Liver transplantation in the elderly: Is caution warranted?

Abstract

COMMENTSThe average age of liver transplant recipients has steadily increased over recent years. During the early liver transplantation experience, most programs set an upper age limit of 50 to 55 years; however, with improved operative procedures and immunosuppressive therapy, liver transplantation was extended to older recipients. The proportion of liver transplant recipients greater than 60 years of age increased from 10% in 1989 to almost 20% in 1998. 1 Transplantation is now being performed in patients as old as 78 years of age. 2 Concerns over the cost effectiveness of medical care and the equitable allocation of donor organs have caused some individuals to question liver transplantation in the elderly. This subject has been studied by many investigators over the past decade, with the prevailing opinion that elderly recipients of liver allografts fare as well as younger recipients. 3 Despite this, several groups are now reexamining the practice of liver transplantation in elderly patients. One such evaluation was reported by Levy et al., in the article abstracted above.Early studies of liver transplantation in the elderly indicated that postoperative survival was comparable in older and younger recipients. In 1991, Pirsch et al. reported that patient and graft survival were equivalent in older and younger recipients, as was postoperative morbidity. 4 Specifically, they noted a 2-year survival of 83% in recipients age 60 and older, compared with 76% in those age 18 to 59. Critics of this and similar studies, however, suggested that the favorable outcome in elderly patients was because of cautious patient selection, with older patients being accepted for transplantation only if they were excellent candidates in all other respects. 2 In 1998, Zetterman et al. undertook a large study in which agerelated outcomes were measured in liver allograft recipients with similar disease severity. 2 Patients over 60 years of age had lower 1-year survival rates after transplantation (81% vs. 90%, P ϭ .004) and longer hospital and ICU stays than younger patients. The excess mortality in the older patients was due primarily to nonhepatic causes, including infections, cardiac disease, and neurologic complications. Although these outcomes favored the younger patients, quality of life after transplantation was comparable between younger and older recipients, and there was a lower incidence of acute rejection among the older patients. Based on these findings, the authors concluded that transplantation was justified in older patients. In a similar recent study, Collins et al. compared liver transplantation outcomes in patients over 60 years of age with those in younger adults. 5 The length of hospitalization was the same for both groups, as was the incidence of rejection, infection, repeat operation, and repeat transplantation. There was a difference in long-term survival between the 2 groups, with poorer 5-year survival (52% vs. 75%, P Ͻ .05) and 10-year survival (35% vs. 60%, P Ͻ .05) in the older patients. Despite the...

Our experience in liver transplantation in patients over 65 yr of age

“…A different interpretation of the data presented and those of others (20)(21)(22) could be that the overall results of transplant in patients over 65 yr are worser than those in the under 65-yr group. Consequently, it would be considered that transplant should not be systematically indicated in elderly patients if waiting-list mortality continues to rise.…”