Impact of elderly donors on the survival and complications in liver transplantation

Impact of elderly donors on the survival and complications in liver transplantation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of elderly donors on the survival and complications in liver transplantation Li Li, Chao Sun, Jinyang Yu, Yifeng Tao, Conghuan Shen, Ruidong Li, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6242550/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Despite increased use, the impact of elder donors on the outcomes of liver transplantation remains controversial, particularly with regard to postoperative complications. Methods Retrospective data of adult liver transplantation with deceased donors between August 1, 2017 to November 30, 2023 were collected. The aim was to compare survival as well as postoperative complications of the recipients with elderly donors (≥ 60 years) to younger donors (< 60 years). Results Out of a total of 950 liver transplants, 201 were elderly donors and 749 were younger donors. No difference in overall survival or disease-free survival in patients with hepatocellular carcinoma between the two groups was demonstrated. Elderly donors were associated with higher incidence of primary nonfunction, re-transplantation, acute rejection, and splenic artery steal syndrome. No difference in biliary complications was observed. Conclusions Elderly donors do not affect patient survival, despite the higher incidence of PNF and re-transplantation. But elder grafts are more susceptible to acute rejection and splenic artery steal syndrome. Additional interventions should be taken to prevent these complications with elderly donors. liver transplantation elder donors primary nonfunction re-transplantation acute rejection splenic artery steal syndrome Figures Figure 1 Figure 2 Introduction Liver transplantation (LT) is the gold standard treatment for patients with end-stage liver disease. Outcomes continue to improve, with 5 years survival now around 75% 1 . But the organ shortage problem remains a significant obstacle, with approximately 23% of waitlisted candidates die or are removed from the waiting list for being too sick 2 . To widen the donor pool, organs from extended criteria donors, including elderly donors, donation after circulatory death, steatotic livers, and split-liver grafts are increasingly being used 3 . There remains controversy regarding advanced donor age and LT outcomes. Many studies have shown that elderly grafts are associated with higher rates of graft lost and post LT mortality 4 – 8 . Nevertheless, encouraging long term survival was observed when recipients were appropriately selected 9 – 11 . Livers of the elderly show reduced regenerative capacity, slowed blood flow and lipid accumulation. These morphological and functional modifications may raise the risk of complications 12 – 16 . In this study, we compared the long-term outcomes of recipients using donors aged 60 years or older and younger donors. Specifically, our aim is to include not only patient survival but also posttransplant complications. Materials and Methods We reviewed all adult recipients (age 18 or older) who underwent LT from donation after brain death at Huashan Hospital, Fudan University between August 1, 2017 and November 30, 2023. Living donor recipients, re-transplant recipients, and cases with missing survival data were excluded. The final cohort was then stratified by donor age using 60 as the breakpoint, which is the most widely studied cut-off point in the past 17 . The study group included all patients who received liver allografts from donors aged 60 years or older (n = 201). A control group consisted of all patients transplanted with allografts from donors younger than 60 years (n = 749). Donor and recipient characteristics were compared using the Wilcoxon rank-sum test for continuous variables and Pearson χ2 test for categorical variables. Unadjusted graft and recipient survival rates were estimated using the Kaplan–Meier method and compared by the log-rank test. A P value less than 0.05 was considered statistically significant. The data were analyzed using IBM SPSS Statistics for Windows, Version 26.0 (IBM Corp., Armonk, NY). This study was approved by the Ethics Committee of Huashan Hospital, Fudan University. The relevant donor variables identified were sex, body mass index, cold ischemia time, sodium, aspartate aminotransferase, alanine transaminase, total bilirubin, hepatitis B surface antigen (HBsAg), anti-hepatitis C virus (anti-HCV). Recipient variables consisted of sex, age, end-stage liver disease (MELD) score, hepatocellular carcinoma (HCC) status. The MELD score was based on laboratory values at time of transplant and did not consider point exceptions for cancer or other diagnoses. The date of primary nonfunction (PNF) was defined as the need for emergent re-transplant when a graft never presented any evidence of initial function after excluding other causes. Acute rejection (AR) was confirmed by serum laboratory studies and a tissue biopsy. Biliary and vascular complications was confirmed by surgery, radiographic examination, or clinical follow-up. Splenic artery steal syndrome is characterized by hypoperfusion of the hepatic artery secondary to a competitive shunt of blood flow into the splenic artery from the celiac trunk and diagnosed on angiography. Overall survival in all recipients and Disease-free survival in HCC recipients were recorded. Results Donor and Recipient Characteristics This study included 950 recipients, of whom 201 received livers from elderly donors livers and 749 received from young donors. The characteristics of recipients and donors are shown in Table 1 . There were no differences in recipient characteristics such as gender, BMI, blood sodium, and MELD score between the two groups. In terms of indicators of graft function, the AST levels of the elderly donors were lower than those of the young donors (elderly: 51.4 vs. young: 73.6, P = 0.021), whereas both groups had similar ALT (elderly: 69.4 vs. young: 86.4 P = 0.120) and total bilirubin (elderly: 19.6 vs. young: 20.3, P = 0.021) levels. In addition, HBsAg positive, HCV and cold ischemia time were similar between the two groups. Table 1 Characteristics of recipients and donors between the elderly donor group and the young donor group. Donors Characteristics Donor age ≥ 60 y (n = 201) Donor age < 60 y (n = 749) P Male sex 162(80.6%) 646(86.2%) 0.109 BMI 23.3 ± 3.2 23.7 ± 3.2 0.082 Na+ (µmol/L) 143.5 ± 14.4 144.8 ± 9.4 0.232 ALT (U/L) 51.4 ± 100.3 73.6 ± 57.5 0.021 AST (U/L) 69.4 ± 120.6 86.4 ± 88.7 0.120 TBil (µmol/L) 19.6 ± 21.6 20.3 ± 27.2 0.718 HBsAg + 19(9.5%) 59(7.9%) 0.470 Anti-HCV + 5(2.5%) 8(1.1%) 0.124 CIT (h) 8.3 ± 0.6 8.3 ± 0.6 0.763 Recipients Characteristics Male sex 173(86.1%) 661(88.3%) 0.402 Age (y) 50.3 ± 10.1 50.1 ± 10.0 0.773 MELD score 24.7 ± 6.1 25.2 ± 5.8 0.332 HCC 78(38.8%) 294(39.3%) 0.346 BMI, body mass index; MELD, model for end-Stage liver disease; CIT, cold ischemic time; HCC, hepatocellular carcinoma; ALT, alanine aminotransferase; AST, aspartate aminotransferase; TBil, total bilirubin Patients and graft survival Recipients were followed for 4–77 months and no significant difference in overall survival between the two groups (Fig. 1 ). 