DAY 2 - Clinical Characteristics of Patients Older Than 70 Years Registered for Liver Transplantation: Analysis of 22 Years Data From UNOS Registry

The increasing number of elderly patients registered for orthotopic liver transplantation (OLT) presents unique challenges due to their higher likelihood of comorbidities, reduced physiological reserves, and increased frailty. However, a lack of large-scale studies has led to a significant knowledge gap regarding the clinical features of elderly transplant candidates.

At the American College of Gastroenterology (ACG) 2024 Annual Scientific Meeting in Philadelphia, Pennsylvania, Dr. Ragesh B. Thandassery, a gastroenterologist at the Central Arkansas Veterans Healthcare System, presented data on the clinical characteristics of liver transplant candidates over the age of 70. 

“One of the most common questions we face as transplant physicians is how old is too old for liver transplantation. What’s critical is the overall physical health,” Dr. Thandassery noted. His team analyzed 22 years of data from the United Network for Organ Sharing (UNOS) registry, examining adult patients ≥18 years listed for OLT from 2003 to 2024 to assess waitlist characteristics, transplant outcomes, and long-term graft survival.

Out of 236,302 patients waitlisted, 97.5% were 70 years or younger, while 2.5% were over 70. More females were listed in the older group, although the groups were similar in terms of ethnicity and BMI. For patients over 70, metabolic dysfunction-associated steatohepatitis (MASH) was the most common liver disease etiology, while chronic hepatitis C predominated among younger patients. A higher proportion of patients in the older group had hepatocellular carcinoma.

By analyzing this patient data, Dr. Thandassery’s team developed a detailed profile of elderly transplant candidates. Patients over 70 generally had higher albumin levels, lower serum creatinine, lower total bilirubin, lower international normalized ratio, and lower MELD scores (Model for End-Stage Liver Disease: a scale indicating medical urgency for liver transplant). The older group was less likely to be on life support or a ventilator at registration, suggesting they were generally less ill and had better functional status at both listing and transplantation. “The waitlist time was slightly shorter, and the need for life support and ventilators at the time of listing was significantly lower for those over 70,” Dr. Thandassery explained. 

Dr. Thandassery acknowledged certain limitations of this study, noting that "while our research provides valuable insights, it is important to consider the retrospective nature of the analysis, as well as the potential for unmeasured confounding factors when interpreting these findings."

Following Dr. Thandassery's presentation, an extensive Q&A session further clarified the study's implications. When questioned about whether the analysis accounted for DCD (donation after circulatory death) versus DBD (donation after brain death) livers concerning ischemic outcomes, Dr. Thandassery indicated that patients over 70 received a higher proportion of DCD organs. Another attendee inquired about potential period effects on MELD, given the evolution of the MELD scoring system over time. Dr. Thandassery explained that his team used the MELD score as recorded at the time of transplantation for each period. He suggested that further exploration of the impact of MELD scoring changes over time could yield additional insights.

This study raises further questions: How can transplant protocols be optimized for elderly patients given their unique clinical profiles? How can we improve long-term outcomes for elderly transplant recipients? These questions set the stage for future research to refine liver transplantation approaches for the elderly.