Liver transplantation in those of advancing age: The case for transplantation

Longevity in the developed world continues to increase. In the United States from 1950 to 2005, those 65 to 75 yr of age increased twice as much as the overall annual growth rate of the population while those 75 yr increased 2.9 times as much. Projections indicate that the rate of growth by 2050 for older age groups will continue to increase more than twice as rapidly as the total population (Fig. 1). It is expected that older patients will continue to seek advanced medical treatments as they age. How will this effect liver transplantation (LT)? As longevity has increased, so has the burden of liver disease in those of advancing age. As of October 27, 2006, there were 2,075 patients 65 yr or older on the United Network for Organ Sharing waiting list. Similarly, the numbers of aged liver recipients has also increased. In 1988, 29 patients of age 65 or older underwent LT in the United States; in 2005, this number was 628, a 2100% increase (Fig. 2). In this issue of Liver Transplantation, Cross et al. describe a series of patients from the King’s College Hospital in London who underwent LT in the 7th decade of life. In a retrospective study from a prospectively maintained database, the authors compared the outcome of recipients aged 60 to 64 yr with those 65 yr at the time of transplantation. Results were further compared with a time-matched group of adult patients 18 to 59 yr old. Outcomes demonstrated no significant difference in survival for all 3 groups at 30-days, 1-yr, and 5-yr after LT; graft survival was similar to patient survival. However, the mean Model for End-Stage Liver Disease (MELD) score for those 65 yr was less than the other 2 cohorts. In addition, the indications for transplantation were different in the groups: the oldest cohort had significantly fewer recipients with hepatitis C and significantly more with primary biliary cirrhosis than the groups 60 to 64 yr and 18 to 59 yr. It is well-known that survival rates for patients transplanted for primary biliary cirrhosis are better than for other indications. This, along with lower MELD scores, may have, in part, led to improved graft and patient survival in the older cohorts. The issue of LT in patients 60 has been addressed in multiple reports from other centers. Survival at 3-yr posttransplantation has ranged from as low as 35% to as high as 83%. At the University of California, Los Angeles (UCLA), we found no statistically significant difference in survival after LT for a group of 62 patients over 70 yr of age when compared to a younger cohort of recipients of age 50 to 59 yr old (in press). These reports of transplantation in the elderly are important in an era of increasing donor shortage particularly when the balance between justice and utility for organ allocation continues to be actively debated. It is the philosophy of most centers that organs should be given to patients with the most years of life to gain, and, when asked, the public tends to agree. However, it is not unrealistic for a 65-yr-old adult with minimal comorbidities living in a developed country to expect to live an additional 20 yr. At the present time, there is no established chronological age limit for organ transplantation, and individual centers set their own rules based on the concept of “physiologic age,” which is not completely defined. In the United States, 10% of all adults die on the liver transplant waiting list. The situation is expected to worsen throughout this decade as more patients with