78 cases of hepatocellular carcinoma were diagnosed in the elderly donor group, compared with 294 cases in the young donor group (elderly: 78 [38.8%] vs. young: 294 [39.3%], P = 0.021). Among patients with hepatocellular carcinoma, the disease-free survival was similar between the elderly donor group and the young donor group, suggesting that elderly donors did not increase the risk of recurrence of hepatocellular carcinoma (Fig. 2 ). 22 of the 950 recipients underwent re-transplantation. The proportion of re-transplantation (elderly: 8 [4.0%] vs. young: 14 [1.9%], P = 0.077) and PNF (elderly: 8 [4.0%] vs. young: 7 [0.9%], P = 0.002) was higher in the elderly donor group. All re-transplantation in the elderly donor group were due to PNF. In the younger donor group, 7 of the 14 re-transplantation were due to PNF, and the remaining included 1 vascular complication, 3 biliary complications, and 3 chronic rejection. Posttransplant complications The posttransplant complications of the two groups are shown in Table 2 . A total of 141 cases of acute rejection were observed, comprising 59 cases in the elderly donor group and 82 cases in the young donor group. The incidence of acute rejection was significantly higher in the elderly donor group than in the young donor group (elderly: 59 [29.4%] vs. young: 82 [10.9%], P = 0.001). Table 2 Posttransplant complications between the elderly donor group and the young donor group. Events Donor age ≥ 60 y (n = 201) Donor age < 60 y (n = 749) P Primary nonfunction 8(4.0%) 7(0.9%) 0.002 Unplanned reoperation 13(6.5%) 42(5.6%) 0.643 Re-transplantation 8(4.0%) 14(1.9%) 0.077 Acute rejection 59(29.4%) 82(10.9%) 0.001 Arterial embolism 1(0.5%) 5(0.7%) 0.787 Portal vein thrombosis 0 5(0.7%) 0.245 Splenic artery steal syndrome 4(2.0%) 4(0.5%) 0.045 Biliary anastomotic stricture 2(1.0%) 5(0.7%) 0.630 Bile leakage 0 6(0.8%) 0.203 Ischemic biliary lesions 3(1.5%) 5(0.7%) 0.256 We also compared the incidence of hepatic artery embolism, portal vein thrombosis, and splenic artery steal syndrome between the two groups. There was no difference in the incidence of hepatic artery embolism (elderly: 1 [0.5%] vs. young: 5 [0.7%], P = 0.787) and portal vein thrombosis (elderly: 0 vs. young: 5 [0.7%], P = 0.245) between the two groups. However, recipients who received donor liver from elderly donor were more likely to have splenic artery steal syndrome (elderly: 4 [2.0%] vs. young: 4 [0.5%], P = 0.021). There was no difference between the two groups in the incidence of biliary complications, whether anastomotic strictures (elderly: 2 [1.0%] vs. young: 5 [0.7%], P = 0.630), bile leakage (elderly: 0 vs. young: 6 [0.8%], P = 0.203), or ischemic biliary lesions (elderly: 3 [1.5%] vs. young: 5 [0.7%], P = 0.256). Discussion As the aging population grows, the use of elderly donors in China has increased rapidly in recent years. However, the impact of advanced donor age on recipients remains controversial. The main cause of elderly donor death is the cerebrovascular accident instead of trauma. So they tend to have shorter hospital stay in intensive care unit, fewer episodes of hemodynamic instability or cardiac arrest, and lower laboratory parameters of liver function than younger donors 18 , 19 . But the diminished regenerative capacity of aged liver cells makes elder livers more susceptible to ischemia-reperfusion injury. According to data from the United Network for Organ Sharing (UNOS), the CIT of liver graft in the United States has decreased from 10 hours in 1990–1994 to 6 hours in 2010–2014, which is a significant contributing factor to the marked improvement in outcomes with elderly donors 20 . Meanwhile, the use of elderly donors in living liver transplantation with a short cold ischemia time has been shown to be safe for recipients 21 , 22 . Nevertheless, the CIT of livers donated by deceased donors in China is noticeably longer due to the size of the country and the mode of transportation 23 . The average CIT in our study was 8.3 hours, both in elderly donor and young donor groups. The results showed that long-term survival in elderly donor group were similar to those in the younger donor group. But the incidence of PNF and re-transplantation was significantly higher in the elderly donor group, indicating the use of elderly donors with CIT over 8 hours is still at significant risk. This study is the first to demonstrate that recipients with elder liver grafts are at an increased risk of developing splenic artery steal syndrome. The mechanism may lie in the thickening hepatic arteriolar walls, diminished endothelial cells fenestration and shrinking volume in senescent liver, leading to a reduction in blood flow 24 , 25 . Therefore, liver transplantation using elderly donors should probably be performed more aggressively with surgical splenic artery ligation and proximal splenic artery embolization. Previous reports on the effect of advanced donor age on acute rejection had conflicting results 4 , 18 . We found the incidence of acute rejection was approximately three times higher in elderly donor group than in the younger donor group. The underlying immunological mechanisms need to be further investigated. Several studies reported higher incidence of biliary complications in the patient with elder liver graft, such as ischemic-type biliary lesions and biliary non-anastomotic stricture 26 , 27 . However, there was no significant difference in biliary complications between elderly and young donors in our study, potentially due to limitations in the sample size. Normothermic machine perfusion has shown promising results in liver transplantation 