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Over the past 2 decades, the need for liver transplants more than doubled among older folks, with non-alcoholic steatohepatitis (NASH) becoming the number one indication for transplantation during this time, a researcher said.

Comparing the periods 2002-2005 and 2018-2020, the proportion of transplant candidates ages 65 or older increased from 8.9% to 23.1% (P<0.0001), reported Maria Stepanova, PhD, of the Center for Outcomes Research in Liver Diseases in Washington, D.C.

And between the two study periods, NASH as the primary diagnosis jumped from 13.1% to 39.1% for these elderly transplant candidates, while hepatitis C declined from 26.7% to 18% (P<0.0001), according to her presentation at the virtual American Association for the Study of Liver Diseases (AASLD) meeting.

"We accept that hepatitis C is no longer a major contributor of patients to the list and NASH is increasing nationwide due to the obesity epidemic, awareness, and earlier diagnosis," said Fredric Gordon, MD, of Lahey Hospital and Medical Center in Burlington, Massachusetts. "I suspect that the proportion of patients with NASH has increased across all age ranges, not just the elderly."

"It is not surprising older patients are on the transplant list, and older patients are being transplanted," said Joseph S. Galati, MD, of Houston Methodist Hospital. "At our transplant center, we are evaluating and accepting patients older and older compared to a decade ago where some programs around the country had an upper age limit -- a cut off over 65 to 75."

He also pointed out that many older transplant patients could have better outcomes if referred 2 or 3 years earlier.

Stepanova said that with the aging liver transplant population, best approaches to organ allocation are being actively discussed. One strategy is pairing organs from older donors to patients with shorter life expectancy, "because the age of the donor is known to affect primarily long-term survival with no impact on short-term outcomes," she said. Though she cautioned that this is far from a perfect solution as "old donor" plus "old recipient" is a risk factor for worse outcomes.

For their study, Stepanova's group evaluated data on 31,209 liver transplant waitlist candidates ages 65 and over from the Scientific Registry of Transplant Recipients from 2002 to 2020. Over half (54%) ultimately received a transplant, 14% were delisted after deterioration and 7% for other reasons, 12% died while awaiting a transplant, and 4% improved.

When the researchers compared these rates to candidates under age 65, they noted a significantly higher proportion of younger candidates went on to receive a transplant (59%) while fewer were removed from waitlist for deterioration (9%; both P<0.0001). On-list mortality was similar between the age groups, while post-transplant mortality was higher in patients 65 and up (P<0.0001).

Despite this, mortality rates at 1, 3, and 5 years post-transplant declined over the study period for older transplant patients (P<0.0001 for trend).

Independent predictors of post-transplant mortality included older age, males, more recent year listed, higher MELD score, type 2 diabetes, retransplant, and HCC (all P<0.01). While independent predictors for receiving a transplant included male sex, a college degree, more recent year of listing, HCC, and a higher MELD score (all P<0.01).

"Notice that weight and BMI were not independent predictors of receiving a transplant or mortality," Gordon added. "Thus, the diagnosis of NASH may not be a driver in whether a patient receives or dies after the liver transplant."

Across the entire study period, about three-fourths of the elderly patients were white, 61% were men, a third had type 2 diabetes, the average body mass index (BMI) was 29, and average Model for End-Stage Liver Disease (MELD) score was 19. The most common transplant indication was NASH (31%), followed by hepatocellular carcinoma (HCC; 30%) and hepatitis C (23%).

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