Case Control Study
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Dec 21, 2018; 24(47): 5391-5402
Published online Dec 21, 2018. doi: 10.3748/wjg.v24.i47.5391
Analyzing predictors of graft survival in patients undergoing liver transplantation with donors aged 70 years and over
Oscar Caso-Maestro, Carlos Jiménez-Romero, Iago Justo-Alonso, Jorge Calvo-Pulido, David Lora-Pablos, Alberto Marcacuzco-Quinto, Félix Cambra-Molero, Alvaro García-Sesma, Marina Pérez-Flecha, Carlos Muñoz-Arce, Carmelo Loinaz-Segurola, Alejandro Manrique-Municio
Oscar Caso-Maestro, Carlos Jiménez-Romero, Iago Justo-Alonso, Jorge Calvo-Pulido, Alberto Marcacuzco-Quinto, Félix Cambra-Molero, Alvaro García-Sesma, Marina Pérez-Flecha, Carlos Muñoz-Arce, Carmelo Loinaz-Segurola, Alejandro Manrique-Municio, Unit of HBP Surgery and Abdominal Organs Transplantation, Department of General Surgery, “12 de octubre” University Hospital, Madrid 28041, Spain
David Lora-Pablos, Clinical Research Department, Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), “12 de octubre” University Hospital, Madrid 28041, Spain
Author contributions: Caso-Maestro O designed research, analyzed data and wrote the paper; Jiménez-Romero C designed the research and analyzed data; Justo-Alonso I participated collected and analyzed data; Calvo-Pulido J, Marcacuzco-Quinto A, Cambra-Molero F, García-Sesma A, Pérez-Flecha M, Muñoz-Arce C and Loinaz-Segurola C collected data; Lora-Pablos D performed the research and contributed new reagents or analytic tools; Manrique-Municio A participated collected and analyzed data.
Institutional review board statement: This study was approved by the institutional review board of “12 de octubre” University Hospital.
Informed consent statement: Patients were not required to give the informed consent to the study because the analysis used the anonymous data that were collected after each patient agreed to treatment.
Conflict-of-interest statement: The authors have declared no conflicts of interest.
Data sharing statement: No additional data is available.
STROBE statement: The authors have read the STROBE checklist and have checked the manuscript accordingly.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author to: Oscar Caso-Maestro, MD, PhD, Associate Professor, Staff Physician, Surgeon, Unit of HBP Surgery and Abdominal Organs Transplantation, Department of General Surgery, “12 de octubre” University Hospital, Av. Córdoba s/n, Madrid 28041, Spain.
Telephone: +34-91-3908294
Received: October 5, 2018
Peer-review started: October 5, 2018
First decision: November 7, 2018
Revised: November 24, 2018
Accepted: November 30, 2018
Article in press: November 30, 2018
Published online: December 21, 2018
Research background

The increased life expectancy of the general population makes that donor age should also increase to ensure the number of available donors. Concerns regarding the use of aged organs are the perception of greater susceptibility to ischemic damage resulting in higher risk of initial poor function or primary non-function. There are limited published data evaluating results of liver transplantation (LT) with these donors and only a few of them try to identify predictors of graft survival.

Research motivation

Some authors have suggested that if we identify which variables are able to predict survival, careful donor to recipient matching could avoid some complications after LT with aged donors and improve patient and graft survival.

Research objectives

The main objective of our study is to evaluate LT outcomes with donors ≥ 70 years old using a large single-center cohort, identify predictors of graft survival and compare our results with previously published.

Research methods

We analyzed all LT performed at our department between April 1986 and May 2016 with donors ≥ 70 years old, then we compared the outcomes with those obtained using younger donors in the same period and finally a multivariate Cox proportional hazard model was applied to analyze the prognostic value for the risk of graft loss in all LT performed with aged donors.

Research results

The use of donors ≥ 70 years old is a safe strategy to expand the donor pool. Graft and patient survivals are similar to those obtained with the use of younger grafts without increasing the risk of complications, especially primary non-function, vascular complications and biliary complications. We identified 5 independent predictors of graft survival: donor serum sodium and serum glutamic-pyruvic transaminase, recipient age, hepatitis C virus (HCV) and donor age X model for end-stage liver disease (D-MELD). Finally, we formulated a score using the D-MELD in combination with the age of the recipient (we called it DR-MELD), and we analyzed its ability to predict graft survival in the study group according to the presence or absence of the HCV. A DR-MELD < 75000 was a good measure to predict graft survival when using grafts ≥ 70 years old regardless the presence of HCV.

Research conclusions

The use of aged donors in LT is not associated with higher primary non-function or other complications if we perform a careful donor selection. The current study emphasizes on the importance of identifying predictors of graft survival before donor to recipient matching. With the arrival of direct-acting antivirals, the results of LT with aged donors in HCV patients have changed and donor age will not influence anymore LT results in HCV recipients. Donor age, recipient age, MELD, cold ischemia time and the presence of steatosis seems to be the best predictors of graft survival after analyze the outcomes of several studies.

Research perspectives

The use of aged donors is a safe alternative to expand the donor pool in LT with brain death donors. Additional studies are needed to investigate if the donor age could also be increased with marginal donors such as non-heart beating, split or living donors.