28 and is a prospective approach at this stage to improve the outcomes of elderly donors. In addition, donor-recipient match, such as the donor MELD (D-MELD) and the donor-recipient MELD (DR-MELD) have also been proposed for optimizing selection of advanced age donors and their recipients 18 , 29 . However, these matching scores requires changes in organ allocation policies, limiting its practical application. In conclusion, survival in liver transplantation with elderly donor was similar to that of young donor, despite the higher incidence of PNF and re-transplantation. However, there is an increased risk of acute rejection, and splenic artery steal syndrome with elder liver grafts. To prevent these complications, additional interventions may be needed when using elderly donors. Abbreviations PNF primary nonfunction LT liver transplantation HBsAg hepatitis B surface antigen HCV hepatitis C virus BMI body mass index MELD model for end-Stage liver disease CIT cold ischemic time HCC hepatocellular carcinoma ALT alanine aminotransferase AST aspartate aminotransferase TBil total bilirubin AR Acute rejection Declarations - The work has not been published previously. - Manuscript is original work and not under consideration for publication elsewhere - Submission is approved by all authors. The authors have no conflict of interest to declare. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. This study was supported by the grants from the National Key Research and Development Program of China 2023YFC2505900, National Natural Science Foundation of China (81873874, 82071797 and 82241225). The institutional ethics board approved the study. Autonomous consent free from coercion was obtained from the donor(s) or their next of kin. Organs/tissues were not sourced from executed prisoners or prisoners of conscience. Author Contributions (I) Conception and design: Zhengxin Wang; (II) Administrative support: Li Li, Chao Sun, Jinyang Yu; (III) Provision of study material or patients: Yifeng Tao, Conghuan Shen, Ruidong Li, Quanbao Zhang; (IV) Collection and assembly of data: Li Li, Chao Sun, Jinyang Yu; (V) Data analysis and interpretation: Li Li, Chao Sun, Jinyang Yu, Zhengxin Wang; (VI) Manuscript writing: Li Li, Chao Sun, Jinyang Yu; (VII) Final approval of manuscript: All authors. References Hughes, C. B. & Humar, A. Liver transplantation: current and future. Abdom. Radiol. N. Y. 46, 2–8 (2021). Heimbach, J. K. & Allen, A. M. Improved Prioritization of the Liver Transplant Waitlist: Weighing the Risks. Transplantation 108, 1062 (2024). Goldaracena, N., Cullen, J. M., Kim, D.-S., Ekser, B. & Halazun, K. J. Expanding the donor pool for liver transplantation with marginal donors. Int. J. Surg. Lond. Engl. 82S, 30–35 (2020). Schneider, S. et al. Long-term outcomes of the octogenarian donor liver recipient: The era of the new centurion. Clin. Transplant. 33, e13629 (2019). Roullet, S. et al. Liver Transplantation With Old Grafts: A Ten-Year Experience. Transplant. Proc. 49, 2135–2143 (2017). Guichelaar, M. M. J. et al. Risk factors for and clinical course of non-anastomotic biliary strictures after liver transplantation. Am. J. Transplant. Off. J. Am. Soc. Transplant. Am. Soc. Transpl. Surg. 3, 885–890 (2003). Heidenhain, C. et al. Incidence of and risk factors for ischemic-type biliary lesions following orthotopic liver transplantation. Transpl. Int. Off. J. Eur. Soc. Organ Transplant. 23, 14–22 (2010). Kim, D. Y. et al. Routine use of livers from deceased donors older than 70: is it justified? Transpl. Int. Off. J. Eur. Soc. Organ Transplant. 18, 73–77 (2005). Dudek, K. et al. Results of liver transplantation from old donors. Transplant. Proc. 46, 2762–2765 (2014). Darius, T. et al. Septuagenarian and octogenarian donors provide excellent liver grafts for transplantation. Transplant. Proc. 44, 2861–2867 (2012). Flemming, J. A., Kim, W. R., Brosgart, C. L. & Terrault, N. A. Reduction in liver transplant wait-listing in the era of direct-acting antiviral therapy. Hepatol. Baltim. Md 65, 804–812 (2017). Slawik, M. & Vidal-Puig, A. J. Lipotoxicity, overnutrition and energy metabolism in aging. Ageing Res. Rev. 5, 144–164 (2006). Petersen, K. F. et al. Mitochondrial dysfunction in the elderly: possible role in insulin resistance. Science 300, 1140–1142 (2003). Maeso-Díaz, R. et al. Effects of aging on liver microcirculatory function and sinusoidal phenotype. Aging Cell 17, e12829 (2018). Ledda-Columbano, G. M. et al. Aging does not reduce the hepatocyte proliferative response of mice to the primary mitogen TCPOBOP. Hepatol. Baltim. Md 40, 981–988 (2004). Mahrouf-Yorgov, M. et al. Increased susceptibility to liver fibrosis with age is correlated with an altered inflammatory response. Rejuvenation Res. 14, 353–363 (2011). Xiang, Z. et al. Current Understanding of Marginal Grafts in Liver Transplantation. Aging Dis. (2024). Caso-Maestro, O. et al. Analyzing predictors of graft survival in patients undergoing liver transplantation with donors aged 70 years and over. World J. Gastroenterol. 24, 5391–5402 (2018). Bruzzone, P., Giannarelli, D., Adam, R., European Liver and Intestine Transplant Association, & European Liver Transplant Registry. A preliminary European Liver and Intestine Transplant Association-European Liver Transplant Registry study on informed recipient consent and extended criteria liver donation. Transplant. Proc. 45, 2613–2615 (2013). Gao, Q. et al. Improvement in Liver Transplant Outcomes From Older Donors: A US National Analysis. Ann. Surg. 270, 333–339 (2019). Han, J. H. et al. Outcomes of living donor liver transplantation using elderly donors. Ann. Surg. Treat. Res. 86, 184–191 (2014). Kadohisa, M. et al. Impact of Donor Age on the Outcome of Living-donor Liver Transplantation: Special Consideration to the Feasibility of Using Elderly Donors. Transplantation 105, 328 (2021). Wang, K. et al. Severity of early allograft dysfunction following donation after circulatory death liver transplantation: a multicentre study. Hepatobiliary Surg. Nutr. 10, 9–19 (2021). Allaire, M. & Gilgenkrantz, H. The aged liver: Beyond cellular senescence. Clin. Res. Hepatol. Gastroenterol. 44, 6–11 (2020). Wynne, H. A. et al. The effect of age upon liver volume and apparent liver blood flow in healthy man. Hepatology 9, 297–301 (1989). Shen, T. et al. Older liver grafts from donation after circulatory death are associated with impaired survival and higher incidence of biliary non-anastomotic stricture. Hepatobiliary Pancreat. Dis. Int. 22, 577–583 (2023). Heidenhain, C. et al. Incidence of and risk factors for ischemic-type biliary lesions following orthotopic liver transplantation. Transpl. Int. Off. J. Eur. Soc. Organ Transplant. 