No Gains in Long-term Survival After Liver Transplantation Over the Past Three Decades

Rana, Abbas; Ackah, Ruth; Webb, Gwilym; Halazun, Karim J.; Vierling, John M.; Líu, Hao; Wu, Meng-Fen; Yoeli, Dor; Kueht, Michael; Mindikoğlu, Ayşe L.; Sussman, Norman; Galván, Nhu Thao Nguyen; Cotton, Ronald T.; O’Mahony, Christine A.; Goss, John A.

doi:10.1097/sla.0000000000002650

Cited by 99 publications

(98 citation statements)

References 28 publications

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“…Only 1.7% of patients died of rejection and graft failure. 3 Long-term side effects of these drugs such as malignancies, opportunistic infections, metabolic disorders, and organ toxicities have now become a major clinical concern. The improvement in 1-year overall survival in the above-mentioned study was not seen when looked at their long-term survival.…”

Section: Introductionmentioning

confidence: 99%

“…4 In patients who have survived more than 1 year, the two leading causes of death were malignancy and infection, seen in 16.4% and 10.5% of patients, respectively. 3 Additionally, LT recipients face other organ toxicities. Renal dysfunction is the most common toxicity with stage 4 to 5 chronic renal disease occurring in nearly one fifth of recipients surviving 5 years post-LT. 5 Corticosteroids and antimetabolites, with the addition of calcineurin inhibitors (CNIs) a decade later, were the first immunosuppressive agents used among LT recipients.…”

Section: Introductionmentioning

confidence: 99%

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Update on Immunosuppression in Liver Transplantation

Taşdoğan

Şimşek

et al. 2017

Euroasian Journal of Hepato-Gastroenterology

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The standard therapy for decompensated end-stage chronic liver disease of any etiology and acute fulminant hepatic failure is liver transplantation (LT). Advances in immunosuppressive therapy decreased the rates of acute and chronic rejections. Thus, graft and patient survivals have significantly improved. However, long-term adverse effects of prolonged use of immunosuppressive agents such as malignancies, opportunistic infections, metabolic disorders, and other organ toxicities have now become a major concern. Consequently, alternative approaches are needed to deescalate the customary drugs and their side effects. Therapy must be individualized and additional preventive measures should be taken by patients with particular risk factors or predisposed to certain adverse effects. Current opinion favors a combination of agents with different mechanism of actions and toxicity profiles. Corticosteroids are employed in immediate and early postoperative period. Although they have a pronounced side effect profile, calcineurin inhibitors (CNIs) are still the backbone of early and late phase immunosuppressive regimens because of their proved efficacy. Antimetabolites are frequent choices for steroid and/or CNI-sparing strategies. Studies also have established a role for mammalian target of rapamycin (mTOR) inhibitors in specific groups of recipients. Biologic agents are a hot topic of interest and made their way into current strategies for induction. Agents extrapolated from other transplantation or immunologic experience are being evaluated.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Update on Immunosuppression in Liver Transplantation

Taşdoğan

Şimşek

et al. 2017

Euroasian Journal of Hepato-Gastroenterology

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“…Also, the temporal improvement we observed in graft and recipient survival in older LT recipients is consistent with improvement in graft and recipient survival for older kidney transplant recipients, supporting our hypothesis that improvements in immunosuppression might play a role. Finally, we found dramatic improvement in long‐term outcomes of older LT recipients that is different from a recent study that showed no improvement in long‐term outcomes for LT recipients of all ages; that report did not stratify outcomes according to age, but the majority of LT recipients are younger than 65, so it would seem that younger recipients drove those results.…”

Section: Discussionmentioning

confidence: 99%

National Trends in Liver Transplantation in Older Adults

Haugen

Holscher

Garonzik-Wang

et al. 2018

J American Geriatrics Society

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Background: The burden of end-stage liver disease in older adults has increased; understanding trends in liver transplantation (LT) and outcomes for older recipients is imperative for evaluation, counseling, and appropriate referral of this vulnerable group of older adults. Study design and setting: We studied 8,627 older (age≥65) deceased donor liver-only transplant recipients using data from the Scientific Registry of Transplant Recipients (1/1/2003–12/31/2016). We evaluated temporal changes in recipient, donor, and transplant characteristics. We also evaluated post-LT length of stay (LOS), acute rejection, graft loss, and mortality using logistic regression and Cox proportional hazards. Results: LT in older adults increased almost 5-fold from 263 in 2003 (9.5% of total LT that year) to 1,144 in 2016 (20.7% of total LT). Recent recipients were more likely to be female, African American, and have a higher BMI and MELD score. Hepatitis C, non-alcoholic steatohepatitis, and hepatocellular carcinoma were the most common indications for LT in recent recipients. Comparing those in 2013–2016 to those in 2003–2006, odds of LOS>2 weeks decreased 34% (adjusted odds ratio [aOR]:0.66, 95%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 number and severity of older adults undergoing LT, 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.

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“…Survival after liver transplantation has improved significantly to > 90% at one-year (80). The high survival rate is attributed to significant advances in immunosuppression therapy, surgical techniques and early detection of post-operative complications.…”

Section: Liver Transplantationmentioning

confidence: 99%