R. Davis1, M. S. Mulvihill1, B. A. Yerokun1, M. G. Hartwig1, A. S. Barbas1 1Duke University Medical Center,Department Of Surgery,Durham, NC, USA
Introduction: Orthotopic liver transplantation (OLT) remains the gold standard for patients with end-stage liver disease. However, the scarcity of ideal donor allografts has led to the use of extended criteria donors (ECD). While a precise definition of an ECD donor is not well defined, donor age > 60 years is thought to negatively impact survival following OLT. Despite this, use of donor allografts > 60 years old has steadily increased with reports of improved outcomes. Here, we hypothesized that the risk to recipients receiving donor allografts > 60 years old has decreased since the inception of ECD liver donation.
Methods: The OPTN/UNOS STAR (Standard Transplant Analysis and Research) file was queried for all first-time isolated adult liver transplants. From 247,723 records in the registry, this yielded 121,399 recipients suitable for analysis, representing transplants from September, 1987 to June, 2015. Cohorts were then developed based on donor age greater than 60 years old and 5-year increments of transplant date. Kaplan-Meier analysis with the log-rank test compared survival between recipients of donor allografts > 60 years across each five-year interval.
Results: Utilization of donor allografts > 60 years old for OLT has steadily increased. Before 1990, no donors over age 60 were accepted for transplant. From 1990 to 1995, 210 recipients received allografts from donors over age 60, and peaked at 3,945 recipients receiving allografts from donors > 60 years between 2005 and 2010, the last complete era available for analysis. Across all eras, recipients of allografts from donors > 60 years old tended to be older (53 vs 56 years) and be on the waitlist longer (82 vs 100 days). Recipient INR, albumin, medical condition at transplant, and creatinine were similar between groups. Donors > 60 years old had similar serum creatinine and percent steatosis. Unadjusted 5-year survival varied significantly by era of transplant, from 54.7% (1990-1995) and increasing to 69% (2010-2015).
Conclusion: This study demonstrates improved long term survival of recipients receiving donor allografts > 60 years old in the current era compared with recipients in previous eras. This data supports the continued use of ECD liver allografts > 60 years old. Further refinement of donor management, surgical techniques, and the potential use of ex vivo liver perfusion should serve to continue the trend toward improved recipient outcomes.
