Objectives: With the increased life span, the need for liver transplant for elderly patients also increased in the world. In this study, we reviewed our experience to determine the outcomes and problems of patients aged > 60 years who had liver transplants.

Materials and Methods: Data of recipients aged > 60 years were reviewed retrospectively. We analyzed 16 elderly patients who had liver transplant for chronic liver disease between 2001 and 2014 in our center.

Results: In our series, there were 5 women and 11 men between age 60 and 65 years. The mean Child-Pugh score was 7.9 ± 1.7 and Model for End-Stage Liver Disease score was 14.1 ± 5.1. Primary liver disease was hepatitis B in 9 patients (34.5%), most of them with hepatocellular carcinoma. The other causes of liver failure were hepatitis C (n = 4), alcoholic cirrhosis (n = 2), and cryptogenic cirrhosis (n = 2); 1 patient had both hepatitis B and hepatitis C virus, and 1 patient had both hepatitis B virus and alcoholic cirrhosis. There were 9 patients who had hepatocellular carcinoma. Mortality was observed in 4 patients. The reasons for mortality were sepsis (n=3) and hepatocellular carcinoma (n=1).

Conclusions: Liver transplant can be safely performed and has acceptable long-term outcomes in low-risk elderly recipients. Age alone should not be a contraindication for liver transplant in elderly patients.

Key words : Age, Liver failure, Survival, Treatment

Introduction

Health care for older people is becoming increasingly important in industrialized nations. Advanced age is not considered an absolute contraindication for liver transplant. When liver transplant began, the upper limit of age for liver transplant was 50 years.¹ Advances in the medical treatment of chronic liver diseases have resulted in an increase in life expectancy.² Along with increased life span, the need for liver transplant for elderly patients also increased worldwide. Transplant in the elderly patient with comorbid diseases still is a subject of debate because of the high risk of surgery. Promising results with liver transplant in elderly people aged > 60 years have been reported recently.¹ We reviewed our experience to determine the outcomes and problems of elderly patients with liver transplant.

Materials and Methods

Data of liver transplant recipients aged > 60 years were reviewed retrospectively. We analyzed 16 elderly patients who had liver transplant for chronic liver disease between 2001 and 2014 in our center. Data included age, sex, cause of liver disease, presence or absence of hepatocellular carcinoma (HCC), Child-Pugh, and Model for End-Stage Liver Disease (MELD) scores, past medical history (alcohol or tobacco abuse, arterial hypertension, diabetes mellitus requiring oral hypoglycemic agents or insulin, and hypercholesterolemia), survival and cause of death, and incidence of the main post­transplant complications (early acute rejection, major infection, cardiovascular and neurologic complications, postoperative dialysis requirement, and incidence of de novo neoplasia).

A recipient for liver transplant had to satisfy the following criteria: a high likelihood of having a healthy daily life after successful living-donor liver transplant; liver transplant was the only treatment option to save the patient’s life; the patient’s vital organs, other than the liver, showed well-preserved function; there was no un­controllable malignancy or active infection in any organ except the liver; and the patient and patient’s supporting family members were expected to show good compliance with medical treatment.

All of our patients satisfied these criteria. All patients were examined in detail by the cardiology, pulmonary, psychiatry, and infectious diseases departments, and nonhepatic malignancies were screened preoperatively.

After transplant, all patients were treated with the same immunosuppressive protocol including tacrolimus, mycophenolate mofetil, and pred­nisolone. No protocol liver biopsy specimens were obtained, and biopsies were performed only for investigation of biochemical abnormalities such as elevated serum transaminase or bilirubin levels.

Results

In our series, there were 5 women and 11 men, aged 60 to 65 years (Table 1). The mean Child score was 7.9 ± 1.7 and MELD score was 14.1 ± 5.1. The most common indication for liver transplant was hepatitis B (n = 11; 68.7%) and 8 of these patients had HCC. The other indications for liver transplant were hepatitis C virus (n = 2), cryptogenic cirrhosis (n = 2), and alcoholic cirrhosis (n = 1). Preoperatively, 2 patients had diabetes mellitus that required oral hypoglycemic agents, and 1 patient had coronary artery disease that was treated with an endovascular stent.

After transplant, all patients stayed in the intensive care unit 1 day, and mean hospitalization was 18.1 ± 10.6 days. There were 3 patients who needed hemodialysis because of acute renal failure early after transplant. During follow-up, creatinine levels were normal. In 1 patient, hepatic artery thrombosis was observed on postoperative day 5 and was treated with an endovascular stent. There were 4 patients who died during follow-up, including 3 patients who died from sepsis; the causative pathogen was Acinetobacter in 2 patients and Aspergillus in 1 patient. During follow-up, major infection was not observed in the other 13 patients. Only 1 patient had 1 acute rejection episode and this was treated with pulse steroids. The 5-year survival rate was 75%. In our series, de novo neoplasia was not observed in any patient.

Discussion

Numerous studies have confirmed that transplant surgery can be performed safely in elderly patients. Investigators have found no differences in perioperative events, length of hospitalization, postoperative complications, incidence of rejection, and short-term survival in elderly liver recipients compared with cohorts of younger adults.³ Individual centers have shown that there is no significant difference in outcome between recipients aged > 60 years compared with younger recipients.⁴

Many centers have reported that the most common causes of mortality in elderly liver transplant patients were de novo or recurrent malignancy, but the incidence of these events was low.^2,3 In addition to posttransplant lympho­proliferative disorder, solid tumors were observed including tumors of the colon, pancreas, lung, and breast. In a study of > 300 cases of liver transplant, de novo malignancy was the leading cause of death 3 years after liver transplant, and the risks for malignancy were advanced age, smoking, Epstein-Barr virus, and sun exposure.⁵ In contrast with reports in the literature, in our series de novo neoplasia was not observed in any patient and recurrent malignancy was observed only in 1 patient.

Many centers have reported fewer episodes of acute cellular rejection in older patients.^3,6 In some studies, researchers have shown defects in both cell mediated and humoral immune systems of the elderly.⁷ The humoral defect is thought to be the result of an exaggerated anti-idiotype antibody response to antigens that down-regulates the antibody response to those antigens, thus inhibiting the humoral response.^8,9 Depending on this defective immunity, it might be expected that a lower incidence of acute rejection and higher rate of opportunistic infections may occur in elderly liver transplant patients. The most common cause of fatal infection in older patients was fungal sepsis.3 In the present study, similar to the literature, we observed only 1 acute rejection episode and 3 of our patients died from bacterial and fungal infections.

In previous studies, the presence of comorbid disease and high MELD and Child scores were independent risk factors for prognosis.^10-13 Although there is not a sufficient number of patients in our series, we could not say that the prognosis for patients with comorbid disease and high MELD score was worse.

In conclusion, liver transplant should not be with­held from older recipients on the basis of age alone. However, comprehensive screening for comorbidities should be performed. Patients aged > 60 years have low rejection rates and excellent graft survival. Careful screening is necessary to detect de novo malignancy and disease recurrence.

References:

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