23, 14–22 (2010). Nasralla, D. et al. A randomized trial of normothermic preservation in liver transplantation. Nature 557, 50–56 (2018). Halldorson, J. B., Bakthavatsalam, R., Fix, O., Reyes, J. D. & Perkins, J. D. D-MELD, a simple predictor of post liver transplant mortality for optimization of donor/recipient matching. Am. J. Transplant. Off. J. Am. Soc. Transplant. Am. Soc. Transpl. Surg. 9, 318–326 (2009). Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6242550","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":432668697,"identity":"af930d3b-e5c9-4669-b12f-d1c7aca031c0","order_by":0,"name":"Li Li","email":"","orcid":"","institution":"Huashan Hospital Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Li","middleName":"","lastName":"Li","suffix":""},{"id":432668698,"identity":"ebb605d3-647b-47c6-bdd7-29de008562c9","order_by":1,"name":"Chao Sun","email":"","orcid":"","institution":"Huashan Hospital Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Chao","middleName":"","lastName":"Sun","suffix":""},{"id":432668699,"identity":"33b9215c-799f-4b0c-9a36-890175f9ef5b","order_by":2,"name":"Jinyang Yu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABB0lEQVRIie3RMUvEMBTA8VcCuSXYNSJcv0KOQkWq51dJCPQWkQNBMlaETPcBHPwQWd1eKdSlOBduqZOLg7eIm+Zu1ZaODvmPIT8eyQMIhf5hNHlDlOKcURLvegPkcMrHyBFcqb43xTyelalop5A5yHTRt3V6vMGMTyIUsODKEuU6WZjK5skpkGrLYHk9SKK7xhO6J01X2dXiqaQ6Z6BvBgmB/RTmibLbna0jhyw7YYCqHCIUMk+4J5quK1tfOow/xwmDVMhW+Oc3FDxRfgodJ5ypXhrpP3lDOL6stKtpevYo9CBJHmZYfYlvv0oWfeBtfuGe71+7d7McJH90WI2Yfj8UCoVCv/sBcIBb0blLPpMAAAAASUVORK5CYII=","orcid":"","institution":"Huashan Hospital Fudan University","correspondingAuthor":true,"prefix":"","firstName":"Jinyang","middleName":"","lastName":"Yu","suffix":""},{"id":432668700,"identity":"25cfaedb-73b5-4df7-b076-b5e635516735","order_by":3,"name":"Yifeng Tao","email":"","orcid":"","institution":"Huashan Hospital Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Yifeng","middleName":"","lastName":"Tao","suffix":""},{"id":432668701,"identity":"de9c58c8-ee52-41c8-9075-f4f8c79871fc","order_by":4,"name":"Conghuan Shen","email":"","orcid":"","institution":"Huashan Hospital Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Conghuan","middleName":"","lastName":"Shen","suffix":""},{"id":432668702,"identity":"c42b7b5e-7c18-4b49-b80f-32ea7f28f64b","order_by":5,"name":"Ruidong Li","email":"","orcid":"","institution":"Huashan Hospital Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Ruidong","middleName":"","lastName":"Li","suffix":""},{"id":432668703,"identity":"4d7d5666-70e9-4553-9267-cd17fcec385e","order_by":6,"name":"Quanbao Zhang","email":"","orcid":"","institution":"Huashan Hospital Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Quanbao","middleName":"","lastName":"Zhang","suffix":""},{"id":432668704,"identity":"379d0443-6b88-43d7-9dd4-32558d701f54","order_by":7,"name":"Zhengxin Wang","email":"","orcid":"","institution":"Huashan Hospital Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Zhengxin","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2025-03-17 08:31:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6242550/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6242550/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":79678867,"identity":"5e948951-dab2-46f7-a732-c37aa973a4cd","added_by":"auto","created_at":"2025-04-01 12:31:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":55111,"visible":true,"origin":"","legend":"\u003cp\u003eOverall survival between the elderly donor group and the young donor group. There is no significant difference in overall survival between the two groups (P=0.681).\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6242550/v1/3b4311fb67b0f6e2b689d031.png"},{"id":79678868,"identity":"d36f8f48-6219-40be-b0f6-27e122af7f99","added_by":"auto","created_at":"2025-04-01 12:31:29","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":56371,"visible":true,"origin":"","legend":"\u003cp\u003eAmong patients with hepatocellular carcinoma, the disease-free survival between the elderly donor group and the young donor group. There is no significant difference in disease-free survival between the two groups (P=0.486).\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6242550/v1/8f165c50e01d68734a7c9935.png"},{"id":80430676,"identity":"bc6806da-dd48-4bdc-aecb-b98c248a820f","added_by":"auto","created_at":"2025-04-12 02:50:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":825045,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6242550/v1/05a93511-0b98-4016-ac14-699e3b8f026b.pdf"}],"financialInterests":"","formattedTitle":"Impact of elderly donors on the survival and complications in liver transplantation","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLiver transplantation (LT) is the gold standard treatment for patients with end-stage liver disease. Outcomes continue to improve, with 5 years survival now around 75%\u003csup\u003e1\u003c/sup\u003e. But the organ shortage problem remains a significant obstacle, with approximately 23% of waitlisted candidates die or are removed from the waiting list for being too sick\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. To widen the donor pool, organs from extended criteria donors, including elderly donors, donation after circulatory death, steatotic livers, and split-liver grafts are increasingly being used\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThere remains controversy regarding advanced donor age and LT outcomes. Many studies have shown that elderly grafts are associated with higher rates of graft lost and post LT mortality\u003csup\u003e\u003cspan additionalcitationids=\"CR5 CR6 CR7\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Nevertheless, encouraging long term survival was observed when recipients were appropriately selected\u003csup\u003e\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eLivers of the elderly show reduced regenerative capacity, slowed blood flow and lipid accumulation. These morphological and functional modifications may raise the risk of complications\u003csup\u003e\u003cspan additionalcitationids=\"CR13 CR14 CR15\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. In this study, we compared the long-term outcomes of recipients using donors aged 60 years or older and younger donors. Specifically, our aim is to include not only patient survival but also posttransplant complications.