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Assessment of Trends in Transplantation of Liver Grafts From Older Donors and Outcomes in Recipients of Liver Grafts From Older Donors, 2003-2016

Educational Objective To identify outcomes from liver transplant–only recipients of older donor grafts in the United States from 2003 to 2016.
1 Credit CME
Key Points

Question  What were the trends in use of liver grafts from older donors (aged ≥70 years) and outcomes in liver-only transplant recipients of older donor grafts in the United States from 2003 to 2016?

Findings  In this cohort study of 4127 liver grafts from older donors and 3350 liver-only recipients of older donor grafts, and 78 990 liver grafts from younger donors (aged 18-69 years) and 64 907 liver-only recipients of younger donor grafts, there was a decrease in the use of liver grafts from older donors despite significant improvements in all-cause graft loss and mortality among liver transplant recipients of older donor grafts. These posttransplant improvements are more substantial than those seen in recipients of younger donor grafts.

Meaning  These findings suggest that clinicians should consider more liberal and broader use of liver grafts from older donors to expand the potential donor pool.

Abstract

Importance  In light of the growing population of older adults in the United States, older donors (aged ≥70 years) represent an expansion of the donor pool; however, their organs are underused. Liver grafts from older donors were historically associated with poor outcomes and higher discard rates, but clinical protocols, organ allocation, and the donor pool have changed in the past 15 years.

Objective  To evaluate trends in demographics, discard rates, and outcomes among older liver donors and transplant recipients of livers from older donors in a large national cohort.

Design, Setting, and Participants  Prospective cohort study of 4127 liver grafts from older donors and 3350 liver-only recipients of older donor grafts and 78 990 liver grafts from younger donors (aged 18-69 years) and 64 907 liver-only recipients of younger donor grafts between January 1, 2003, and December 31, 2016, in the United States. The Scientific Registry of Transplant Recipients, which includes data on all transplant recipients in the United States that are submitted by members of the Organ Procurement and Transplantation Network, was used.

Exposures  Year of liver transplant and age of liver donor.

Main Outcomes and Measures  Odds of graft discard and posttransplant outcomes of all-cause graft loss and mortality.

Results  In this study, 4127 liver grafts from older donors were recovered for liver transplant across the study period (2003-2016); 747 liver grafts from older donors were discarded, and 3350 liver grafts from older donors were used for liver-only recipients. After adjusting for donor characteristics other than age and accounting for Organ Procurement Organization–level variation, liver grafts from older donors were more likely to be discarded compared with liver grafts from younger donors in 2003-2006 (adjusted odds ratio [aOR], 1.97; 95% CI, 1.68-2.31), 2007-2009 (aOR, 2.55; 95% CI, 2.17-3.01), 2010-2013 (aOR, 2.04; 95% CI, 1.68-2.46), and 2013-2016 (aOR, 2.37; 95% CI, 1.96-2.86) (P < .001 for all). Transplants of liver grafts from older donors represented a progressively lower proportion of all adult liver transplants, from 6.0% (n = 258 recipients) in 2003 to 3.2% (n = 211 recipients) in 2016 (P = .001). However, outcomes in recipients of grafts from older donors improved over time, with 40% lower graft loss risk (adjusted hazard ratio, 0.60; 95% CI, 0.53-0.68; P < .001) and 41% lower mortality risk (adjusted hazard ratio, 0.59; 95% CI, 0.52-0.68; P < .001) in 2010 through 2016 vs 2003 through 2009; these results were beyond the general temporal improvements in graft loss (interaction P = .03) and mortality risk (interaction P = .04) among recipients of liver grafts from younger donors.

Conclusions and Relevance  These findings show that from 2003 to 2016, liver graft loss and mortality among recipients of liver grafts from older donors improved; however, liver graft discard from older donors remained increased and the number of transplants performed with liver grafts from older donors decreased. Expansion of the donor pool through broader use of liver grafts from older donors might be reasonable.

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Article Information

Accepted for Publication: October 28, 2018.

Corresponding Author: Dorry L. Segev, MD, PhD, Department of Surgery, Johns Hopkins University School of Medicine, 2000 E Monument St, Baltimore, MD 21205 (dorry@jhmi.edu).

Published Online: February 13, 2019. doi:10.1001/jamasurg.2018.5568

Author Contributions: Drs Haugen and Segev had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Haugen, Luo, Garonzik-Wang, Philosophe, McAdams-DeMarco, Segev.

Acquisition, analysis, or interpretation of data: Haugen, Holscher, Luo, Bowring, Orandi, Thomas, Massie, McAdams-DeMarco, Segev.

Drafting of the manuscript: Haugen, Holscher, Luo, Orandi, Thomas, McAdams-DeMarco, Segev.

Critical revision of the manuscript for important intellectual content: Haugen, Holscher, Luo, Bowring, Orandi, Thomas, Garonzik-Wang, Massie, Philosophe, Segev.

Statistical analysis: Haugen, Holscher, Luo, Bowring, Thomas, McAdams-DeMarco.

Obtained funding: Haugen, McAdams-DeMarco.

Administrative, technical, or material support: Haugen, Holscher, Bowring, Massie, Philosophe.

Supervision: Orandi, Garonzik-Wang, Massie, Philosophe, Segev.

Conflict of Interest Disclosures: Drs Holscher, Massie, and Segev reported grants from the National Institute of Diabetes and Digestive and Kidney Diseases, and Drs Haugen and McAdams-DeMarco reported grants from the National Institute on Aging during the conduct of the study. No other disclosures were reported.

Funding/Support: Funding for this study was provided by grants F32AG053025 (Dr Haugen), F32DK109662 (Dr Holscher), K01AG043501 and R01AG055781 (Dr McAdams-DeMarco), and K24DK101828 (Dr Segev) from the National Institute of Diabetes and Digestive and Kidney Disease and the National Institute on Aging.

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The interpretation and reporting of these data are the sole responsibility of the authors and should not be seen as an official policy of or interpretation by the Scientific Registry of Transplant Recipients, Organ Procurement and Transplantation Network, United Network for Organ Sharing, or the US government.

Additional Information: Data have been supplied by the Minneapolis Medical Research Foundation as the contractor for the Scientific Registry of Transplant Recipients.

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