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Utilization of older deceased donors for pediatric liver transplant may negatively impact long-term survival
Sakil S Kulkarni1, Neeta A Vachharajani2, Angela L Hill2
1Department of Pediatrics, Division of Pediatric Hepatology, St. Louis Children's Hospital, St. Louis, Missouri, USA.
Insights
Older donor livers in pediatric transplantation are associated with worse outcomes, especially for deceased donor grafts. However, living donor liver transplants from older donors show a less negative impact on patient survival.
Area of Science:
- Hepatology
- Transplantation Surgery
- Pediatric Medicine
Background:
- Adult studies suggest older donors (ODs) can expand the donor pool.
- The impact of ODs on pediatric liver transplantation (PLT) outcomes remains unclear.
Purpose of the Study:
- To investigate the outcomes of pediatric liver transplantation (PLT) using grafts from older donors (ODs).
- To compare the survival rates and identify predictors of success in PLT recipients of OD grafts versus younger donor (YD) grafts.
Main Methods:
- Utilized the UNOS database to identify pediatric liver transplants (≤18 years) in the US (2002-2022).
- Classified donors ≥40 years as ODs and performed propensity score matching for comparative analysis.
- Employed Kaplan-Meier and Cox regression analyses to assess patient and graft survival.
Main Results:
- 669 out of 10,024 PLT recipients received grafts from ODs.
- OD recipients had higher acuity (e.g., higher MELD/PELD scores, ICU status) at transplantation.
- Kaplan-Meier analysis revealed worse patient and graft survival for OD recipients compared to YD recipients (p<0.001).
- This survival disparity was significant for deceased donor grafts but not for living donor grafts from ODs.
Conclusions:
- OD livers are allocated to higher acuity pediatric candidates.
- Pediatric recipients of OD grafts experience poorer outcomes than those receiving YD grafts.
- Living donor liver transplantation from ODs demonstrates the least negative impact on recipient outcomes.
Background:
Multiple adult studies have investigated the role of older donors (ODs) in expanding the donor pool. However, the impact of donor age on pediatric liver transplantation (LT) has not been fully elucidated.
Methods:
UNOS database was used to identify pediatric (≤18 years) LTs performed in the United States during 2002-22. Donors ≥40 years at donation were classified as older donors (ODs). Propensity analysis was performed with 1:1 matching for potentially confounding variables.
Results:
A total of 10,024 pediatric liver transplantation (PLT) patients met inclusion criteria; 669 received liver grafts from ODs. Candidates receiving OD liver grafts were more likely to be transplanted for acute liver failure, have higher Model End-Stage Liver Disease/Pediatric End-Stage Liver Disease (MELD/PELD) scores at LT, listed as Status 1/1A at LT, and be in the intensive care unit (ICU) at time of LT (all p < 0.001). Kaplan-Meier (KM) analyses showed that recipients of OD grafts had worse patient and graft survival (p < 0.001) compared to recipients of younger donor (YD) grafts. KM analyses performed on candidates matched for acuity at LT revealed inferior patient and graft survival in recipients of deceased donor grafts (p < 0.001), but not living donor grafts (p > 0.1) from ODs. Cox regression analysis demonstrated that living donor LT, diagnosis of biliary atresia and first liver transplant were favorable predictors of recipient outcomes, whereas ICU stay before LT and transplantation during 2002-12 were unfavorable.
Conclusion:
Livers from ODs were used for candidates with higher acuity. Pediatric recipients of livers from ODs had worse outcome compared to YDs; however, living donor LT from ODs had the least negative impact on recipient outcomes.
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