Use of Octogenarian Donors for Liver Transplantation: A Survival Analysis

Abstract

Use of very old donors in liver transplantation (LT) is controversial because advanced donor age is associated with a higher risk for graft dysfunction and worse long-term results, especially for hepatitis C virus (HCV)-positive recipients. This was a retrospective, single-center review of primary, ABO-compatible LT performed between 2001 and 2010. Recipients were stratified in four groups based on donor age (<60 years; 60-69 years; 70-79 years and !80 years) and their outcomes were compared. A total of 842 patients were included: 348 (41.3%) with donors <60 years; 176 (20.9%) with donors 60-69 years; 233 (27.7%) with donors 70-79 years and 85 (10.1%) with donors !80 years. There was no difference across groups in terms of early ( 30 days) graft loss, and graft survival at 1 and 5 years was 90.5% and 78.6% for grafts <60 years; 88.6% and 81.3% for grafts 60-69 years; 87.6% and 75.1% for grafts 70-79 years and 84.7% and 77.1% for grafts !80 years (p ¼ 0.065). In the group !80 years, the 5-year graft survival was lower for HCV-positive versus HCV-negative recipients (62.4% vs. 85.6%, p ¼ 0.034). Based on our experience, grafts from donors !80 years may provide favorable results but require appropriate selection and allocation policies.

Liver transplant using octogenarian donors

“…(3) If death occurs in increasingly older individuals, it is reasonable to expect deceased donor age to rise as well. In accordance with this hypothesis, Ghinolfi et al (4) report that liver transplantations (LTs) from octogenarian donors increased constantly between 2001 (3.5%) and 2010 (16.1%); this result is consistent with data from Spain (5) and from the European Liver Transplant Registry. (6) In our series (1571 liver transplants performed between December 1985 and December 2015), the first LT with an octogenarian donor was in 2002; in 2015, 11% of LTs were performed with octogenarian grafts.…”

“…Furthermore in the current decade, the control over HCV infection (an independent predictor of poor survival in transplants from octogenarian grafts (4) ) may lessen concerns on accepting and allocating very old grafts thus increasing their use.…”

Strategies to optimize the use of marginal donors in liver transplantation

“…Despite numerous studies, the impact of each donor variable on recipient outcome is still debated due to controversial results. Some authors reported that careful liver graft selection provides comparable results vs optimal donor grafts, and some recent studies confirm these findings [4][5] . Nevertheless, the reported results may be related to specific donor demographic characteristics (i.e., healthier life styles) or to the experience of transplant teams with management of these donors [6] .…”

“…The concept of extended criteria donors (ECD) was introduced to indicate donors associated with a higher risk of primary non function (PNF) of the liver graft, delayed graft function (DGF), and a poorer prognosis after transplantation. Elderly donors (> 60 years), donors with malignancies, infections, macrovescicular steatosis > 30%, donors after cardiac death (DCD), hypernatremia, hemodynamic instability, prolonged cold ischemia time (CIT), split liver grafts, and living donor liver transplants (LDLT) are all included in this category [3][4][5] . Despite numerous studies, the impact of each donor variable on recipient outcome is still debated due to controversial results.…”

Reply

“…(2) The key factors for the successful use of elderly donors are surgical experience, accurate evaluation of graft quality and vascular patency, and a flexible algorithm of donor-to-recipient allocation. (3) A recent survey appointed by the Regional Ministry of Health in Tuscany and based on hospital discharge forms has investigated the number of patients admitted to regional hospitals in 2015 with severe acute cerebrovascular accidents and dying within 72 hours after admission. Of 1675 patients, 389 (23%) were admitted to intensive care units and resulted in 332 brain death evaluations, whereas 1286 (77%) were admitted to nonintensive care settings and were reported as cardiac deaths (with a mean and median age of 84 and 86 years, respectively).…”