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eWe reviewed all adult recipients (age 18 or older) who underwent LT from donation after brain death at Huashan Hospital, Fudan University between August 1, 2017 and November 30, 2023. Living donor recipients, re-transplant recipients, and cases with missing survival data were excluded. The final cohort was then stratified by donor age using 60 as the breakpoint, which is the most widely studied cut-off point in the past\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. The study group included all patients who received liver allografts from donors aged 60 years or older (n\u0026thinsp;=\u0026thinsp;201). A control group consisted of all patients transplanted with allografts from donors younger than 60 years (n\u0026thinsp;=\u0026thinsp;749).\u003c/p\u003e \u003cp\u003eDonor and recipient characteristics were compared using the Wilcoxon rank-sum test for continuous variables and Pearson χ2 test for categorical variables. Unadjusted graft and recipient survival rates were estimated using the Kaplan\u0026ndash;Meier method and compared by the log-rank test. A P value less than 0.05 was considered statistically significant. The data were analyzed using IBM SPSS Statistics for Windows, Version 26.0 (IBM Corp., Armonk, NY). This study was approved by the Ethics Committee of Huashan Hospital, Fudan University.\u003c/p\u003e \u003cp\u003eThe relevant donor variables identified were sex, body mass index, cold ischemia time, sodium, aspartate aminotransferase, alanine transaminase, total bilirubin, hepatitis B surface antigen (HBsAg), anti-hepatitis C virus (anti-HCV). Recipient variables consisted of sex, age, end-stage liver disease (MELD) score, hepatocellular carcinoma (HCC) status. The MELD score was based on laboratory values at time of transplant and did not consider point exceptions for cancer or other diagnoses.\u003c/p\u003e \u003cp\u003eThe date of primary nonfunction (PNF) was defined as the need for emergent re-transplant when a graft never presented any evidence of initial function after excluding other causes. Acute rejection (AR) was confirmed by serum laboratory studies and a tissue biopsy. Biliary and vascular complications was confirmed by surgery, radiographic examination, or clinical follow-up. Splenic artery steal syndrome is characterized by hypoperfusion of the hepatic artery secondary to a competitive shunt of blood flow into the splenic artery from the celiac trunk and diagnosed on angiography. Overall survival in all recipients and Disease-free survival in HCC recipients were recorded.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eDonor and Recipient Characteristics\u003c/h2\u003e \u003cp\u003eThis study included 950 recipients, of whom 201 received livers from elderly donors livers and 749 received from young donors. The characteristics of recipients and donors are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. There were no differences in recipient characteristics such as gender, BMI, blood sodium, and MELD score between the two groups. In terms of indicators of graft function, the AST levels of the elderly donors were lower than those of the young donors (elderly: 51.4 vs. young: 73.6, P\u0026thinsp;=\u0026thinsp;0.021), whereas both groups had similar ALT (elderly: 69.4 vs. young: 86.4 P\u0026thinsp;=\u0026thinsp;0.120) and total bilirubin (elderly: 19.6 vs. young: 20.3, P\u0026thinsp;=\u0026thinsp;0.021) levels. In addition, HBsAg positive, HCV and cold ischemia time were similar between the two groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of recipients and donors between the elderly donor group and the young donor group. \u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDonors Characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDonor age\u0026thinsp;\u0026ge;\u0026thinsp;60 y\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;201)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDonor age \u0026lt; 60 y\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;749)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMale sex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e162(80.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e646(86.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.109\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.082\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNa+ (\u0026micro;mol/L)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e143.5\u0026thinsp;\u0026plusmn;\u0026thinsp;14.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e144.8\u0026thinsp;\u0026plusmn;\u0026thinsp;9.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.232\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eALT (U/L)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51.4\u0026thinsp;\u0026plusmn;\u0026thinsp;100.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73.6\u0026thinsp;\u0026plusmn;\u0026thinsp;57.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAST (U/L)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69.4\u0026thinsp;\u0026plusmn;\u0026thinsp;120.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86.4\u0026thinsp;\u0026plusmn;\u0026thinsp;88.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.120\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTBil (\u0026micro;mol/L)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.6\u0026thinsp;\u0026plusmn;\u0026thinsp;21.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.3\u0026thinsp;\u0026plusmn;\u0026thinsp;27.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.718\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHBsAg +\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19(9.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59(7.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.470\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnti-HCV +\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(2.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8(1.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.124\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCIT (h)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.763\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRecipients Characteristics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMale sex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e173(86.