Outcomes Among Older Adult Liver Transplantation Recipients in the Model of End Stage Liver Disease (MELD) Era

Abstract

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/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.

The Impact of the Meld Score on Liver Transplant Allocation and Results: An Integrative Review

“…Only one study did not include patients with a special MELD score, such as those with hepatocarcinoma 24 and one other 16 examined only cases involving patients aged over 50. …”

Liver transplantation: need, indications, patient selection and pre-transplant care

“…Age: there is no current upper age limit for transplantation in the UK. Some studies demonstrate that long-term survival decreases with age above 60 (Collins et al 2000, Malinis et al 2014 mainly due to malignancy and infection whereas others found no differences in outcomes for appropriately selected older recipients (Bromley et al 1994, Garcia et al 2001, Cross et al 2007, Sonny et al 2015.…”

Defining the threshold for too sick for transplant

“…Older age has repeatedly been associated with worse pre- and post-transplant outcomes, 2,11,12 despite selection bias towards listing and transplanting only the “healthiest” of older patients. Candidates ≥65 years compared to <65 years experience a 35% increased odds of death or delisting for being too sick for transplant and 9% decreased odds of transplant (Table 1).…”

“…13 After transplant, older recipient age is associated with an increasing adjusted risk of graft loss (Table 1). 2 There exists a powerful interaction between age and laboratory MELD score at the time of transplant. At high MELD scores, defined as >28, liver transplant recipients between 65–69 years and ≥70 years (compared to <60 years) experienced significantly increased risk of graft loss (for 65–69 years: HR 1.4, 95%CI 1.2–1.7; for ≥70 years: HR 2.4, 95%CI 1.7–3.3) [p=0.01 for the interaction between age and laboratory MELD at transplant].…”

“…Increased adjusted hazard of graft loss for recipients age 65–69 years (compared to 50–54 years): HR 1.43 (95% 1.32–1.54) and for recipients age ≥70 years: HR 1.72 (95% 1.53–1.93) 2 …”