Orthotopic liver transplantation (OLT) is an established life-saving procedure for alcoholic cirrhotic (AC) patients, but the incidence of de novo tumors ranges between 2.6% and 15.7% and is significantly increased in comparison with patients who undergo OLT for other etiologies. Tobacco, a known carcinogen, has been reported to be between 52% and 83.3% in AC patients before OLT. Other risk factors that contribute to the development of malignancies are dose-dependent immunosuppression, advanced age, viral infections, sun exposure, and premalignant lesions (inflammatory bowel disease, Barrett's esophagus). A significantly more frequent incidence of upper aerodigestive (UAD) tract, lung, skin, and kidney-bladder tumors has been found in OLT recipients for AC in comparison with other etiologies. Liver transplant recipients who develop de novo non-skin tumors have a decreased long-term survival rate compared with controls. This significantly lower survival rate is more evident in AC recipients who develop UAD tract or lung tumors after OLT mainly because the diagnosis is usually performed at an advanced stage. All transplant candidates, especially AC patients, should be encouraged to cease smoking and alcohol consumption in the pre- and post-OLT periods, use skin protection, avoid sun exposure and over-immunosuppression, and have a yearly otopharyngolaryngeal exploration and chest computed tomography scan in order to prevent or reduce the incidence of de novo malignancies. Although still under investigation, substitution of calcineurin inhibitors for sirolimus or everolimus may reduce the incidence of de novo tumors after OLT.

AIMTo increase the number of available grafts.METHODSThis is a single-center comparative analysis performed between April 1986 and May 2016. Two hundred and twelve liver transplantation (LT) were performed with donors ≥ 70 years old (study group). Then, we selected the first cases that were performed with donors < 70 years old immediately after the ones that were performed with donors ≥ 70 years old (control group).RESULTSGraft and patient survivals were similar between both groups without increasing the risk of complications, especially primary non-function, vascular complications and biliary complications. We identified 5 risk factors as independent predictors of graft survival: recipient hepatitis C virus (HCV)-positivity [hazard ratio (HR) = 2.35; 95% confidence interval (CI): 1.55-3.56; P = 0.00]; recipient age (HR = 1.04; 95%CI: 1.02-1.06; P = 0.00); donor age X model for end-stage liver disease (D-MELD) (HR = 1.00; 95%CI: 1.00-1.00; P = 0.00); donor value of serum glutamic-pyruvic transaminase (HR = 1.00; 95%CI: 1.00-1.00; P = 0.00); and donor value of serum sodium (HR = 0.96; 95%CI: 0.94-0.99; P = 0.00). After combining D-MELD and recipient age we obtained a new scoring system that we called DR-MELD (donor age X recipient age X MELD). Graft survival significantly decreased in patients with a DR-MELD score ≥ 75000, especially in HCV patients (77% vs 63% at 5 years in HCV-negative patients, P = 0.00; and 61% vs 25% at 5 years in HCV-positive patients; P = 0.00).CONCLUSIONA DR-MELD ≥ 75000 must be avoided in order to obtain the best results in LT with donors ≥ 70 years old.

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Resumen El trasplante hepático ortotópico (THO) es el tratamiento de elección en hepatopatía crónica terminal y fallo hepático fulminante. Los excelentes resultados han llevado a un aumento de los pacientes en lista de espera, mientras que el número de donantes permanece estable. Por tanto, la principal limitación del THO es el acceso a un injerto hepático. La manera de conseguir más injertos hepáticos es utilizar donantes marginales, grupo no bien definido donde se incluyen donantes >60 años, con hipernatremia o macroesteatosis hepática >30%, donantes con infección viral VHC o VHB, isquemia fría >12 h, donantes después de muerte circulatoria e injertos procedentes de bipartición hepática o donante vivo. Actualmente, la medida más práctica y frecuente para aumentar el número de injertos hepáticos, y así reducir la mortalidad en lista de espera, es utilizar los injertos de edad avanzada. El objetivo de este trabajo es revisar el proceso de envejecimiento hepático y revisar las experiencias referidas en la literatura en cuanto a utilización de injertos añosos para ver si se debe establecer un límite de edad para THO. Actualmente, hay suficientes estudios que acreditan el uso de injertos sexagenarios y septuagenarios para THO en comparación con donantes más jóvenes. Respecto al uso de donantes octogenarios hay menos experiencias y con menos casos, aunque su utilización está progresivamente aumentando por la necesidad de disminuir la mortalidad de los pacientes en lista de espera. Para obtener buenos resultados utilizando injertos hepáticos sin límite de edad, debe hacerse una selección cuidadosa de los donantes (función hepática normal, buenas condiciones y estabilidad hemodinámica, estancia en UCI<72 h, isquemia fría <8 h, isquemia caliente <1 h, macroesteatosis <30%, ausencia de ateromatosis en arteria hepática y alteraciones histológicas), biopsia hepática en donantes >80 años y evitar implantar estos injertos en receptores con mala función hepática (puntuación MELD alta).