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e661(88.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.402\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (y)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50.3\u0026thinsp;\u0026plusmn;\u0026thinsp;10.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.1\u0026thinsp;\u0026plusmn;\u0026thinsp;10.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.773\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMELD score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.332\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHCC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78(38.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e294(39.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.346\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\u003cp\u003eBMI, body mass index; MELD, model for end-Stage liver disease; CIT, cold ischemic time; HCC, hepatocellular carcinoma; ALT, alanine aminotransferase; AST, aspartate aminotransferase; TBil, total bilirubin\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePatients and graft survival\u003c/h3\u003e\n\u003cp\u003eRecipients were followed for 4\u0026ndash;77 months and no significant difference in overall survival between the two groups (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). 78 cases of hepatocellular carcinoma were diagnosed in the elderly donor group, compared with 294 cases in the young donor group (elderly: 78 [38.8%] vs. young: 294 [39.3%], P\u0026thinsp;=\u0026thinsp;0.021). Among patients with hepatocellular carcinoma, the disease-free survival was similar between the elderly donor group and the young donor group, suggesting that elderly donors did not increase the risk of recurrence of hepatocellular carcinoma (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e22 of the 950 recipients underwent re-transplantation. The proportion of re-transplantation (elderly: 8 [4.0%] vs. young: 14 [1.9%], P\u0026thinsp;=\u0026thinsp;0.077) and PNF (elderly: 8 [4.0%] vs. young: 7 [0.9%], P\u0026thinsp;=\u0026thinsp;0.002) was higher in the elderly donor group. All re-transplantation in the elderly donor group were due to PNF. In the younger donor group, 7 of the 14 re-transplantation were due to PNF, and the remaining included 1 vascular complication, 3 biliary complications, and 3 chronic rejection.\u003c/p\u003e\n\u003ch3\u003ePosttransplant complications\u003c/h3\u003e\n\u003cp\u003eThe posttransplant complications of the two groups are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. A total of 141 cases of acute rejection were observed, comprising 59 cases in the elderly donor group and 82 cases in the young donor group. The incidence of acute rejection was significantly higher in the elderly donor group than in the young donor group (elderly: 59 [29.4%] vs. young: 82 [10.9%], P\u0026thinsp;=\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePosttransplant complications between the elderly donor group and the young donor group.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEvents\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDonor age\u0026thinsp;\u0026ge;\u0026thinsp;60 y\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;201)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDonor age \u0026lt; 60 y\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;749)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary nonfunction\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8(4.0%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7(0.9%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnplanned reoperation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13(6.5%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42(5.6%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.643\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRe-transplantation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e8(4.0%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e14(1.9%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.077\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcute rejection\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e59(29.4%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e82(10.9%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eArterial embolism\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1(0.5%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e5(0.7%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.787\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePortal vein thrombosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e5(0.7%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.245\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSplenic artery steal syndrome\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e4(2.0%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e4(0.5%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.045\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBiliary anastomotic stricture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2(1.0%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e5(0.7%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.630\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBile leakage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e6(0.8%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.203\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIschemic biliary lesions\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3(1.5%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e5(0.7%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.256\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWe also compared the incidence of hepatic artery embolism, portal vein thrombosis, and splenic artery steal syndrome between the two groups. There was no difference in the incidence of hepatic artery embolism (elderly: 1 [0.5%] vs. young: 5 [0.7%], P\u0026thinsp;=\u0026thinsp;0.787) and portal vein thrombosis (elderly: 0 vs. young: 5 [0.7%], P\u0026thinsp;=\u0026thinsp;0.245) between the two groups. However, recipients who received donor liver from elderly donor were more likely to have splenic artery steal syndrome (elderly: 4 [2.0%] vs. young: 4 [0.5%], P\u0026thinsp;=\u0026thinsp;0.021).