Use of Marginal Donors in Elderly Liver Transplant Recipients

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Use of Marginal Donors in Elderly Liver
Transplant Recipients

• RS Mangus, D Larson, J Fridell, R Vianna, AJ
  Tector
  
• Indiana University, School of Medicine
• Transplantation Section

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Background

• Use of extended criteria donors (ECD) is one way
  known to alleviate the shortage of donor organs
  
• Liver transplant outcomes from ECD donors are not
  well described
  
• Extended criteria for liver transplantation is
  not defined

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Background

• Potential donor factors associated with worse
  outcome in liver transplantation

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Background

• Indiana University Medical Center
• 2000 Transplants 56
• Wait List 250-300
• Wait time 3 years
• 2005 Transplants 200
• Wait List 30-40
• Wait time Median 18 days

Aggressive use of ECD (cadaveric)
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Background

• To demonstrate the impact of an intervention (use
  of ECD donors) on a population (liver transplant
  recipients), test group at highest risk for the
  anticipated outcome (poor graft function, graft
  failure, patient death).

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Background

• Levy and colleagues issued a call for caution
  in transplanting elderly persons
  
• Decreased long-term survival with increasing age
• Single center review, 1,446 OLTs, 13 years
• Age 60 years cited as an independent risk
  factor for poor outcome
  

Levy MF, Somasundar PS, Jennings LW, et al. The
elderly liver transplant recipient A call for
caution. Ann Surg 2001 233(1) 107-13.
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Background

• Liver transplantation in the elderly population
  is increasingly common, despite the scarcity of
  donor livers
  
• Account for 10-15 of liver transplants
• Elderly liver transplant patients at particularly
  high-risk given higher rate of co-morbidities
  
• Coronary artery disease
• Renal insufficiency
• Peripheral vascular disease
• Decreased functional capacity

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Background

• Transplant outcomes using ECD livers in elderly
  recipients has not been described
  
• This study evaluates the transplant outcomes in
  our elderly patients over a 3 ½ year
  period
  
• Primary non-function
• 30-day liver function
• One-year graft / patient survival

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Methods

• Database review of all liver transplants at
  Indiana University Medical Center between July 1,
  2001 and December 31, 2004 with demographics and
  transplant outcomes (n550)
• Database review of all liver donors for elderly
  recipients during same time period
  
• Inclusion Recipients 60 yrs of age (n102)
• Exclusions None

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Methods

• Extended criteria donor
• Age 60 years
• BMI 35
• Non-heart beating donor
• Serum sodium 170
• Total bilirubin 1.5
• AST or ALT 4X upper limit normal
• Serology positive HCV, HBcAb
• Cold ischemia 12 hours

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Methods

• Outcomes
• Primary non-function
• 1, 6, 12-month graft and patient survival
• 30-day post-operative liver function tests
• Total bilirubin
• AST/ALT
• Alkaline phosphatase
• Serum Creatinine

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Results
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Results
Meeting ECD criteria (number / percent)
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Results
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Figure 1. Overall graft survival
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Figure 2. Overall patient survival
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Results
30-day lab values
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Results
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Conclusions

• These results suggest that elderly recipients
  (high risk population) can routinely accept liver
  grafts from extended criteria donors
  
• 64 of donors classified as ECD
• 30-day function similar
• Primary non-function equivalent
• One-year graft / patient survival similar
• More aggressive use of extended criteria donors
  would help to alleviate the shortage of donor
  organs