in preoperative demographic data as well as postoperative liver function. Complication rates, length of ICU and hospital stay, graft loss, and mortality were similar in both groups, as well as the 1-, and 3-year overall and disease-free survival rates (77.4%, and 64.5% vs 82.8%, and 44.6%, P = 0.458; 94.7%, and 80.7% vs 98.6%, and 85.9%, P = 0.661). When recipients were further stratified into group E1, E2, Y1, and Y2, no significant difference was found in 1-, and 3-year overall and disease-free survival rates. In multivariate analysis, recipients' age was not a predictor for long-term survival.Following rigorous listing criteria, if overall clinical conditions and comorbidities allowed, elderly HCC recipients achieved similar LDLT outcomes and survival rates with the younger HCC recipients.

Elderly versus young liver transplant recipients: patient and graft survival

The indications for organ transplantation continue to broaden with advances in perioperative care and immunosuppression. The elderly have especially benefited from this progress; advanced age is no longer considered a contraindication to transplantation at most centers. Although numerous studies support the use of renal allografts in older patients, only a few centers have addressed this issue as it pertains to liver transplantation. Published studies have revealed that operative course, length of hospitalization, and incidence of perioperative complications among patients older than 60 years of age are comparable with their younger adult counterparts. In our study we analyzed the clinical experiences of two centers with primary cadaveric orthotopic liver transplantations comparing patients older than 63 with patients younger than 40 years of age, suggesting no difference in unadjusted survival with age stratification. Now age cannot be considered to be a contraindication to liver transplantation.

Outcomes among older adult liver transplantation recipients in the model of end stage liver disease (MELD) era

BACKGROUND

Since 2002, the Model of End Stage Liver Disease (MELD) score has been the basis of the liver transplant (LT) allocation system. Among older adult LT recipients, short-term outcomes in the MELD era were comparable to the pre-MELD era, but long-term outcomes remain unclear.

MATERIAL AND METHODS

This is a retrospective cohort study using the UNOS data on patients age ≥ 50 years who underwent primary LT from February 27, 2002 until October 31, 2011.

RESULTS

A total of 35,686 recipients met inclusion criteria. The cohort was divided into 5-year interval age groups. Five-year over-all survival rates for ages 50-54, 55-59, 60-64, 65-69, and 70+ were 72.2%, 71.6%, 69.5%, 65.0%, and 57.5%, respectively. Five-year graft survival rates after adjusting for death as competing risk for ages 50-54, 55-59,60-64, 65-69 and 70+ were 85.8%, 87.3%, 89.6%, 89.1% and 88.9%, respectively. By Cox proportional hazard modeling, age ≥ 60, increasing MELD, donor age ≥ 60, hepatitis C, hepatocellular carcinoma (HCC), dialysis and impaired pre-transplant functional status (FS) were associated with increased 5-year mortality. Using Fine and Gray sub-proportional hazard modeling adjusted for death as competing risk, 5-year graft failure was associated with donor age ≥ 60, increasing MELD, hepatitis C, HCC, and impaired pre-transplant FS.

CONCLUSIONS

Among older LT recipients in the MELD era, long-term graft survival after adjusting for death as competing risk was improved with increasing age, while over-all survival was worse. Donor age, hepatitis C, and pre-transplant FS represent potentially modifiable risk factors that could influence long-term graft and patient survival.

De novo malignancy post-liver transplantation: a single center, population controlled study

BACKGROUND

With the growing numbers of liver transplant recipients, it is increasingly important to understand the risks of de novo malignancy after liver transplantation.

AIM

To characterize the incidence of de novo malignancy after liver transplantation compared with a control non-transplant population.

METHODS

We studied 534 Indiana state residents undergoing liver transplantation at our center between 1997 and 2004, followed through August 2010. The incidence and predictors of malignancy were determined. The standardized incidence ratio (SIR) of cancer in our cohort was compared with age-, gender-, and period-matched state population using the Indiana State Cancer Registry.

RESULTS

After a mean follow-up of 5.7 ± 3.2 yr, 73 patients (13.7%) developed 80 cancers, with five- and 10-yr incidence rates of 11.7% and 24.8%, respectively. These included 24 (30%) skin, 16 (20%) hematologic, and 40 (50%) solid tumors. The most common solid cancers were aerodigestive. Compared with matched state population, liver transplant recipients had significantly higher incidence of all cancers (SIR: 3.1, 95% CI [Confidence interval]: 2.9-3.2), skin (melanoma) (SIR: 5.8, 95% CI: 4.7-7.0), hematologic (SIR: 7.1, 95% CI: 6.3-8.0), and solid (SIR: 2.7, 95% CI: 2.5-2.8) tumors.