\u003c/p\u003e \u003cp\u003eThere was no difference between the two groups in the incidence of biliary complications, whether anastomotic strictures (elderly: 2 [1.0%] vs. young: 5 [0.7%], P\u0026thinsp;=\u0026thinsp;0.630), bile leakage (elderly: 0 vs. young: 6 [0.8%], P\u0026thinsp;=\u0026thinsp;0.203), or ischemic biliary lesions (elderly: 3 [1.5%] vs. young: 5 [0.7%], P\u0026thinsp;=\u0026thinsp;0.256).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAs the aging population grows, the use of elderly donors in China has increased rapidly in recent years. However, the impact of advanced donor age on recipients remains controversial. The main cause of elderly donor death is the cerebrovascular accident instead of trauma. So they tend to have shorter hospital stay in intensive care unit, fewer episodes of hemodynamic instability or cardiac arrest, and lower laboratory parameters of liver function than younger donors\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. But the diminished regenerative capacity of aged liver cells makes elder livers more susceptible to ischemia-reperfusion injury. According to data from the United Network for Organ Sharing (UNOS), the CIT of liver graft in the United States has decreased from 10 hours in 1990\u0026ndash;1994 to 6 hours in 2010\u0026ndash;2014, which is a significant contributing factor to the marked improvement in outcomes with elderly donors\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Meanwhile, the use of elderly donors in living liver transplantation with a short cold ischemia time has been shown to be safe for recipients\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Nevertheless, the CIT of livers donated by deceased donors in China is noticeably longer due to the size of the country and the mode of transportation\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. The average CIT in our study was 8.3 hours, both in elderly donor and young donor groups. The results showed that long-term survival in elderly donor group were similar to those in the younger donor group. But the incidence of PNF and re-transplantation was significantly higher in the elderly donor group, indicating the use of elderly donors with CIT over 8 hours is still at significant risk.\u003c/p\u003e \u003cp\u003eThis study is the first to demonstrate that recipients with elder liver grafts are at an increased risk of developing splenic artery steal syndrome. The mechanism may lie in the thickening hepatic arteriolar walls, diminished endothelial cells fenestration and shrinking volume in senescent liver, leading to a reduction in blood flow\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Therefore, liver transplantation using elderly donors should probably be performed more aggressively with surgical splenic artery ligation and proximal splenic artery embolization.\u003c/p\u003e \u003cp\u003ePrevious reports on the effect of advanced donor age on acute rejection had conflicting results\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. We found the incidence of acute rejection was approximately three times higher in elderly donor group than in the younger donor group. The underlying immunological mechanisms need to be further investigated.\u003c/p\u003e \u003cp\u003eSeveral studies reported higher incidence of biliary complications in the patient with elder liver graft, such as ischemic-type biliary lesions and biliary non-anastomotic stricture\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. However, there was no significant difference in biliary complications between elderly and young donors in our study, potentially due to limitations in the sample size.\u003c/p\u003e \u003cp\u003eNormothermic machine perfusion has shown promising results in liver transplantation\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e and is a prospective approach at this stage to improve the outcomes of elderly donors. In addition, donor-recipient match, such as the donor MELD (D-MELD) and the donor-recipient MELD (DR-MELD) have also been proposed for optimizing selection of advanced age donors and their recipients\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. However, these matching scores requires changes in organ allocation policies, limiting its practical application.\u003c/p\u003e \u003cp\u003eIn conclusion, survival in liver transplantation with elderly donor was similar to that of young donor, despite the higher incidence of PNF and re-transplantation. However, there is an increased risk of acute rejection, and splenic artery steal syndrome with elder liver grafts. To prevent these complications, additional interventions may be needed when using elderly donors.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePNF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eprimary nonfunction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eliver transplantation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHBsAg\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ehepatitis B surface antigen\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHCV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ehepatitis C virus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ebody mass index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMELD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emodel for end-Stage liver disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCIT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecold ischemic time\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHCC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ehepatocellular carcinoma\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eALT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ealanine aminotransferase\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAST\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003easpartate aminotransferase\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTBil\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003etotal bilirubin\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAcute rejection\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e- The work has not been published previously.\u003c/p\u003e\n\u003cp\u003e- Manuscript is original work and not under consideration for publication elsewhere\u003c/p\u003e\n\u003cp\u003e- Submission is approved by all authors.\u003c/p\u003e\u003cp\u003eThe authors have no conflict of interest to declare.\u003c/p\u003e \u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.