Propensity Score–Matched Analysis of Posttransplant Outcomes in Living Donor Liver Transplantation for Older Adult Recipients

Abstract

The impact of increasing recipient age on morbidity and mortality following living donor liver transplantation (LDLT) remains controversial. The study aims to analyze the impact of recipient age on outcomes following LDLT. Data on adult LDLTs performed between November 2009 and February 2020 were retrieved from a prospectively maintained database. Patients were stratified into 2 groups based on recipient age: 18 to 65 years (younger adults) and >65 years (older adults). Propensity score matching (PSM) using nearest-neighbor matching was used to match each older recipient with up to 2 younger adult recipients using multiple preoperative parameters. Outcomes evaluated were duration of ventilation, need for reintubation, tracheostomy, intensive care unit (ICU) readmission, length of ICU and hospital stays, postoperative complications, reoperation within 90 days, and patient survival. A total of 801 adult LDLT recipients were included in the study; 751 (93.7%) were younger adults, and 50 (6.3%) were older adults. Older recipients were more likely to be diabetic (60.0% versus 39.7%) and hypertensive (44.0% versus 20.4%) with preexisting cardiac disease (28.0% versus 11.2%). However, their pretransplant Model for End-Stage Liver Disease score was significantly lower (14.5 versus 17.7), and they were more likely to receive a transplant because of hepatocellular carcinoma (38.0% versus 17.7%). Older recipients had longer durations of ventilation after LT both before (3.7 versus 1.9 days) and after PSM (4.0 versus 1.5 days). After PSM, the 30-day (13.0% versus 2.4%), 90-day (15.2% and 2.4%), and overall mortality rates (21.7% versus 7.1%) were significantly higher for older recipients when compared with younger recipients. There was no difference between the younger and older recipients with respect to other postoperative outcomes. This propensity score-matched study shows that the older LDLT recipients have higher 30-day, 90day, 1-year, and 5-year mortality rates when compared with matched younger counterparts.

Survival after LDLT in recipients ≥70 years old in the United States. An OPTN/UNOS liver transplant registry analysis

“…However, as specific comparison between older and younger recipients was not performed 28 . Most of the other reported experience is from single center reports, evaluating outcomes of adults ≥60–65y compared to younger LDLT recipients 29–36 . The present study is the first, to the best of our knowledge, specifically comparing outcomes of adult recipients ≥70y old undergoing LDLT versus DDLT.…”

Variation in adult living donor liver transplantation in the United States: Identifying opportunities for increased utilization

“…26 However, recent data suggest that older patients can successfully undergo LDLT, and increased utilization may reduce waitlist death by allowing older patients to undergo transplant with lower severity of illness and decreased risk of sarcopenia. 27 Etiology and severity of ESLD have been clearly associated with reduced utilization of LDLT in the United States. Patients with high MELD scores appear to have less physiologic reserve, less ability to survive early allograft dysfunction from a partial graft, and a higher rate of perioperative complications.…”

“…In the A2ALL analysis, lack of acceptable donors was raised as a possible issue, given restrictions on the age of eligible donors 26 . However, recent data suggest that older patients can successfully undergo LDLT, and increased utilization may reduce waitlist death by allowing older patients to undergo transplant with lower severity of illness and decreased risk of sarcopenia 27 …”

Living Donor Liver Transplantation: Is Recipient Age a Barrier?

“…(3)(4)(5)(6)(7) In this issue of Liver Transplantation, Hakeem et al assessed the impact of older recipients (aged >65 years) on the outcomes of LDLT by analyzing prospectively collected data from a large cohort of LDLTs performed at a single institute in India during a span of over 10 years. (8) The authors compared the outcomes of this population to their younger cohort of LDLT recipients (aged 18-65 years) by means of propensity score matching for preoperative recipient and donor parameters associated with LDLT outcomes. They demonstrated that recipient age is correlated with worse outcomes after LDLT, as the elderly group had higher rates of early 30-day and 90-day mortality, which leads to reduced long-term (1-year and 5-year) survival compared with younger LDLT recipients.…”