Hepatology & Liver Intensive Care; Hospital Beaujon, Clichy, France; INSERM U1149, France; University Paris Diderot, Paris, France.
Division of Gastroenterology and Hepatology, Northwestern Feinberg School of Medicine, Chicago, IL, USA.
J Hepatol. 2019 Apr;70(4):745-758. doi: 10.1016/j.jhep.2018.12.009. Epub 2018 Dec 18.
The average age of liver transplant donors and recipients has increased over the years. Independent of the cause of liver disease, older candidates have more comorbidities, higher waitlist mortality and higher post-transplant mortality than younger patients. However, transplant benefit may be similar in older and younger recipients, provided older recipients are carefully selected. The cohort of elderly patients transplanted decades ago is also increasingly raising issues concerning long-term exposure to immunosuppression and aging of the transplanted liver. Excellent results can be achieved with elderly donors and there is virtually no upper age limit for donors after brain death liver transplantation. The issue is how to optimise selection, procurement and matching to ensure good results with elderly donors. The impact of old donor age is more pronounced in younger recipients and patients with a high model for end-stage liver disease score. Age matching between the donor and the recipient should be incorporated into allocation policies with a multistep approach. However, age matching may vary depending on the objectives of different allocation policies. In addition, age matching must be revisited in the era of direct-acting antivirals. More restrictive limits have been adopted in donation after circulatory death. Perfusion machines which are currently under investigation may help expand these limits. In living donor liver transplantation, donor age limit is essentially guided by morbidity related to procurement. In this review we summarise changing trends in recipient and donor age. We discuss the implications of older age donors and recipients. We also consider different options for age matching in liver transplantation that could improve outcomes.
多年来，肝移植供体和受者的平均年龄都有所增加。与肝脏疾病的病因无关，老年候选者比年轻患者有更多的合并症、更高的等候名单死亡率和更高的移植后死亡率。然而，如果老年受者经过精心选择，移植的获益可能与年轻受者相似。几十年前接受移植的老年患者群体也越来越多地提出与长期免疫抑制暴露和移植肝老化有关的问题。老年供者可以取得极好的结果，脑死亡后肝移植实际上没有供者年龄上限。问题是如何优化选择、获取和匹配，以确保老年供者取得良好的效果。在年轻受者和终末期肝病模型评分较高的患者中，供者年龄较大的影响更为明显。供者和受者之间的年龄匹配应纳入分配政策，并采用多步骤方法。然而，年龄匹配可能因不同分配政策的目标而有所不同。此外，在直接作用抗病毒药物时代，年龄匹配必须重新考虑。在心脏死亡后捐献中，已经采取了更严格的限制。目前正在研究的灌注机可能有助于扩大这些限制。在活体供肝移植中，供者年龄限制主要由获取相关的发病率决定。在这篇综述中，我们总结了受者和供者年龄的变化趋势。我们讨论了老年供者和受者的影响。我们还考虑了肝移植中改善结果的不同年龄匹配选择。
