Octogenarian Liver Grafts Reaching Centennial Age After Transplantation
From April 1986 to October 2016, we performed 1870 LT at our institution. In 58 recipients, we used octogenarian liver grafts, and at present, 4 of these livers have reached or surpassed a total lifespan of 100 years. Three recipients are currently alive and well with normal liver function, and the fourth recipient died 11 years after LT because of renal failure and coronary disease, but with normal liver function and histology (Table 1).
The blood flow, synthetic, excretory, and metabolic changes of liver function are affected by aging, and these consequences may have clinical relevance.3 After the age of 50 years, the liver becomes progressively smaller, so that it decreases from 2.5% of total body weight in young people to about 1.6% in the nonagenarian population, and several morphological changes with aging indicate that the liver cells in advanced old age are in a hyperfunctioning state, possibly trying to compensate for the decline in total cell number.4 However, it has been suggested that aging has a limited effect on liver functions but more on its response to extrahepatic factors,5 disease states or increased metabolic demands to which elderly people may have an impaired ability to respond.4
Atheromatosis usually affects the celiac trunk in old donors but, although this happens rarely, when atheroma occurs distally at the level of the right hepatic artery or at the bifurcation of the gastroduodenal and the common hepatic artery, the liver graft must be discarded for LT.2
The LT procedure is a scenario in which many donor risk factors may be involved. Thus, in our previous brief communication on octogenarian liver donors, we recommended the use of liver grafts with no age limit but in good preprocurement condition (hemodynamic stability, low doses of vasopressor drugs), short intensive care unit stay, good liver function tests, soft liver consistency, absence of hepatic artery atheromatosis, cold ischemia time less than 9 hours, and macrosteatosis less than 30%.1 From that time, we have continued applying the same criteria, but in recent years we have added other conditions such as implanting the octogenarian livers into recipients without Hepatitis C virus (HCV) cirrhosis and model for end-stage liver disease scores lower than 20 who could tolerate well a probable transient graft dysfunction.2 As we have seen in this short experience, it is possible that an octogenarian liver graft can reach the centennial age after transplant while the recipient maintains a normal liver function and a good quality of life if a good donor selection is done, and recipients with HCV cirrhosis or advanced liver disease are excluded, but at present, with the current introduction of new anti-HCV drugs, we are also using these older donors in HCV recipients to decrease the waiting list mortality. However, further investigations are needed to demonstrate good results using octogenarian liver donors in HCV recipients.