Beyond the Limit

Approaching Systematic Use of Nonagenarian Donors in Liver Transplantation

Use of livers from very old donors is a way to expand the donor pool, but this practice is not universally implemented due to concerns about the risk of primary non-function (PNF), delayed graft function (DGF), and worse long-term graft survival.¹ Recently, our experience with use of octogenarian deceased liver donors was reported and showed favorable overall long-term results when proper donor evaluation and donor-to-recipient matching are assured.² Beyond some anecdotal case reports,³ wider use of nonagenarian donors is still scarce.

During the last 18 months, four nonagenarian donors were reported to our Unit for evaluation for liver transplantation (LT). Donors were evaluated as per our institutional flow chart, as reported elsewhere.² One donor graft was discarded and three were procured and transplanted. Graft biopsy was obtained on surgeon evaluation at time of procurement, livers retrieved with dual portal and arterial perfusion, and transplantations performed with cava replacement and simultaneous arterial and portal reperfusion. The clinical characteristics of donors and recipients are summarized in Table 1 along with their clinical outcome. All recipients were discharged from hospital in good clinical conditions. Trans T-tube cholangiography 3 months after LT showed no bile duct abnormalities and no vascular or biliary complications occurred at a mean follow-up of 11 months. One patient experienced Pseudomonas aeruginosa wound infection treated with antibiotics and vacuum-assisted closure therapy. The patient transplanted for hepatitis C virus (HCV)-related cirrhosis underwent a preLT course of sofosbuvir and ribavirin for 36 weeks, was HCV-RNA negative at the time of transplantation, and remained negative at 12 weeks.

TABLE 1: Nonagenarian donors evaluated at University of Pisa Liver Transplant Center from April 2014 to September 2015

A recent report from the Italian National Transplant Center (CNT) showed that older age is one of the reasons for preventing organ donor’s evaluation in our country: the so-called “missed brain deaths” that may account up to 60% of total potential organ donors.⁴ In our experience, more than 50% of reported octogenarian donors are used for LT,² and similar rates might be obtained considering nonagenarian ones. A nonprejudicial attitude on the part of local coordinators and transplant surgeons towards very old donors might have a deep impact on the clinical practice of LT. Although the clinical variables associated with better outcome when very old donors are used are largely unknown, two factors seem pivotal: appropriate donor evaluation combined with clinical experience, and a flexible allocation flowchart allowing prioritization for stable, low model for end-stage liver disease (MELD) score recipients. Further improvement in long-term graft and patient outcome might be contributed by use of direct antivirals against HCV graft reinfection.

Acceptance rate and outcomes of nonagenarian donors may vary across regions and countries due to different lifestyles and the incidence of comorbidities in different populations.⁵ Even if experience and data on nonagenarian donors are still very limited, in view of an ever aging population of organ donors, expanding age limits may have the potential to boost graft availability and reduce mortality on the waiting list.