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Korean J Transplant 2021; 35(2): 100-107

Published online June 30, 2021


© The Korean Society for Transplantation

Outcomes of deceased donor liver transplantation from elderly donors

Minjae Kim , Shin Hwang , Chul-Soo Ahn , Ki-Hun Kim , Deok-Bog Moon , Tae-Yong Ha , Gi-Won Song , Dong-Hwan Jung , Gil-Chun Park , Young-In Yoon , Woo-Hyoung Kang , Hwui-Dong Cho , Byeong-Gon Na , Sang Hoon Kim , Sung-Gyu Lee

Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

Correspondence to: Shin Hwang
Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpagu, Seoul 05505, Korea
Tel: +82-2-3010-3930
Fax: +82-2-3010-6701
E-mail: shwang@amc.seoul.kr

Received: October 19, 2020; Revised: February 2, 2021; Accepted: March 2, 2021

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background: Favorable outcomes achieved after deceased donor liver transplantation (DDLT) suggest that use of elderly donors may be an effective way to expand donor pool.
Methods: This was a retrospective analysis of adult DDLT using elderly donors. It was a double-arm study that compared posttransplant outcomes to ascertain whether use of elderly donors (aged ≥76 years) has adverse effects on outcome of DDLT. Elderly donor study group included 14 donors aged ≥76 years and elderly donor control group comprised 39 donors aged 66–75 years.
Results: Mean donor age of the study and control groups was 78.2±3.1 years and 68.9±2.7 years, respectively (P<0.001). Other clinical parameters were comparable between these two donor groups. The 1-, 3-, and 5-year graft survival rates in the elderly study group were 83.6%, 59.7%, and 59.7%, respectively, and those in the elderly control group were 79.4%, 68.1%, and 59.6%, respectively (P=0.97). The overall 1-, 3-, and 5-year survival rates after donation from elderly study group were 83.6%, 59.7%, and 59.7%, respectively, and those after donation from control group were 79.3%, 72.1%, and 64.1%, respectively (P=0.74). Regarding overall patient survival, univariate analysis identified pretransplant requirement for ventilator support (P=0.021) and pretransplant renal replacement therapy (P=0.025) as statistically significant risk factors; however, neither was significant on multivariate analysis.
Conclusions: The results of this study suggest that using an elderly donor graft might not worsen the posttransplant outcomes significantly; thus, advanced age per se may not be an exclusion criterion for organ donation.

Keywords: Donor age, Elderly donor, Deceased donor liver transplantation, Octogenarian, Septuagenarian

  • This was a retrospective double-arm analysis of adult deceased donor liver transplantation using elderly donors aged ≥76 years.

  • The data suggest that organs from elderly donors do not worsen posttransplant outcomes.

  • Advanced age should not be an exclusion criteria criterion; indeed, using such donors could be the key to increasing the supply of liver grafts.

Liver transplantation (LT) has become the treatment of choice for patients with end-stage liver disease because of improved results and broadening of indications. However, the shortage of organ donors and increased demand for LT have led to widening of concepts to increase the availability of grafts for LT. Acceptance of old and marginal liver donors, along with development of alternative techniques such as liver graft splitting, and the use of living donors and the domino procedure, have been proposed to reduce the mortality of patients on the waiting list. Although these procedures have increased the deceased donor organ pool, a profound shortage still remains.

Use of marginal donors, particularly older donors, is an important approach to expanding the donor pool [1,2]. Although favorable LT outcomes have been achieved with elderly donors [1-4], there is still a certain reluctance to use them due to concerns about early graft function and long-term graft survival. We present a retrospective analysis of our experience of adult deceased donor liver transplantation (DDLT) in a high-volume LT center using elderly donors aged ≥76 years.

The study protocol was approved by the Institutional Review Board of Asan Medical Center, which waived the requirement for informed consent due to the retrospective nature of this study (IRB No. 2020-0857). This study was performed in accordance with the ethical guidelines of the World Medical Association Declaration of Helsinki 2013.

Patient Selection and Study Design

This study was a retrospective single-center analysis of DDLT data. Initially, the institutional LT database was searched to identify DDLT cases that used elderly donors ≥76 years of age during a 10-year period from January 2010 to December 2019. These LT cases were classified as the elderly donor study group. In addition, DDLT cases that received a graft from donors aged between 66 years and 75 years were used as an elderly donor control group. The study design was set to be a double-arm study comparing posttransplant outcomes between the study and control groups. The purpose was to ascertain whether using elderly donors had an adverse effect on the outcome of DDLT. Donor age was the only factor to classify the DDLT groups because detailed information on the donor condition and graft status was not available in the institutional medical record system. The patients in this study were followed up until April 2020.

Statistical Analysis

Numerical data are presented as the mean±standard deviation. Continuous variables were compared using Student t-test. Incidence variables were compared using the chi-square test and Fisher’s exact test. Survival rates were estimated using the Kaplan-Meier method and compared using the log-rank test. A P-value <0.05 was considered statistically significant. All statistical analyses were performed using IBM SPSS ver. 22 (IBM Corp., Armonk, NY, USA).

Patient Profiles

The age of the 430 adult DDLT donors during the 10-year study period is depicted in Fig. 1. The number of donors aged ≥76 years and 66–75 years was 14 (3.3%; elderly donor study group) and 39 (9.1%; elderly donor control group), respectively. The donor and recipient characteristics within these two groups are presented in Table 1.