CONCLUSION

There is a significantly increased risk of de novo malignancies after liver transplantation, highlighting the need for surveillance strategies in this population.

Autoimmune hepatitis in diverse ethnic populations and geographical regions

Autoimmune hepatitis has diverse clinical phenotypes and outcomes in ethnic groups within a country and between countries, and these differences may reflect genetic predispositions, indigenous etiological agents, pharmacogenomic mechanisms and socioeconomic reasons. In the USA, African-American patients have cirrhosis more commonly, treatment failure more frequently and higher mortality than white American patients. Survival is poorest in Asian-American patients. Autoimmune hepatitis in other countries is frequently associated with genetic predispositions that may favor susceptibility to indigenous etiological agents. Cholestatic features influence treatment response; acute-on-chronic liver disease increases mortality and socioeconomic and cultural factors affect prognosis. Ethnic-based deviations from classical phenotypes and the frequency of late-stage disease can complicate the diagnosis and management of autoimmune hepatitis in non-white populations.

Model for end-stage liver disease dynamic stratification of survival benefit

Only patients with Model for End-stage Liver Disease (MELD) scores ≥18 or ≥17 experience a survival benefit (SB) at 12 and 36 months after liver transplantation (OLT). The SB calculation estimates the difference after stratification for risk categories between the survival rate of transplanted versus waiting list patients. The aim of this study was to perform a short- and long-term (60 months) SB analyses of a Italian OLT program. One-hundred seventy-one patients were stratified into four MELD classes (6-14, 15-18, 19-25, 26-40), and two groups: namely, waiting list (WL) and transplanted groups (TX). The median waiting time for transplanted patients was 4.4 months (range, 0-35). SB was expressed as mortality hazard ratio (MHR) as obtained through a Cox regression analysis using as a covariate the status of each patient in the waiting list (WL = 0, reference group) or the TX group (TX = 1). Values over 1 indicated the MHR in favor of the WL with the values below 1 indicating MHR in favor of Tx. In the MELD class 6 to 14, the MHR was above 1 at 3 and 6 months, indicating an SB in favor of WL; subsequently, the MHR dropped below 1, indicating an SB in favor of TX (P < .05). In the MELD class 15 to 18 the MHR was above 1 at 3 months, but below 1 subsequently (P < .05). For MELD classes 19 to 25 and 26 to 40, the MHR was always below 1 (P < .01). According to the SB approach, patients in the MELD class 6 to 14 could safely wait for at least 36 months; patients in the MELD class 15 to 18 should likely remain no longer than 12 months on the waiting list, and all the remaining patients with MELD > 18 should be transplanted as soon as possible. OLT should not be precluded but only postponed for MELD < 19 patients.

Liver transplantation trends in the HIV population

There is a paucity of information on the utilization patterns of liver transplantation (LT) for HIV-positive individuals. The aim of this study is to examine the trends in LT of HIV patients in the US. This study was a retrospective analysis using the UNOS database (1999-2008). There were 135 HIV-positive patients. There was a steady increase in the number of LT recipients over time as well as regional variation. Ethnic minorities accounted for 33.3% and there was no ethnic difference in survival. Though LT for HIV-positive patients is on the rise, significant variations exist in patient demographics, geographic location, and insurance payer.

The MELD score in patients awaiting liver transplant: strengths and weaknesses

Adoption of the Model for End-stage Liver Disease (MELD) to select and prioritize patients for liver transplantation represented a turning point in organ allocation. Prioritization of transplant recipients switched from time accrued on the waiting list to the principle of "sickest first". The MELD score incorporates three simple laboratory parameters (serum creatinine and bilirubin, and INR for prothrombin time) and stratifies patients according to their disease severity in an objective and continuous ranking scale. Concordance statistics have demonstrated its high accuracy in stratifying patients according to their risk of dying in the short-term (three months). Further validations of MELD as a predictor of survival at various temporal end-points have been obtained in independent patient cohorts with a broad spectrum of chronic liver disease. The MELD-based liver graft allocation policy has led to a reduction in waitlist new registrations and mortality, shorter waiting times, and an increase in transplants, without altering overall graft and patient survival rates after transplantation. MELD limitations are related either to the inter-laboratory variability of the parameters included in the score, or to the inability of the formula to predict mortality accurately in specific settings. For some conditions, such as hepatocellular carcinoma, widely accepted MELD corrections have been devised. For others, such as persistent ascites and hyponatremia, attempts to improve MELD's predicting power are currently underway, but await definite validation.

