Skyrocketing Demand for Liver Transplant Among Older Americans

NEW YORK (Reuters Health) – Over the past two decades, the need for liver transplant (LT) in older adults has risen sharply, due to rising rates of nonalcoholic steatohepatitis (NASH), and the outcomes of LT in these patients has been improving, according to new research.

“In the past, older patients were routinely denied listing for liver transplantation because doctors believed they were less likely to survive the surgery and post-transplant management,” Dr. Maria Stepanova of the Center for Outcomes Research in Liver Diseases, in Washington, D.C., said in a news release from the Liver Meeting, held by the American Association for the Study of Liver Diseases (AASLD).

“Following transplant, however, older patients are now faring better than ever before. Age limits are largely being abandoned as exclusion criteria, but the mid- and long-term outcomes of elderly transplant candidates and recipients are still not well understood,” Dr. Stepanova said.

She and her colleagues from Inova Health System, in Falls Church, Virginia, did a trends analysis using registry data on more than 31,000 adults aged 65 and older who were waitlisted for LT from 2002 to 2020.

They found that the proportion of LT candidates aged 65 and older increased from 9% in 2002 to 2005 to 23% from 2018 to 2020 (trend P<0.0001).

During the study period, the proportion of older LT candidates with NASH rose from 13% to 39% while the proportion with hepatitis C virus (HCV) decreased from 27% to 18% (trend P<0.0001).

Compared with younger LT candidates, elderly candidates were significantly less apt to receive LT (54% vs. 59%) and were more apt to be removed from the waitlist due to deterioration (14% vs. 9%), but their mortality rates while waitlisted were similar to that of younger candidates.

In multivariate analysis, factors that predicted a higher chance of LT in elderly were more recent listing, being male, having a college degree, a higher MELD score or diagnosis of hepatocellular carcinoma (HCC). Factors that predicted lower likelihood of LT included being Hispanic, being on Medicaid or having diabetes.

Rates of post-transplant mortality were higher along elderly LT recipients relative to younger ones at one-, three- and five-years (all P<0.0001). Despite this, post-transplant mortality continued to decline in the elderly group over time (trend P<0.0001).

“We believe that multiple implications will arise from changing LT demographics,” Dr. Stepanova said in email to Reuters Health.

First, transplant teams will see more older patients with multiple comorbidities and screening for comorbidities at LT listing and at preoperative evaluation will be important, she said. While age is no longer a limitation when considering LT, “given the overall shortage of organs, it is still important to avoid futility.”

“Regarding resource utilization, it is Medicare that will have to cover not only LT itself for a growing number of its enrollees but also those pre- and likely post-LT services. Notably, older age at LT comes with a change in LT etiologies which must be managed differently from before,” Dr. Stepanova explained.

“Until recently, hepatitis C was the major culprit for the national LT burden in the U.S. At present, however, it is increasingly NASH. In fact, NASH is now the number one LT etiology in the elderly, and its share is still rapidly growing,” she noted.

“This is important not only for prevention but also post-LT because older patients will also have more pre-transplant diabetes owing to both their older age and a higher rate of NASH.”

“Regarding allocation in the context of an aging LT population, “what should be the best allocation strategy is still being actively discussed, and there’s no new consensus (beyond standard MELD-based “sickest first” with all the caveats),” Dr. Stepanova added.

SOURCE: The Liver Meeting, held November 12 to 15, 2021.

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