Casavilla, A

Fung, JJ

Gordon, RD

Mieles, L

Reyes, J

Richard Selby, R

Starzl, TE

Stieber, AC

Todo, S

Tzakis, AG

English

Selby, RR

Name not available

Liver transplantation in patients over sixty years of age

D-Scholarship@Pitt

0041-1337/91/5101-0271$03.00/0 TRANSPLANTATION Copyright © 1991 by Williams & Wilkins \'\ f;}· \ Vol. 51, OT1·~U4I No.1, .January 1991 Printed in U.S.A. Transplantation BRIEF COMMUNICATIONS LIVER TRANSPLANTATION IN PATIENTS OVER SIXTY YEARS OF AGE 1,2 Orthotopic liver transplantation has been considered the accepted form of therapy for a number of end-stage liver diseases for several years (1). Until the early 1980s, the unof-ficially accepted limit for OL TX candidates was 50 years of age. Although a recent UNOS report seems to suggest that the survival of older patients with OL TX is poorer than that of the general adult transplant population (2), we have previously reported excellent preliminary results with OL TX in patients over 50 years of age (3). We have now expanded our series to 156 patients over 60 years of age at the time they received their transplant, and the results are reported here. Our study indi-cates that results after liver transplantation in patients over 60 years of age are comparable to the results obtainable in other age groups and that advanced age per se is not a contraindica-tion to liver transplantation. Between January 1, 1985 and November 30, 1989, 1475 patients underwent OL TX at the University of Pittsburgh. There were 125 (8.5%) infants (under 2 years of age), 229 (15.5%) children (between 2 and 18 years of age), 965 (65.4%) adults, and 156 (10.6%) seniors (over 60 years of age) (Fig. lA). Of the 156 senior patients, 80 were males (51.3%), and 76 were females (48.7%). One hundred fifty-two patients (97.4%) were in the seventh decade of their life, while 4 patients (2.6%) were in the eighth decade. Forty-nine patients (31.4%) were UNOS class 1 (out of hospital) at the time of the operation, 62 (39.7%) were class 2 (in the hospital), 24 (15.4%) were class 3 (in the intensive care unit), and 21 (13.5%) were class 4 (urgent) (Fig. IB). Of the entire group, 129 patients (82.7%) received one graft, 26 patients (16.7%) 2 grafts, and 1 patient (0.6%) received 3 grafts (Fig. lC). The indications for transplantation were: postnecrotic cir-rhosis (PNC)* 65 (41.7%); primary biliary cirrhosis (PBC) 40 (25.6%); primary hepatic malignancy (CA) 19 (12.2%); alcoholic cirrhosis (ETOH) 17 (10.9%); primary sclerosing cholangitis (PSC) 6 (3.8%); metabolic disorders (MET) 5 (3.2%); acute hepatic failure (AHF) 2 (1.3%); and miscellaneous (OTH) 2 (1.3%) (Fig. lD). Actuarial survival analysis was performed using the lL mod-ule of BMDP/PC, 1988 release (BMDP Statistical Software, Los Angeles, CAl on an IBM-PC compatible microcomputer. Differences were considered significant if P <0.05 and highly significant if P <0.01. 1 Presented at the 16th Annual Meeting of the American Society of Transplant Surgeons, May P~-gune 1, 1990, Chicago, IL. 2 This work was supported by research grants from the Veterans Administration and Project Grant No. AM 29961 from the National Institutes of Health, Bethesda, MD. • Abbreviations: AHF, acute hepatic failure; CA, primary hepatic malignancy; ETOH, alcoholic cirrhosis; MET, metabolic disorders; PBC, primary biliary cirrhosis; PNC, postnecrotic cirrhosis; PSC, primary sclerosing cholangitis; OTH, miscellaneous. The actuarial survival rates (life-table method) for patients with primary grafts was 71.3% after 1 year and 65.5% after 3 years. By comparison, the adult survival ranges were 78% and 71.4%, respectively (Fig. 2A). For retransplantations, the senior survival rates were 50% at 1 year and 30.7% at 3 years. By comparison, the adult survival rates were 56% and 43.1%, respectively (Fig. 2B). When the UNOS status was considered, the survival was significantly worse for class 4 (P <0.02) (Fig. 2C). Of the survivors, 66 (66.7%) are fully functional (status 1); 27 (27.3%) are functional with some limitation (status 11); 5 (5.0%) are partially disabled and in need of some assistance (status III); and 1 (1.0%) is disabled and needing full-time assistance (status IV) (Fig. 3A). The senior group had characteristics similar to the general adult liver transplant population, with the exception of age. This includes primary liver disease, male/female ratio, and medical urgency status (UNOS class). The overall survival for the senior group compared favorably with that of the infant and adult groups. The adult group was used for comparison as a "standard" for survival, while the infants were used as another "high-risk" group. The positive results with the older age population may come as a surprise at first glance, but to us it is clear that the physiological age is vastly more important than the chronological age toward sur-vival. Our oldest recipient was 76 years old when she was given a transplant for PBC, and is still well and an active grand-mother at 4 years later. In fact, over the years, the number of transplants in older patients has proportionally increased, com-pared to those in the adult population, as we have become more confident of achieving good results in this patient population (Fig. 3B). As anticipated, the survival for the much sicker patients in class 4 was statistically poorer. This is consistent with previous observations of a correlation between preoperative patient con-dition and survival with OLTX (4, 5). The preoperative evaluation of the older OL TX candidates is similar to that of the general population, although sometimes it may be more complex, as it is more frequently necessary to study the cardiopulmonary condition in greater detail. But once severe concurrent conditions have been ruled out, the prognosis is as good as that for the general adult population. Many of these patients, especially those with primary biliary cirrhosis, present with advanced hepatic osteopathy that is often the rate-limiting pathology for recuperation after liver transplan-tation. This is one of the reasons for which we advocate early referral and transplantation for such patients, before the crip-pling effects of advanced and irreversible bone disease have set in. It is frequently possible and often important to use less-aggressive steroid regimens for immunosuppression in these older patients, in order to avoid worsening of the osteopathy, onset of steroid-dependent diabetes, and cataracts. As in the rest of the surgical population, early mobilization is extremely 271 272 TRANSPLANTATION Vol. 51, No. a. b. OLTX by age group 22t 15.5" • ' .. .,.': ..... "~K 50 Child 1S1 1Q.ft ~ Adul : ....... 1 ....... " c. Senior OL TX population distribution by graft # '20 d. Senior OLTX population distribution byclass* Senior OL TX population distribution by diagnosis .. .-!IIPBC \'leA ·UNOSC ..... .. ,....,. , ..... (1 ETCH ~mpC ollET OAHF DOTH FIGURE 1. (A) OL TX by age group; (B) senior OLTX population distribution by class; (C) senior OL TX population distribution by graft number; and (D) senior OL TX population distribution by diagnosis. Patient survival (primary graft) Infant .. -._- ------------- -.- ---·----.c.!L .... • !\.<tu_" •• 20 20 C. Senior OL TX population survival by UNOS class 100 1":-':-':-:':-.:-::-') 80 T -..... KKIKKKKKK~K:"D::-::-:K~K:K~K~:-:KD::~:KD::i_ ••.• ~_ .•.• ~K_ ••.• _ •.•.•••.•.•• ____ i~~ '-: . __ =~ __ ~-K_I~--K-IK-----~-- - .. _-_ .. _.----1..-.