Factors predicting futility of liver transplant in elderly recipients: A single-center experience

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.

Assessment of advanced age candidates for liver transplantation warrants more caution

“…Interestingly, the authors identified CHF to be strongly associated with poor outcomes. Although the results by Kleb et al [ 1 ] are compelling, they need to be interpreted with caution. The data presented have been retrospectively reviewed, but some important indexes to estimate frailty and comorbidities, such as the Charlston Comorbidity Index[ 4 ] and Liver Frailty Index[ 5 ] have not been calculated.…”

“…We read with great interest the study from Kleb et al [ 1 ]. The authors analysed the outcome of 260 elderly patients (65 years old) undergoing liver transplantation (LT) with the aim of identifying features associated with futility, defined as death within 90 d post transplantation.…”

“…The authors analysed the outcome of 260 elderly patients (65 years old) undergoing liver transplantation (LT) with the aim of identifying features associated with futility, defined as death within 90 d post transplantation. In this retrospective study, Kleb et al [ 1 ] demonstrated that congestive heart failure (CHF) is strongly associated with futility of LT in elderly patients. Furthermore, patients aged 65 years or older had even when adjusting for severity of liver disease and comorbidities.…”

Futility and poor outcomes are not the same thing: A clinical perspective of refined outcomes definitions in liver transplantation

“…[4] Despite this, the concept of futility permeates in liver transplantation studies and remains in the OPTN statement. [5][6][7][8][9][10][11] There remains no consensus in the literature as to what defines a "futile" transplant. Proposed definitions include 1-year mortality or graft loss, [12] 90-day mortality, [5,6] 90-day or in-hospital mortality, [7] posttransplant mortality > waiting list mortality, [8] 1-year mortality after retransplant, [9] and long-term survival of <50% at 5 years.…”

“…[5][6][7][8][9][10][11] There remains no consensus in the literature as to what defines a "futile" transplant. Proposed definitions include 1-year mortality or graft loss, [12] 90-day mortality, [5,6] 90-day or in-hospital mortality, [7] posttransplant mortality > waiting list mortality, [8] 1-year mortality after retransplant, [9] and long-term survival of <50% at 5 years. [10,11] A long-term survival of <50% at 5 years after transplant has been adopted as the metric of poor posttransplant outcomes in European countries, but is not specifically related to "futility."…”