Survival benefit of accepting livers from deceased donors over 70 years old

Abstract

Livers from older donors (OLDs; age ≥70) are risky and often declined; however, it is likely that some candidates will benefit from OLDs versus waiting for younger ones. To characterize the survival benefit of accepting OLD grafts, we used 2009-2017 SRTR data to identify 24 431 adult liver transplant (LT) candidates who were offered OLD grafts eventually accepted by someone. Outcomes from the time-of-offer were compared between candidates who accepted an OLD graft and matched controls within MELD ± 2 who declined the same offer. Candidates who accepted OLD grafts (n = 1311) were older (60.5 vs. 57.8 years, P < .001), had a higher median MELD score (25 vs. 22, P < .001), and were less likely to have hepatitis C cirrhosis (14.9% vs. 31.2%, P < .001). Five-year cumulative mortality among those who accepted versus declined the same OLD offer was 23.4% versus 41.2% (P < .001). Candidates who accepted OLDs experienced an almost twofold reduction in mortality (aHR:_0.45 0.52_0.59 , P < .001) compared to those who declined the same offer, especially among the highest MELD (35-40) candidates (aHR:_0.10 0.24_0.55 , P = .001). Accepting an OLD offer provided substantial long-term survival benefit compared to waiting for a better organ offer, notably among candidates with MELD 35-40. Providers should consider these benefits as they evaluate OLD graft offers.

Keywords: Scientific Registry for Transplant Recipients (SRTR); clinical research/practice; donors and donation: deceased; donors and donation: extended criteria; liver transplantation/hepatology; organ acceptance.

Figure 1:. Outcomes among candidates who ever declined an older liver donor (OLD) graft between 12/28/2009–1/6/2017 (n= 23,709) stratified by allocation MELD at the time of first OLD decline. Candidates were followed forward from the date of initial OLD graft decline.

Five-year cumulative incidence is reported for each potential outcome in figure. OLD = older liver donor, DDLT= deceased donor liver transplant, *Reasons for removal from waitlist included declined transplant, transplanted at another center or in another country, candidate condition improved, living donor liver transplant, unable to contact candidate, and other

Figure 2:. Cumulative mortality after OLD offer acceptance and decline among candidates with (A) MELD 15–22, (B) MELD 23–28, (C) MELD 29–34, and (D) MELD 35–40 at time of offer.

Candidates matched on the liver offered and MELD score (within 2 points) at time of offer. Cumulative mortality post-decision to decline OLD offer includes candidates who subsequently underwent living donor LT, underwent younger donor deceased donor LT, were removed from the waitlist, and those who remained on the waitlist.