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• W2016138085 abstract "Receiving an application to join the American Association of Retired Persons is a rite of passage after a person's 50th birthday and signifies a major transition in most people's lives. No longer counted among the youth, these individuals are considered over the hill by some and even elderly by others. Despite the aging population of the United States, life expectancy continues to increase significantly and is fueling the popular belief that “50 is the new 40.” However, this is not true when someone is being considered as an organ donor; “50 is now the new 60” is the sine qua non of an extended criteria donor. ECS, extended criteria surgery; HAT, hepatic artery thrombosis; HCV, hepatitis C virus; MHV, middle hepatic vein. In this issue of Liver Transplantation, Dayangac et al.1 report their experience with and the outcomes of living donor liver transplantation using right lobe grafts provided by elderly donors (≥50 years, n = 28) and younger donors (<50 years, n = 122). They have striven to determine the impact of donor age on both donor and recipient morbidity and mortality. As the authors correctly point out, there is little information in the literature regarding the limits of donor age for living donor right hepatectomy. Indeed, over the years, our program has vacillated on the age limits for living liver donors because of the relatively limited clinical evidence. Because of the ethical, medical, and psychosocial issues surrounding donor safety, studies like this one are important for bringing an important issue into focus. Unfortunately, the observations and conclusions of Dayangac et al.1 have not clarified the issue significantly and raise additional questions. The conclusions seem to be more intuitive than based on the data presented. For example, numerous reports and a growing consensus suggest that outcomes are worse for recipients with end-stage liver disease secondary to hepatitis C virus (HCV) infection when older donors instead of younger ones are used.2, 3 Therefore, it is not difficult to believe that the same may be true for non–HCV-infected recipients. In this study, HCV-infected recipients of liver grafts obtained from elderly donors did no worse than recipients of grafts from younger donors, but the very small sample size of the elderly group may have confounded the results. Among non–HCV-infected recipients, the authors report a “striking finding that emerged from this study”: recipients of grafts from donors ≥ 50 years had worse outcomes in terms of 30-day and 1-year patient survival. However, this assertion did not reach statistical significance. Although there was a numerical trend, the calculated P values of 0.1 and 0.3, respectively, suggest no difference. A type 2 statistical error due to the small number of recipients of grafts from elderly donors may explain the result. Regardless of recipient outcomes, the primary purpose of the study was to examine donor complications. Dayangac et al.1 have concluded that donors who are 50 years old or older suffer more postoperative complications but only when the limits of surgery are extended. Interestingly, the overall complication rate was 28.6% for elderly donors and 32% for younger donors (P = 0.7), and the major complication rates were 14.3% and 8.2%, respectively (P = 0.2). Only when elderly donors experienced 2-parameter extended criteria surgery (ECS) did they suffer significantly more complications. Two-parameter ECS is likely a euphemism for subtotal hepatectomy including the middle hepatic vein (MHV) that results in a donor remnant volume < 35%. The issue of MHV inclusion with a right lobe graft is controversial. Although studies have shown that donor safety can be maintained,4 most surgeons would agree that larger hepatic resection results in more complications, especially when the physiological limits of the remnant volume are approached. In this report, justification for including the MHV with the graft was determined with an algorithm based on the need to leave the donor with a >30% remnant volume and the need to preserve drainage to segments V and VIII of the graft.5 In appreciation of the increased risk to the donors, the authors have concluded that neither elderly donors nor anyone else (unless the remnant volume is anticipated to be >30%) should undergo 2-parameter ECS (MHV inclusion and a remnant volume < 35%).5 Although I applaud the authors' decision to abandon the routine inclusion of the MHV when the physiological limits of the remnant volume are approached, there is a growing consensus that other remedies are available to both preserve a good outcome for the recipient and increase donor safety. These include selective reconstruction of the MHV with various vascular conduits, the use of left lobe grafts with or without inflow modification, and the use of an alternative donor. Recently, there has been renewed interest in investigating methods to make smaller left lobe grafts safer for both donors and recipients,6 and this will be one of the initiatives investigated in the multicenter, National Institutes of Health–sponsored Adult-to-Adult Living Donor Liver Transplantation Cohort Study (part 2). Despite Dayangac et al.'s relatively aggressive approach to donor hepatectomy, all would agree with their statement that “an expansion of the limits of donor surgery should not place donors at increased risk.” Remarkably, no recipient suffered any vascular complications [hepatic artery thrombosis (HAT) or portal vein thrombosis] in Dayangac et al.'s study.1 Much of the details of the surgery are not covered, and no discussion regarding these impressive findings is provided. The reported HAT rate in the Adult-to-Adult Living Donor Liver Transplantation Cohort Study (part 1) was approximately 6%.7 One potential explanation is that the large graft size and excellent outflow with routine MHV inclusion may have helped to prevent thrombosis by mitigating the hepatic artery buffer response.8 In our experience, many HAT events are clinically silent; therefore, unless the authors were routinely looking for HAT, they may have missed some of those events. Unfortunately, no information regarding graft surveillance has been provided. The authors report higher peak international normalized ratios and total bilirubin levels for recipients of grafts from elderly donors, but these findings did not reach statistical significance. However, ischemic times were significantly longer in grafts procured from elderly donors who underwent 2-parameter ECS; thus, differences in recipient outcomes may be related as much to graft ischemia as to donor age. Not surprisingly, elderly donors who underwent 2-parameter ECS and had a remnant volume < 35% had significantly higher peak international normalized ratios and a trend toward higher bilirubin levels on postoperative day 7. One interesting finding of this report is the suggestion of a reduced regeneration rate in recipients of elderly livers versus recipients of younger ones. Unfortunately, regeneration was measured only at 7 days when changes in the graft size likely reflected graft edema and changes in blood flow just as much as true growth. In our living donor series, recipients have reached the standard liver volume within 4 weeks after the operation, whereas donors have taken up to 3 months to reach a plateau of regeneration; therefore, a single measurement 7 days after the operation has limited value.9, 10 This study by Dayangac et al.1 does confirm long-proven surgical tenets: more aggressive surgery is likely to lead to more complications than less aggressive surgery, and elderly patients tend to do worse than younger ones. However, the exception to this rule is that chronological age often does not reflect physiological age. Clearly, additional studies evaluating the effects of donor age on recipient and donor morbidity and mortality are warranted. What is not in doubt is that a good outcome after living donor liver transplantation requires sound judgment, good preparation, technical acumen, and attention to detail." @default.
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• W2016138085 date "2011-04-19" @default.
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• W2016138085 title "Elderly donors? 50 is the new 60" @default.
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• W2016138085 doi "https://doi.org/10.1002/lt.22286" @default.
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