BOSTON: Patients with advanced liver disease who accept liver transplants donated by people over age 70 reduce their long-term risk of death significantly compared with similar patients who decline the same offer. That survival benefit remains across the range of Model for End-stage Liver Disease (MELD) scores, according to new research findings presented at the American College of Surgeons Clinical Congress 2018.
Transplant surgeons predominately use livers from donors under age 70 in order to avoid risks such as graft failure or mortality. But because there is more demand than supply for organs, many patients do not survive while on the transplant waiting list.
Previous research shows that some recipients incur additional risks of graft failure with older liver donors, but the use of older liver donors may also offer a survival benefit,* according to lead study author Christine Haugen, MD, a surgery resident at Johns Hopkins Hospital, Baltimore. "We wanted to see if the use of older donors provided a survival benefit for patients across all MELD scores and also what happened to the patients who did not accept an older donor offer."
For the analysis, investigators from Johns Hopkins University looked at data from the Scientific Registry of Transplant Recipients, a prospectively collected database of all adult liver transplant candidates in the U.S. Candidates who were offered livers from donors over age 70 between 2009 and 2017 were included in the study and followed from the time of organ offer until death or end of the study.
Researchers found that 1,383 candidates on the waiting list accepted the older organ offer and 29,142 declined. The average age of the patients who declined was 58 years old and for those who accepted, 60 years old.
The study compared survival rates of patients who obtained a liver from an older donor with rates of patients who declined the same offer. Matched population groups were created based on MELD scores. Everyone on a liver transplant waiting list is given a MELD score in a range from 6 to 40, which is calculated from laboratory values. The higher the score, the more advanced the liver disease is for patients.
The researchers found that candidates who accepted an older liver donor were at a 61 percent lower risk of mortality compared with candidates who declined the organ offer.
"Our primary finding is that regardless of MELD score--that is the 15 to 40 range--there was nearly a twofold decrease in mortality beyond 90 days with acceptance of an older donor," Dr. Haugen said.
Transplant surgeons are hesitant to transplant patients with a MELD score greater than 35 using an older donor because those patients are the sickest ones on the waiting list. Their 90-day mortality is between 55 and 70 percent, Dr. Haugen said. But this analysis found that in this patient group, candidates who accepted an older liver donor reduced their risk of death by 75 percent.
"Some surgeons are reluctant to use livers from older donors because they are reluctant to use these organs in high MELD score candidates," Dr. Haugen explained. "In our study, we demonstrate that if you get an offer from an older donor, you should probably consider accepting the organ, because there is now a demonstrated survival benefit in doing so."
Additionally, in the 29 to 34 MELD score group, acceptance of an older liver donor was associated with a 60 percent lower risk of mortality. In the 23 to 28 MELD score group, acceptance of an older liver donor was associated with a 43 percent reduced risk of death. And in the 15 to 22 MELD score group, acceptance an older liver donor was associated with a 56 percent reduced risk of death.
The main takeaway is that accepting an older donor confers survival benefits for wait list candidates across the full range of MELD scores, Dr. Haugen said. "Therefore, surgeons should be aware of the consequences of declining an older liver donor for patients with any MELD score. After declining an older donor, you don't know if a candidate is going to get an offer from another donor. And unfortunately, up to one fourth of these patients will end up dying without ever receiving a transplant."
Other study authors include Courtenay M. Holscher, MD; Mary Grace Bowring, MPH; Andrew M. Cameron, MD, FACS; Benjamin Philosophe, MD, PhD; Mara McAdams-DeMarco, PhD; Dorry L. Segev, MD, FACS; and Jacqueline M. Garonzik-Wang, MD.
Funding for this study was provided by the National Institute of Diabetes and Digestive and Kidney Disease and the National Institute on Aging (grant numbers: F32AG053025, F32DK109662, F32DK113719, R01AG055781, and K24DK101828).
"FACS" designates that a surgeon is a Fellow of the American College of Surgeons.
* Haugen CE, Thomas AG, Garonzik-Wang J, Massie AB, Segev DL. Minimizing Risk Associated With Older Liver Donors by Matching to Preferred Recipients: A National Registry and Validation Study. Transplantation. 2018;102(9):1514-1519.
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