\u003c/p\u003e \u003cp\u003eThis study was supported by the grants from the National Key Research and Development Program of China 2023YFC2505900, National Natural Science Foundation of China (81873874, 82071797 and 82241225).\u003c/p\u003e \u003cp\u003e The institutional ethics board approved the study. Autonomous consent free from coercion was obtained from the donor(s) or their next of kin. Organs/tissues were not sourced from executed prisoners or prisoners of conscience.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contributions\u003c/h2\u003e \u003cp\u003e(I) Conception and design: Zhengxin Wang; (II) Administrative support: Li Li, Chao Sun, Jinyang Yu; (III) Provision of study material or patients: Yifeng Tao, Conghuan Shen, Ruidong Li, Quanbao Zhang; (IV) Collection and assembly of data: Li Li, Chao Sun, Jinyang Yu; (V) Data analysis and interpretation: Li Li, Chao Sun, Jinyang Yu, Zhengxin Wang; (VI) Manuscript writing: Li Li, Chao Sun, Jinyang Yu; (VII) Final approval of manuscript: All authors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHughes, C. B. \u0026amp; Humar, A. Liver transplantation: current and future. \u003cem\u003eAbdom. Radiol. N. Y.\u003c/em\u003e 46, 2\u0026ndash;8 (2021).\u003c/li\u003e\n\u003cli\u003eHeimbach, J. K. \u0026amp; Allen, A. M. Improved Prioritization of the Liver Transplant Waitlist: Weighing the Risks. \u003cem\u003eTransplantation\u003c/em\u003e 108, 1062 (2024).\u003c/li\u003e\n\u003cli\u003eGoldaracena, N., Cullen, J. M., Kim, D.-S., Ekser, B. \u0026amp; Halazun, K. J. Expanding the donor pool for liver transplantation with marginal donors. \u003cem\u003eInt. J. Surg. Lond. Engl.\u003c/em\u003e 82S, 30\u0026ndash;35 (2020).\u003c/li\u003e\n\u003cli\u003eSchneider, S. \u003cem\u003eet al.\u003c/em\u003e Long-term outcomes of the octogenarian donor liver recipient: The era of the new centurion. \u003cem\u003eClin. Transplant.\u003c/em\u003e 33, e13629 (2019).\u003c/li\u003e\n\u003cli\u003eRoullet, S. \u003cem\u003eet al.\u003c/em\u003e Liver Transplantation With Old Grafts: A Ten-Year Experience. \u003cem\u003eTransplant. Proc.\u003c/em\u003e 49, 2135\u0026ndash;2143 (2017).\u003c/li\u003e\n\u003cli\u003eGuichelaar, M. M. J. \u003cem\u003eet al.\u003c/em\u003e Risk factors for and clinical course of non-anastomotic biliary strictures after liver transplantation. \u003cem\u003eAm. J. Transplant. Off. J. Am. Soc. Transplant. Am. Soc. Transpl. Surg.\u003c/em\u003e 3, 885\u0026ndash;890 (2003).\u003c/li\u003e\n\u003cli\u003eHeidenhain, C. \u003cem\u003eet al.\u003c/em\u003e Incidence of and risk factors for ischemic-type biliary lesions following orthotopic liver transplantation. \u003cem\u003eTranspl. Int. Off. J. Eur. Soc. Organ Transplant.\u003c/em\u003e 23, 14\u0026ndash;22 (2010).\u003c/li\u003e\n\u003cli\u003eKim, D. Y. \u003cem\u003eet al.\u003c/em\u003e Routine use of livers from deceased donors older than 70: is it justified? \u003cem\u003eTranspl. Int. Off. J. Eur. Soc. Organ Transplant.\u003c/em\u003e 18, 73\u0026ndash;77 (2005).\u003c/li\u003e\n\u003cli\u003eDudek, K. \u003cem\u003eet al.\u003c/em\u003e Results of liver transplantation from old donors. \u003cem\u003eTransplant. Proc.\u003c/em\u003e 46, 2762\u0026ndash;2765 (2014).\u003c/li\u003e\n\u003cli\u003eDarius, T. \u003cem\u003eet al.\u003c/em\u003e Septuagenarian and octogenarian donors provide excellent liver grafts for transplantation. \u003cem\u003eTransplant. Proc.\u003c/em\u003e 44, 2861\u0026ndash;2867 (2012).\u003c/li\u003e\n\u003cli\u003eFlemming, J. A., Kim, W. R., Brosgart, C. L. \u0026amp; Terrault, N. A. Reduction in liver transplant wait-listing in the era of direct-acting antiviral therapy. \u003cem\u003eHepatol. Baltim. Md\u003c/em\u003e 65, 804\u0026ndash;812 (2017).\u003c/li\u003e\n\u003cli\u003eSlawik, M. \u0026amp; Vidal-Puig, A. J. Lipotoxicity, overnutrition and energy metabolism in aging. \u003cem\u003eAgeing Res. Rev.\u003c/em\u003e 5, 144\u0026ndash;164 (2006).\u003c/li\u003e\n\u003cli\u003ePetersen, K. 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Surg.\u003c/em\u003e 9, 318\u0026ndash;326 (2009).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"liver transplantation, elder donors, primary nonfunction, re-transplantation, acute rejection, splenic artery steal syndrome","lastPublishedDoi":"10.21203/rs.3.rs-6242550/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6242550/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDespite increased use, the impact of elder donors on the outcomes of liver transplantation remains controversial, particularly with regard to postoperative complications.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eRetrospective data of adult liver transplantation with deceased donors between August 1, 2017 to November 30, 2023 were collected. The aim was to compare survival as well as postoperative complications of the recipients with elderly donors (\u0026ge;\u0026thinsp;60 years) to younger donors (\u0026lt;\u0026thinsp;60 years).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOut of a total of 950 liver transplants, 201 were elderly donors and 749 were younger donors. No difference in overall survival or disease-free survival in patients with hepatocellular carcinoma between the two groups was demonstrated. Elderly donors were associated with higher incidence of primary nonfunction, re-transplantation, acute rejection, and splenic artery steal syndrome. No difference in biliary complications was observed.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eElderly donors do not affect patient survival, despite the higher incidence of PNF and re-transplantation. But elder grafts are more susceptible to acute rejection and splenic artery steal syndrome. Additional interventions should be taken to prevent these complications with elderly donors.\u003c/p\u003e","manuscriptTitle":"Impact of elderly donors on the survival and complications in liver transplantation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-01 12:31:24","doi":"10.21203/rs.3.rs-6242550/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bda6587f-4d1c-45f8-9fe3-ba4a028e21e7","owner":[],"postedDate":"April 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-04-12T02:42:27+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-01 12:31:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6242550","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6242550","identity":"rs-6242550","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}