Living Donors Ages 60 or Older in Right Lobe Living Donor Liver Transplantation

How old is too old for right lobe living liver donors? In the modern era of rising life expectancy, safe use of elderly donors can be compatible with the continuing efforts to expand the donor pool. Perioperative and long-term outcomes with at least 1 year follow-up of both living donors aged 60 years or older and their recipients in right lobe living donor liver transplantation (LDLT) in a single center between March 2008 and March 2013 were analyzed retrospectively on prospectively collected database by donor selection criteria: preservation of middle hepatic vein, a remnant liver volume of 30% or greater, and no or mild fatty change in healthy condition. The donor selection criteria and evaluation have been described previously.1-3 Initial acceptance criteria in terms of age had included adults aged 16 to 59 years since the inception of our LDLT program in January 2005.1 Then, elderly donors aged 60 years or older have been selectively accepted since March 2008. All living donors volunteered and signed the informed consent about the items deliberated by the Ethics Group of the Vancouver Forum.4 Full medical and psychiatric assessment was done by healthcare professionals. Imaging evaluation included Doppler ultrasonography, computed tomography with volumetry, and intraoperative cholangiography or magnetic resonance cholangiography. Upper and lower endoscopy examinations were routinely done to donor candidates aged 60 years or older. No potential donor with any abnormal medical or psychological condition proceeded to liver donation. Furthermore, smoking or taking oral contraceptives was prohibited in all donor candidates within 6 weeks before surgery in order to reduce the risk of venous thromboembolic disease. The surgical technique was previously specified with postoperative care and follow-up.2,5,6 During the study period, of the 15 donor candidates aged 60 years or older evaluated, 5 were rejected due to comorbidity (n = 3) and abnormal liver function tests (n = 2) and 10 underwent donor right hepatectomy. Donor and recipient characteristics are listed in Table 1. The median age of donors was 62.5 years (range, 60 to 76 years). The median operative time was 180 minutes (range, 130 to 283 minutes). The median estimated blood loss was 400 mL (range, 200 to 600 mL). No donor received blood transfusion during or after operation. The median postoperative hospital stay was 8 days (range, 7 to 14 days). In all donors, serum aspartate aminotransferase, alanine aminotransferase, total bilirubin, and international normalized ratio levels were normalized within 1 month. At a median postoperative follow-up of 31.4 months (range, 12.1 to 71.9 months), wound infection in a living donor was the one and only complication. All donors recovered completely and returned to their previous activities. All 10 recipients showed good initial function with 1-year graft and recipient survival both at 100%.TABLE 1: Demographic and perioperative data of the donors and recipientsIn the recipients whose median age was 54.5 years, the median model for end-stage liver disease score was 15.5, and the median graft-to-recipient weight ratio was 1.1. Four of 10 recipients were ABO-incompatible. All the recipients except one had hepatocellular carcinoma. The median serum total bilirubin and INR levels on postoperative day 7 were 1.6 mg/dL (range, 0.5 to 5.5 mg/dL) and 1.26 mg/dL (range, 1.16 to 1.49 mg/dL), respectively. All 10 recipients showed good initial function with 1-year graft and recipient survival both at 100%. Three recipients died over median postoperative follow-up of 29.8 months (range, 12.1 to 70.3 months); recipient 1 with recurrent hepatocellular carcinoma with extrahepatic metastases 56 months after surgery, recipient 3 with graft failure due to immunosuppressive nonadherence 42 months after surgery, recipient 4 with pneumonia 26 months after surgery. The other 7 recipients are in good health with normal liver function at the time of writing. We described a novel group of living donors aged 60 years or older that was generated from a cohort of 348 right lobe living donors during a 5-year experience at a single institution. Previous reports have defined “older donors” as those older than 44 or 50 years,7,8 thereby diluting any contribution from those aged 60 years or older. A major concern for elderly living donors is regarding the potential age-related morbidity, and a recent report showed that donor age older than 50 years was associated with a higher risk of major complications.9 In this study, all recipients had no other potential donors but the older ones. However, an age of 60 years or older was strictly restricted to those who met the abovementioned 3 criteria. These donors were matched to the recipients on the basis of 2 factors: graft-to-recipient weight ratio of 0.8 or higher and a model for end-stage liver disease score less than 24. Our criteria have been expanded with increasing experience and improved surgical management in LDLT. The current criteria for living donor younger than 60 years are as follows: a remnant liver volume of 30% or higher, mild fatty liver (macrovesicular steatosis <33%), body mass index less than 30. However, if donors younger than 50 years are in good health without more than mild fatty liver or any medical disorder including laboratory abnormality, a remnant liver volume less than 30% is selected carefully with the middle hepatic vein absolutely preserved in donors.3 The important potential limitation to this study includes a relatively small number of subjects, only 10 donor-recipient pairs, and the absence of a control group. The possibility of a type II error due to the small sample size deterred the comparison with the potential control group younger than 60 years that included 338 living donors during the same study period. Furthermore, the comparison would have created too wide an age range of controls (ages 16 to 59 years) to make meaningful inferences. These results suggest that the age factor should never be considered as an isolated exclusion criteria for living donor right hepatectomy and living donors 60 years or older deserve consideration.

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