Careful donor selection is key to improving post-liver transplant graft survival in older patients with acute-on-chronic liver failure

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Conference Proceeding

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Am J Transplant


Background: Elderly liver transplant (LT) patients with acute-on-chronic liver failure (ACLF) may be at higher risk for adverse post-transplant outcomes. This study aims to determine appropriate donor selection for older ACLF patients.

Methods: Using OPTN/UNOS data, we analyzed elderly LT recipients (>60 years) with ACLF between 2004 and 2019. ACLF were identified using the EASL-CLIF criteria. Risk factors were analyzed. Based on multivariable analysis, points corresponding to hazard ratios (HRs) were assigned to the significant donor factors. Total risk score was calculated by multiplying HRs. Patients were categorized into lower-, mid-, and higher-risk donor group based on cut-off scores determined by 25 and 75 percentile. One-year graft survival were compared in each ACLF grade.

Results: A total of 8,146 older ACLF patients were eligible for this study. Multivariable model revealed national share (HR 1.52, p=0.007), DCD donors (HR 1.74, p<0.001), prolonged CIT (>6 hours, HR 1.18, p=0.021) and older donors (age>50, HR 1.34, p<0.001) had an increased risk of 1-year graft loss. Based on these donor factors, risk scores for the high, mid, and low-risk groups were >1.34, 1.01-1.34, and ≤1.00. The higher-risk group had higher adjusted risk of one-year graft loss than the lower-risk group in ACLF-1 and 3 (Figure). Use of higher-risk donors for patients with ACLF-3 was associated with worse one-year graft survival (68.0%).

Conclusion: In older ACLF patients, prolonged CIT and the use of DCD, older donor, and national share organs were associated with worse post-transplant outcomes. Careful donor selection is key to ensure successful outcomes.




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