Elderly Transplant Recipients

While the total number of organs transplanted in this country has increased over the years, there is still an ever-widening gap between the need for organs and our capacity to meet that need as the overall waiting list continues to grow. This is due in part to significant advances in transplant techniques and outcomes such that Americans with organ failure now seek transplants in greater numbers. Additionally, life-expectancy gains in the United States are creating an aging population who are more likely to suffer organ failure than younger Americans. The national transplant waiting list has continued to shift toward older candidates. The Scientific Registry of Transplant Recipients (SRTR) reported that at the end of 2007, 59.7% of all 97,248 candidates on the waiting list for all organs were 50 years old or older, and 14.9% were 65 years or older. These percentages are substantially higher than they were in 1998 (41.5 and 8.1%, respectively) [1].

Recipient-based approach to tailoring immunosuppression in liver transplantation

Improvements in the field of transplant immunosuppression (IS) have led to significant advances in long-term survival of liver transplant recipients. Despite this progress, survival rates vary depending on recipient, donor and/or perioperative factors. Tailoring IS based on recipient factors is of growing interest among health care providers involved in the care of organ transplant recipients. To date there is no consensus document addressing individualized IS therapy for liver transplant recipients. This review will discuss the information available on the effect of the various IS drugs on recipient-based factors such as age, ethnicity, and liver disease etiology.

From cancer to transplantation: an evaluation of period analysis for calculating up-to-date long-term survival estimates

The timeliness of survival monitoring is particularly important in a field such as transplantation medicine, where progress occurs rapidly. Period analysis, a method successfully applied for improving the timeliness of survival monitoring in population-based cancer survival analysis, could potentially be useful in the field of transplantation as well. Using data from the Collaborative Transplant Study, the authors compared the ability of traditional, cohort-based analysis methods and the period analysis method to provide timely 5-year graft and patient survival estimates for kidney, heart, and liver transplants in 6 age groups (0-17, 18-29, 30-39, 40-49, 50-59, >or=60 years) on 378 occasions between 1990-1992 and 2000-2002. Overall, period estimates provided superior predictions for the survival of most recent transplants on 344 of 378 occasions (91%); in the organ-specific analysis, this proportion ranged between 83% for heart and 100% for kidney graft survival. This evaluation provides evidence that the period analysis method can improve the timeliness of survival monitoring in solid organ transplantation. The method appears useful for providing more up-to-date long-term survival estimates than traditional methods, and its use in pertinent studies is encouraged.

Six score systems to evaluate candidates with advanced cirrhosis for orthotopic liver transplant: Which is the winner?

Many prognostic systems have been devised to predict the outcome of liver transplantation (LT) candidates. Today, the Model for End-Stage Liver Disease (MELD) is widely used for organ allocation, but it has shown some limitations. The aim of this study was to investigate the performance of MELD compared to 5 different score models. We evaluated the prognostic ability of MELD, modified Child-Turcotte-Pugh, MELD-sodium, United Kingdom MELD, updated MELD, and integrated MELD in 487 candidates with cirrhosis for LT at the Bologna Transplant Centre, Bologna, Italy, between 2003 and 2008. Calibration analysis by Hosmer-Lemeshow test, calibration curves, and concordance c-statistics (area under the receiver operating characteristic curve [AUC]) were calculated at 3, 6, and 12 months. Actual cumulative survival curves, taking into account the event of interest in the presence of competing risk, were obtained using the best cutoffs identified by AUC. For each score, the Hosmer-Lemeshow test revealed a good calibration. Integrated MELD showed calibration curves closer to the line of perfect predicting ability, followed by MELD-sodium at 3 months and modified Child-Turcotte-Pugh at 6 months. MELD-sodium AUCs at 3 and 6 months (0.798 and 0.765, respectively) and integrated MELD AUC at 6 months (0.792) were better than standard MELD (P < 0.05). Actual survival curves showed that these 2 scores were able to identify the patients with the highest drop-out risk. In conclusion, MELD-sodium and integrated MELD were the best prognostic models to predict drop-out rates among patients awaiting LT.