Liver Transplant Using Donor Organs With High Liver Enzymes
Liver Transplant Using Donor Organs With High Liver Enzymes
Background: The lack of sufficient donors to satisfy the waiting list requirements has prompted many to expand the acceptance criteria. The purpose of this study was to evaluate our liver transplantation (LT) experience with donors beyond the average lifespan.
Patients and methods: From January 2008 to December 2009, we received 75 liver offers involving donors ≥75 years of age. Donor and recipient data were analysed by both uni- and multivariate Cox proportional hazard model analyses.
Results: We performed 32 adult liver transplants (43%). Half of the patients received organs through rescue allocations. Seven recipients (22%) developed initial poor function. Two had primary graft non-function (PNF). Four recipients were re-transplanted (two PNF and two ischaemic-type bile lesions). One- and 3-year cumulative survival was 62 and 51% respectively. PNF, lab model for end-staged liver disease (MELD), post-LT haemodialysis, post-LT re-operations and post-LT sepsis were significant predictors by univariate analysis. Only PNF reached multivariate significance (P = 0.0307). Rescue offer allocation reached significance as a predictor of PNF by general linear model forward analysis. One- and 3-year 'MELD based allocation' (n=16) vs 'rescue allocation' (n=16) survival rates were 44 and 29% vs 82 and 76% respectively (P = 0.0197).
Conclusions: Although grafts from donors ≥75 years allow for an expansion of the donor pool, long-term recipient survival is inferior to that encountered with younger donors. Acceptable results could be obtained by identifying 'preferred' recipients for rescue allocations.
Although liver transplantation (LT) has become a routine procedure, and improvements in surgical technique, immunosuppression and patient management have been associated with better outcomes, the incidence of deaths among waiting list patients continues to increase. Options such as split LT, living donor LT and domino LT remain confined to large transplant centres, and the procurement of non-heart beating donors is possible only in countries with appropriate legislation (Germany not being one of them). A promising alternative to augment the donor pool is the use of expanded/extended criteria (previously called marginal) organs/donors. Although the definition of 'expanded liver donor criteria' is not clearly established, variables such as obesity [body mass index (BMI) > 27–30 kg/m), macrovesicular steatosis > 30–50%, intensive care unit (ICU) stay > 4–5 days, hypotensive episodes > 1 h with mean blood pressure < 60 mmHg, high vasopressor requirements (dopamine dose > 10 μg/kg/min or the use of other catechol amines), cardiac arrest, cold ischaemia time (CIT) > 12–14 h, warm ischaemia time (WIT) > 40–45 min, peak serum sodium > 150–155 mEq/l, sepsis, hepatitis infections, alcoholism, bilirubin level > 2.0 mg/dl, alanine aminotransferase (ALT) > 170 U/l and aspartate aminotransferase (AST) > 150 U/l represent risk factors for initial poor graft function (IPF) and primary graft non-function (PNF). Long-term patient survival, however, does not seem to be influenced.
Donor age also represents a potential factor associated with post-transplant outcome, and could constitute one of the parameters characterizing extended donor criteria. The impact of donor age on short- and long-term graft/patient survival is well documented in the literature. Initial reports addressing donors > 50 years or > 55 years were followed by publications extending the age to > 60 years, to > 65 years, to septuagenarians and eventually to octogenarians.
We herein describe our LT experience with organs from donors over 75 years of age, the average life expectancy for males in USA according to the World Health Organization.
Abstract and Introduction
Abstract
Background: The lack of sufficient donors to satisfy the waiting list requirements has prompted many to expand the acceptance criteria. The purpose of this study was to evaluate our liver transplantation (LT) experience with donors beyond the average lifespan.
Patients and methods: From January 2008 to December 2009, we received 75 liver offers involving donors ≥75 years of age. Donor and recipient data were analysed by both uni- and multivariate Cox proportional hazard model analyses.
Results: We performed 32 adult liver transplants (43%). Half of the patients received organs through rescue allocations. Seven recipients (22%) developed initial poor function. Two had primary graft non-function (PNF). Four recipients were re-transplanted (two PNF and two ischaemic-type bile lesions). One- and 3-year cumulative survival was 62 and 51% respectively. PNF, lab model for end-staged liver disease (MELD), post-LT haemodialysis, post-LT re-operations and post-LT sepsis were significant predictors by univariate analysis. Only PNF reached multivariate significance (P = 0.0307). Rescue offer allocation reached significance as a predictor of PNF by general linear model forward analysis. One- and 3-year 'MELD based allocation' (n=16) vs 'rescue allocation' (n=16) survival rates were 44 and 29% vs 82 and 76% respectively (P = 0.0197).
Conclusions: Although grafts from donors ≥75 years allow for an expansion of the donor pool, long-term recipient survival is inferior to that encountered with younger donors. Acceptable results could be obtained by identifying 'preferred' recipients for rescue allocations.
Introduction
Although liver transplantation (LT) has become a routine procedure, and improvements in surgical technique, immunosuppression and patient management have been associated with better outcomes, the incidence of deaths among waiting list patients continues to increase. Options such as split LT, living donor LT and domino LT remain confined to large transplant centres, and the procurement of non-heart beating donors is possible only in countries with appropriate legislation (Germany not being one of them). A promising alternative to augment the donor pool is the use of expanded/extended criteria (previously called marginal) organs/donors. Although the definition of 'expanded liver donor criteria' is not clearly established, variables such as obesity [body mass index (BMI) > 27–30 kg/m), macrovesicular steatosis > 30–50%, intensive care unit (ICU) stay > 4–5 days, hypotensive episodes > 1 h with mean blood pressure < 60 mmHg, high vasopressor requirements (dopamine dose > 10 μg/kg/min or the use of other catechol amines), cardiac arrest, cold ischaemia time (CIT) > 12–14 h, warm ischaemia time (WIT) > 40–45 min, peak serum sodium > 150–155 mEq/l, sepsis, hepatitis infections, alcoholism, bilirubin level > 2.0 mg/dl, alanine aminotransferase (ALT) > 170 U/l and aspartate aminotransferase (AST) > 150 U/l represent risk factors for initial poor graft function (IPF) and primary graft non-function (PNF). Long-term patient survival, however, does not seem to be influenced.
Donor age also represents a potential factor associated with post-transplant outcome, and could constitute one of the parameters characterizing extended donor criteria. The impact of donor age on short- and long-term graft/patient survival is well documented in the literature. Initial reports addressing donors > 50 years or > 55 years were followed by publications extending the age to > 60 years, to > 65 years, to septuagenarians and eventually to octogenarians.
We herein describe our LT experience with organs from donors over 75 years of age, the average life expectancy for males in USA according to the World Health Organization.