Should advanced donor age be a deterrent in the utilization of grafts from donation after cardiac death in deceased donor liver transplantation? The Toronto experience.
Samrat Ray, Chaya Shwaartz, Blayne Amir Sayed, Gonzalo Sapisochin, Anand Ghanekar, Ian McGilvray, Mark Cattral, Leslie Lilly, Nazia Selzner, Cynthia Tsien, Mamatha Bhat, Elmar Jaeckel, Markus Selzner, Trevor W Reichman
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Abstract
Background: Advanced donor age paired with donation after cardiac death (DCD) increases the risk of transplantation, precluding widespread use of grafts from such donors worldwide. Our aim was to analyze outcomes of liver transplantation using grafts from older DCD donors and donation after brain death (DBD) donors.
Methods: Patients who underwent liver transplantation using grafts from deceased donors between January 2016 and December 2021 were included in the study. Short-and long-term outcomes were analyzed for 4 groups of patients: those who received DCD and DBD grafts from younger (< 50 yr) and older (≥ 50 yr) donors.
Results: Of the 807 patients included in the analysis, 44.7% (n = 361) of grafts were received from older donors, with grafts for older DCD donors comprising 4.7% of the total cohort (n = 38). Patients who received grafts from older donors had a lower incidence of biliary strictures than those who received grafts from younger donors (7.9% v. 20.0% for DCD donation, p = 0.14, and 4.9% v. 6.8% for DBD donation, p = 0.34), with a significantly lower incidence of ischemic-type biliary strictures in patients who received grafts from older versus younger DCD donors (2.6% v. 18.0%, p = 0.04). There was no difference in 1- and 3-year graft survival rates among patients who received grafts from older and younger DCD donors (92.1% v. 90.8% and 80.2% v. 80.9%, respectively) and those who received grafts from older and younger DBD donors (90.1% v. 93.2% and 85.3% v. 84.4%, respectively) (p = 0.85). Pretransplantation admission to the intensive care unit (hazard ratio [HR] 9.041, p < 0.001) and nonalcoholic steatohepatitis (HR 2.197, p = 0.02) were found to significantly affect survival of grafts from older donors.
Conclusion: Donor age alone should not be the criterion to determine the acceptability of grafts in liver transplantation. With careful selection criteria, older DCD donors could make a valuable contribution to expanding the liver donor pool, with grafts that produce comparable results to those obtained with standard-criteria grafts.
背景:高龄供者与心脏死亡(DCD)后的捐赠相结合，增加了移植的风险，阻碍了这类供者在世界范围内广泛使用移植物。我们的目的是分析老年DCD供者和脑死亡后供者肝移植的结果。方法:研究纳入了2016年1月至2021年12月期间接受已故供体肝移植的患者。分析四组患者的短期和长期结果:接受年轻(< 50岁)和年长(≥50岁)供者DCD和DBD移植的患者。结果:在纳入分析的807例患者中，44.7% (n = 361)的移植来自老年供者，老年DCD供者的移植占总队列的4.7% (n = 38)。老年供者的胆道狭窄发生率低于年轻供者(DCD为7.9% vs 20.0%， p = 0.14, DBD为4.9% vs 6.8%， p = 0.34)，老年供者的胆道缺血性狭窄发生率明显低于年轻DCD供者(2.6% vs . 18.0%， p = 0.04)。接受老年和年轻DCD供者移植的患者(分别为92.1% vs . 90.8%和80.2% vs . 80.9%)和接受老年和年轻DBD供者移植的患者(分别为90.1% vs . 93.2%和85.3% vs . 84.4%)的1年和3年移植存活率无差异(p = 0.85)。移植前入住重症监护病房(危险比[HR] 9.041, p < 0.001)和非酒精性脂肪性肝炎(危险比[HR] 2.197, p = 0.02)显著影响老年供者移植物的存活。结论:供体年龄不应单独作为判断肝移植可接受性的标准。通过仔细的选择标准，年龄较大的DCD供者可以为扩大肝脏供者库做出有价值的贡献，其移植产生的结果与标准标准移植获得的结果相当。
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