National Trends in Liver Transplantation in Older Adults

Abstract

Objectives: To explore trends in liver transplantation (LT) and outcomes for older recipients for evaluation, counseling, and appropriate referral of this vulnerable group of older adults.

Design: Prospective national cohort study.

Setting: Scientific Registry of Transplant Recipients (January 1, 2003-December 31, 2016).

Participants: Older (aged ≥ 65) deceased donor liver-only transplant recipients (n=8,627).

Measurements: We evaluated temporal changes in recipient, donor, and transplant characteristics and post-LT length of stay (LOS), acute rejection, graft loss, and mortality using logistic regression and Cox proportional hazards.

Results: LT in older adults almost quadrupled, from 263 in 2003 (9.5% of total LTs that year) to 1,144 in 2016 (20.7% of total LTs). Recent recipients were more likely to be female and African American and have a higher body mass index and Model for End-Stage Liver Disease score. Hepatitis C, nonalcoholic steatohepatitis, and hepatocellular carcinoma were the most common indications for LT in recent recipients. Odds of LOS longer than 2 weeks decreased 34% from 2003-06 to 2013-16 (adjusted odds ratio (aOR)=0.66, 95% confidence interval (CI)=0.57-0.76, P < .001), 1-year acute rejection decreased 30% (aOR=0.70, 95% CI=0.56-0.88, P = .002), all-cause graft loss decreased 54% (adjusted hazard ratio (aHR)=0.46, 95% CI=0.40-0.52, P < .001), and mortality decreased 57% (aHR=0.43, 95% CI=0.38-0.49, P < .001).

Conclusion: Despite the substantial increase in the number of older adults undergoing LT and the severity of their condition, LOS, rejection, graft loss, and mortality have significantly decreased over time. These trends can help guide appropriate LT referral and counseling in older adults with end-stage liver disease. J Am Geriatr Soc 66:2321-2326, 2018.

Keywords: graft loss; liver transplantation; mortality; older recipients.

Figure 1.

Trends in 8,627 older liver transplant (LT) recipients according to year of transplant. (A) The number of older LT recipients is shown as a bar (left y-axis), and the percentage of total older LT recipients among 58,598 adult LT recipients is shown as a line (right y-axis). (B) For all older LT recipients from 2003–2016, the nested cumulative distribution of age at the time of LT is displayed according to year of transplant.

Figure 2.

Cumulative incidence of (A) all-cause graft loss and (B) mortality in older LT recipients by year. The year and number of LT recipients is seen to the right of the curve. The most recent time periods were split at 6/18/2013 after the allocation policy implementation of Share35. This policy increases regional liver allograft offers to patients with MELD score ≥35 to direct allografts to sicker candidates.