-_ •• ---------_ •• _--i .. _ .. _ .. _ .. _ .. _ .. _ .. _ .. _ .. _ .. _ .. _ .. _ .. _ .. _._ .. _ .. _ .. _ .. _ .. _ .. _ .. _ .. _ .. _ .. _ .. _ .. _Kp_:<K:~ 20 12 24 31 48 Monlha FIGURE 2. (A) Patient survival (primary graft); (B) patient survival (retransplants); and (Cl senior OLTX population survival by UNOS class. important. Otherwise, the postoperative care does not differ significantly from the "standard." A large percentage of the older patients do recuperate com-pletely or almost completely (93.9% of the survivors in our series have a functional status I or II) and can be active and productive again. Besides assuring them satisfactory quality for the rest of their lives, liver transplantation has the potential to increase the pool of productive population, in an era in which there will be an ever· higher percentage of elderly persons who retire late or reenter the job market. a. Senior OL TX population: functional status statui I ~ statui II ~ statui III • Statuilvi b . Senior OL TX population by year 800 800 400 f-- .-.------.. ----.--.-.-.---- - .. 1300 i 200 100 o 1_ For 1989 only until Nov. 30 1_ 1987 V .. r 1988 1989 FIGURE 3. (A) Senior OLTX population; functional status; and (B) senior OLTX population by year. We conclude that advanced age is not a contraindication to liver transplantation. The results after liver transplantation in patients over the age of 60 were comparable to results for the general transplant population. These statistics were in contrast to the recent UNOS report for the calendar year 1988, during which the I-year mortality rate was 50% for patients 65 years or older (2). ANDREI C. STIEBER ROBERT D. GORDON SATORU TODO ANDREAS G. TZAKIS JOHN J. FUNG ADRIAN CASAVILLA R. RICHARD SELBY LUIS MIELES JORGE REYES THOMAS E. STARZL3 The Transplantation Division, Department of Surgery University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania 3 Address requests for reprints to: Thomas E. Starzl, M.D., Ph.D., Falk Clinic 5 C, 3601 5th Avenue, Pittsburgh, PA 15213. DISCUSSION DR. SHAW (Omaha, Nebraska): Have you noticed any dif-ference in the frequency or severity of rejection episodes in older patients? We certainly noticed that in a series of patients over 65 years of age, for instance, that their hospital course and the number and severity of rejection episodes, seems to be a bit less than the rest of the population. January 1991 BRIEF COMMUNICATIONS 273 DR. STIEBER: Their immune system is probably more depressed to begin with. We observed a lower incidence of episodes of rejection, which was not statistically significant, though. On the other hand, they have to spend maybe a few days longer in the leU on a respirator, about a week longer in the hospital. So that compensates a little bit for the lower incidence of rejection. DR. WALL: (London, Ontario): In the cardiac workup of your patients are you satisfied with 3-D echoes in assessing ventricular function or do you do angiography? DR. STIEBER: Well, we usually do the echo and the MUGA scan. If the MUGA scan is abnormal, then we proceed with an angiography. But the angiography is not done as a routine by any means. DR. WALL: And have you performed liver transplants on any patients who've had angina or who've been on Digoxin to treat congestive heart failure? DR. STIEBER: No. REFERENCES 1. EASL: National Institutes of Health Consensus Development Con-ference statement: liver transplantation-June 20-23, 1983. Hepatology 1984: 4: 107S. 2. United Network for Organ Sharing, Health Care Financing Ad-ministration and the Division of Organ Transplantation. Annual report on the Scientific Registry and the Organ Procurement and Transplantation Network, 1988 and 1989. June 1990. 3. Starzl TE, Todo S, Gordon RD, et al. Liver transplantation in older patients [Letter]. N Engl J Med 1987; 316: 484. 4. Shaw BW Jr, Wood RP, Gordon RD, et al. Influence of selected patient variables and operative blood loss on six-month survival following liver transplantation. Semin Liver Dis 1985; 5: 344. 5. Markus BH, Dickson ER, Grambsch PM, et al. Efficacy of liver transplantation in patients with primary biliary cirrhosis. N Engl J Med 1989; 320: 1709. Received 14 June 1990. Accepted 4 September 1990. 

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Liver transplantation in patients over sixty years of age

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