Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD.
Transplantation. 2018 Sep;102(9):1514-1519. doi: 10.1097/TP.0000000000002190.
Allografts from older liver donors (OLDs), 70 years or older are often discarded for fear of inferior outcomes. We previously identified "preferred recipients" who did not suffer the higher risk of graft loss and mortality associated with OLDs. Preferred recipients were first-time, non-status 1 registrants older than 45 years, body mass index less than 35, indication other than hepatitis C, and cold ischemia time less than 8 hours.
We assessed the validity of the preferred recipient construct in a larger, more recent cohort (38 891 patients, 2006-2013). We compared recipients of OLD grafts to recipients of average liver donors (ALDs, age = 40-69) and ideal liver donors (ILDs, age = 18-39) grafts using multilevel Cox regression adjusting for recipient and transplant factors.
The use of OLD grafts in preferred recipients has increased from 2006 to 2013 (P = 0.02). Preferred recipients Model for End-Stage Liver Disease scores ranged 6 to 40. Preferred recipients had similar 5-year all-cause graft loss (ACGL) with OLD versus ALD and ILD grafts (25.4% vs 24.5% and 21.6%). Conversely, nonpreferred recipients had higher 5-year ACGL with OLD versus ALD and ILD grafts (41.4% vs 32.9% and 25.6%). After adjustment, preferred recipients had similar graft loss with OLD versus ALD grafts (hazard ratio [HR], 0.921.081.27; P = 0.3) and ILD grafts (HR, 0.981.161.39, P = 0.09); however, nonpreferred recipients had higher ACGL risk with OLD grafts versus ALD (HR, 1.281.411.56, P < 0.001) and ILD grafts (HR, 1.501.671.86, P < 0.001). Similar trends are seen with mortality.
Because preferred recipients comprise 43.3% (n = 2916) of the current waitlist and span the full range of Model for End-Stage Liver Disease scores, transplanted OLD allografts could be distributed without added risk of graft loss or mortality.
由于担心移植物功能丧失和死亡率的风险增加，70 岁或以上的老年供肝（OLD）常被弃用。我们之前确定了“优选受者”，他们没有因 OLD 而增加移植物丢失和死亡的风险。优选受者为首次接受肝移植、非 1 级注册、年龄大于 45 岁、体重指数小于 35、非丙型肝炎和冷缺血时间小于 8 小时的患者。
我们在一个更大的、更近的队列（38891 例患者，2006-2013 年）中评估了优选受者的构建效度。我们使用多水平 Cox 回归，调整了受者和移植因素，比较了 OLD 移植物受者与普通肝供者（ALD，年龄 40-69 岁）和理想肝供者（ILD，年龄 18-39 岁）移植物受者的结果。
从 2006 年到 2013 年，优选受者中使用 OLD 移植物的比例增加（P = 0.02）。优选受者的终末期肝病模型评分范围为 6 至 40 分。优选受者与 OLD-ALD 和 ILD 移植物的 5 年全因移植物丢失（ACGL）相似（25.4%比 24.5%和 21.6%）。相反，非优选受者与 OLD-ALD 和 ILD 移植物相比，5 年 ACGL 更高（41.4%比 32.9%和 25.6%）。调整后，与 ALD 移植物相比，优选受者与 OLD 移植物的移植物丢失相似（风险比[HR]，0.921.081.27；P = 0.3）和 ILD 移植物（HR，0.981.161.39，P = 0.09）；然而，与 ALD 移植物（HR，1.281.411.56，P < 0.001）和 ILD 移植物（HR，1.501.671.86，P < 0.001）相比，非优选受者的 ACGL 风险更高。死亡率也有类似的趋势。
由于优选受者占当前候补名单的 43.3%（n = 2916），并且涵盖了终末期肝病模型评分的全部范围，因此可以分配 OLD 同种异体移植物，而不会增加移植物丢失或死亡率的风险。
