Worse waitlist and liver transplant outcomes for those ages 18 to 24

Last Updated: 2017-03-29

By Marilynn Larkin

NEW YORK (Reuters Health) - Compared with younger and somewhat older liver transplant candidates, 18- to 24-year-olds have poorer waitlist and posttransplant outcomes, researchers in Seattle say.

Dr. Noelle Ebel of the University of Washington School of Medicine told Reuters Health, “18 to 24 year olds are not only more likely to die on the waiting list before receiving a liver transplant, after they are transplanted they also have the highest mortality rate compared to 0 to 17 and 25 to 34 year olds.”

“This may reflect a culture of advocacy for younger children who have a higher utilization of exception scores and therefore are more likely to be transplanted early,” she said by email. “18 to 24 year olds in essence may be aging out of allocation benefits afforded to the youngest pediatric patients.”

Dr. Ebel and colleagues analyzed United Network for Organ Sharing data on 13,979 wait-listed candidates for primary liver transplant and 8,718 liver recipients. Waiting list registrants and recipients were divided into five age groups: 0 to 5, 6 to 11, 12 to 17, 18 to 24, and 25 to 34 years old.

As reported in Transplantation, online February 22, the proportion of patients with acute liver failure was higher in the 18- to 24-year-old group (at 29.0%) than in other age groups. The next most common indications for transplant in the 18- to 24-year-olds were primary sclerosing cholangitis (15.7%) and metabolic liver disease (13.1%).

Among registrants with Status 1A priority, 18- to 24-year-olds were more likely to be removed from the waiting list due to improved condition.

However, among non-Status 1A registrants, both 0- to 17- and 25- to 34-year-olds were less likely than 18- to 24-year-olds to be removed from the waiting list due to disease progression or death (adjusted hazard ratio: 0 to 5 year olds=0.36, 6 to 11=0.29, 12 to 17=0.48, 18 to 24=1.00, 25-34=0.82).

Although there was no difference in risk of graft failure across age groups, both younger and older age groups had a significantly lower risk of posttransplant mortality compared with 18 to 24 year olds (AHR for 0 to 5 year olds=0.53, 6 to 11=0.48, 12 to 17=0.70, 18 to 24=1.00, 25 to 34=0.77).

The probability of survival at one, two and five years was lowest in the 18-to-24 group, at 0.91, 0.88 and 0.79, respectively, compared with all other age groups. Associations were similar for males and females.

Dr. Ebel concluded, “Given the potential survival benefit in transplanting young adults and the shortage of solid organs for transplant, improving wait-list and posttransplant outcomes in 18-24 year olds remains paramount.”

Dr. Steven Flamm, medical director of the liver transplant program at Northwestern Memorial Hospital in Chicago, told Reuters Health by email, “Studies such as this provide the impetus to reassess the liver allocation system for children and young adults, and the way the special case requests are considered by regional review boards.”

Dr. Johnny Hong, director of Solid Organ Transplant at Children’s Hospital of Wisconsin in Milwaukee told Reuters Health, “These patients are best served by liver transplant programs that have the expertise . . . to address both medical and psycho-socio-economic risk factors.”

To reduce risks and optimize outcomes, he said by email, “an ideal liver transplant program should have the capabilities to offer all liver graft options (whole liver from deceased donors and partial liver grafts from deceased and live donors) in order to increase the patients’ access to liver transplantation.”

“They should also have expertise in the care of high acuity and complex patients,” he added. A multidisciplinary team approach is “imperative,” he added, to address issues such as transition of care from the pediatric to adult programs, non-adherence, financial counseling and access to care, etc.

Dr. Adnan Said of the University of Wisconsin in Madison, a member of the American Liver Foundation’s National Medical Advisory Committee, agreed that differences in organ allocation policy as well as “socio-behavioral challenges as young adults transition from parental dependence to independence” could contribute to disparities.

“Collaboration between pediatric and adult transplant practitioners is needed to develop practical evidence-based guidelines” for transitioning patients, he told Reuters Health by email. “Resources should be provided to assist these young adults as they transition to independence with medication compliance, insurance coverage and medication coverage.”

SOURCE: http://bit.ly/2ob99dD

Transplantation 2017.