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Older donor livers still discarded despite improving mortality outcomes

Between 2003 and 2016, liver graft loss and mortality rates among recipients of grafts from older donors improved; however, discard rates of older donor grafts continued to increase and use of older donor grafts decreased, according to a study published in JAMA Surgery.

“Our findings of improved posttransplant mortality and all-cause graft loss may be associated with several factors, including patient care, surgical technique, or improved donor to recipient matching,” Christine E. Haugen, MD, from the Johns Hopkins University School of Medicine in Baltimore, Maryland, and colleagues wrote. “Exclusion of a potential organ donor should not be based on age alone, but donor age should be evaluated with donor to recipient matching and consideration of potential cold ischemia time.”

During the study period, most of the 4,127 liver grafts recovered for liver transplantation from older donors (54.3%) and most of the 747 discarded older donor grafts (51%) were from individuals aged 70 years to 74 years.

The discard rate of older donor grafts increased from 11.6% in 2003 to 24.5% in 2008 with a slight decrease to 15.4% in 2016. According to Haugen and colleagues, graft discard from older donors was higher every year in the study period compared with graft discard from younger donors.

Grafts from older donors are significantly more likely to be discarded compared with younger donor grafts between 2003 and 2006 (adjusted OR = 1.97; 95% CI, 1.68-2.31), 2007 and 2009 (aOR = 2.55; 95% CI, 2.17-3.01), 2010 and 2013 (aOR= 2.04; 95% CI, 1.68-2.46), and the 2013 to 2016 period (aOR = 2.37; 95% CI, 1.96-2.86).

Between the periods of 2003 to 2009 and 2010 to 2016, 1-year mortality for recipients of older donor grafts improved from 18% to 11%, 3-year mortality from 28% to 18%, 5-year mortality from 37% to 23%. In the same period comparison, 1-year graft loss improved from 23% to 15%, 3-year from 34% to 22%, and 5-year from 43% to 27%.

Recipients of older donor grafts had a 41% lower risk for mortality (aHR = 0.59; 95% CI, 0.52-0.68) and a 40% lower risk for graft loss (aHR = 0.6; 95% CI, 0.53-0.68) in the 2010 to 2016 period compared with 2003 to 2009. Recipients of younger donor grafts had a 31% lower risk for mortality and 30% lower risk for graft loss.

“We previously identified a recipient phenotype, a preferred recipient, who is likely to not incur additional risk associated with graft use from an older donor,” Haugen and colleagues wrote.

Preferred recipients for older donor grafts are first-time transplant recipients older than 45 years with a BMI less than 35 kg/m², non-status 1 registration, cold ischemia time of less than 8 hours, and have an indication for liver transplantation other than hepatitis C.

This preferred recipient phenotype was more often assigned older donor grafts in 2013 than 2006 (59.1% vs. 28.4%), “meaning that grafts from older donors were more frequently being transplanted in recipients who were likely to not incur additional risk of all-cause graft loss or mortality with liver grafts from older donors,” the researchers wrote. “These preferred recipients represent a potential group that could be used for broader use of grafts from older donors.” – by Talitha Bennett

Disclosure: Haugen reports grants from the National Institute on Aging during the conduct of the study. Please see the full study for the other authors’ relevant financial disclosures.