Retrospective Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Transplant. Oct 18, 2021; 11(10): 421-431
Published online Oct 18, 2021. doi: 10.5500/wjt.v11.i10.421
Factors predicting futility of liver transplant in elderly recipients: A single-center experience
Cerise Kleb, Muhammad Salman Faisal, Cristiano Quintini, Charles M Miller, K V Narayanan Menon, Jamak Modaresi Esfeh
Cerise Kleb, Muhammad Salman Faisal, Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
Cristiano Quintini, Charles M Miller, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
K V Narayanan Menon, Jamak Modaresi Esfeh, Department of Gastroenterology & Hepatology, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
Author contributions: Kleb C designed, performed the research and wrote the paper; Faisal MS contributed to the design of the study and performed analysis of the data; Quintini C, Miller CM and Menon KN helped with critical revisions of the study; Modaresi Esfeh J supervised, helped design the study, made critical revisions to the manuscript and gave final approval.
Institutional review board statement: This study was reviewed and approved by the Cleveland Clinic Foundation Institutional Review Board.
Informed consent statement: This study qualified by a Waiver of Informed Consent as determined by our hospital’s IRB as it was a retrospective study that involved no more than minimal risk to the subjects, could not be reasonably carried out without the waiver, and was not a threat to the rights or welfare of the subjects.
Conflict-of-interest statement: We have no financial relationships to disclose.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Jamak Modaresi Esfeh, MD, Assistant Professor, Department of Gastroenterology & Hepatology, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, United States. modarej@ccf.org
Received: February 23, 2021
Peer-review started: February 23, 2021
First decision: May 3, 2021
Revised: May 19, 2021
Accepted: September 19, 2021
Article in press: September 19, 2021
Published online: October 18, 2021
Processing time: 233 Days and 7 Hours
Abstract
BACKGROUND

As the population of the United States ages, there has been an increasing number of elderly patients with cirrhosis listed for transplant. Previous studies have shown variable results in terms of the relative survival benefit for elderly liver transplant (LT) recipients. There may be factors that are associated with a poor post-transplant outcome which may help determine which elderly patients should and should not be listed for LT.

AIM

To identify factors associated with futility of transplant in elderly patients.

METHODS

This was a retrospective study of all patients above the age of 45 who underwent liver transplantation at our tertiary care center between January 2010 and March 2020 (n = 1019). “Elderly” was defined as all patients aged 65 years and older. Futile outcome was defined as death within 90 d of transplant. Logistic regression analysis was performed to determine what variables, if any were associated with futile outcome in elderly patients. Secondary outcomes such as one year mortality and discharge to facility (such as skilled nursing facility or long-term acute care hospital) were analyzed in the entire sample, compared across three age groups (45-54, 55-64, and 65 + years).

RESULTS

There was a total of 260 elderly patients who received LT in the designated time period. A total of 20 patients met the definition of “futile” outcome. The mean Model of End-Stage Liver Disease scores in the futile and non-futile group were not significantly different (21.78 in the futile group vs 19.66 in the “non-futile” group). Of the variables tested, only congestive heart failure was found to have a statistically significant association with futile outcome in LT recipients over the age of 65 (P = 0.001). Of these patients, all had diastolic heart failure with normal ejection fraction and at least grade I diastolic dysfunction as measured on echocardiogram. Patients aged 65 years and older were more likely to have the outcomes of death within 1 year of LT [hazard ratio: 1.937, confidence interval (CI): 1.24-3.02, P = 0.003] and discharge to facility (odds ratio: 1.94, CI: 1.4-2.8, P < 0.001) compared to patients in younger age groups.

CONCLUSION

Diastolic heart failure in the elderly may be a predictor of futility post liver transplant in elderly patients. Elderly LT recipients may have worse outcomes as compared to younger patients.

Keywords: Liver transplantation; Liver cirrhosis; Heart failure; Diastolic; Medical futility; Liver diseases; Organ transplantation

Core Tip: This was a retrospective study to identify factors associated with futility of liver transplant (LT) in elderly recipients, as well as investigate the risk of certain outcomes such as discharge to facility in elderly LT recipients. Diastolic congestive heart failure (CHF) was found to be a predictor of futility of LT in elderly recipients (P = 0.001). Elderly patients also had nearly twice the risk of being discharged to a facility and had decreased survival at one year. Diastolic CHF may be an important comorbidity for liver transplant committees to consider when deciding whether or not to list elderly patients.