Table 1. Comparison of patient profiles

VariableElderly donor study group (≥76 yr)Elderly donor control group (66–75 yr)P-value
No. of patients1439-
Recipient sex (male:female)11:325:140.44
Recipient age (yr)50.8±11.551.1±13.30.93
Primary disease0.91a)
HBV-LC6 (42.9)16 (41.0)
HCV-LC1 (7.1)0
ALD5 (35.7)11 (28.2)
Others2 (14.3)12 (30.8)
Recipient ABO blood group0.09b)
A9 (64.3)12 (30.8)
B4 (28.6)13 (33.3)
O1 (7.1)8 (20.5)
AB06 (15.4)
Preoperative laboratory finding
Total bilirubin (mg/dL)20.7±11.923.2±14.70.54
Serum creatinine (mg/dL)1.52±0.962.21±2.110.11
Prothrombin time (INR)2.29±0.912.41±0.890.71
MELD score31.0±9.332.2±9.90.72
Pretransplant ventilator support4 (28.6)11 (28.2)0.98
Pretransplant renal replacement3 (21.4)16 (41.0)0.19
HCC at explant liver5 (35.7)6 (15.4)0.11
Donor sex (male:female)7:727:120.20
Donor age (yr)78.2±3.168.9±2.7<0.001
Graft typeNA
Whole liver14 (100)39 (100)
Split right liver00
Graft weight (g)1181.9±239.51294.9±234.50.14
Graft-recipient weight ratio1.59±0.531.98±0.840.42
Donor anti-HBc IgG6 (42.9)19 (48.7)0.71
Ischemic time (min)
Early (<3 mo)01 (2.6)
Late (>3 mo)03 (7.7)

Values are presented as mean±standard deviation or number (%).

HBV, hepatitis B virus; LC, liver cirrhosis; HCV, hepatitis C virus; ALD, alcoholic liver disease; INR, international normalization ratio; MELD, Model for End-Stage Liver Disease; HCC, hepatocellular carcinoma; NA, not available; anti-HBc IgG, hepatitis B virus core antibody immunoglobulin G.

a)Comparison between HBV-LC and other groups; b)Comparison between blood group A and B versus O and AB.

Figure 1. Distribution of ages of deceased donors for a 10-year study period in Korea.

The mean donor age of the elderly donor study group was 78.2±3.1 years (range, 76–86 years), which was significantly higher than that of the control group (68.9±2.7 years). Other parameters were comparable between the two groups. The Model for End-Stage Liver Disease (MELD) scores for the elderly donor study and control groups were 31.0±9.3 and 32.2±9.9, respectively (P=0.72).

Posttransplant Survival Results

None of the cases that received grafts from the elderly donor study group required retransplantation; however, four cases (10.3%) that received grafts from the elderly donor control group did: one patient required early retransplantation due to graft dysfunction and three patients required late retransplantation due to chronic rejection. The graft survival rates at 1, 3, and 5 years were 83.6%, 59.7%, and 59.7%, respectively, for the elderly donor study group, and 79.4%, 68.1%, and 59.6%, respectively, for the elderly donor control group (P=0.97) (Fig. 2A).

Figure 2. Comparison of graft (A) and overall patient (B) survival outcomes according to donor age.

The overall patient survival rates at 1, 3, and 5 years were 83.6%, 59.7%, and 59.7%, respectively, in the elderly donor study group and 79.3%, 72.1%, and 64.1%, respectively, in the elderly donor control group (P=0.74) (Fig. 2B). Four patients that received grafts from the elderly donor study group died due to posttransplant sepsis (n=1), late chronic rejection (n=1), and recurrence of hepatocellular carcinoma (n=2). Thus, peritransplant in-hospital mortality was one case (7.1%). By contrast, 13 patients (33.3%) that received grafts from the elderly donor control group died. Peritransplant in-hospital mortality occurred in six cases (15.4%), in which the underlying causes were graft dysfunction (n=2) and sepsis (n=4). Late mortality was caused by infection including pneumonia (n=3), chronic rejection (n=2), recurrence of hepatocellular carcinoma (n=1), and unknown causes (n=1).

Risk Factor Analysis for Patient Survival

Donor age was not a risk factor for patient survival; therefore, this parameter was excluded from the analysis. Univariate analysis revealed that pretransplant requirement for ventilator support (P=0.021) (Fig. 3A) and pretransplant requirement for renal replacement therapy were significant risk factors for overall survival (P=0.025) (Fig. 3B). A MELD score ≥31 was not a significant risk factor (P=0.63) (Fig. 3C). Retransplantation showed a noticeable prognostic contrast, but the significance was only marginal, primarily due to the small sample number (P=0.097) (Fig. 3D). Multivariate analysis did not identify pretransplant ventilator support, pretransplant renal replacement therapy, or retransplantation as independent risk factors (Table 2).

Table 2. Results of univariate and multivariate analyses for overall patient survival

VariableNo. of casesUnivariate analysisMultivariate analysis

3-Year patient survival rate (%)P-valueHazard ratio (95% CI)P-value
Pretransplant ventilatory support
Yes1543.80.0212.41 (0.79–7.35)0.12
Pretransplant renal replacement therapy
Yes1956.00.0252.32 (0.76–6.94)0.13
Yes425.00.0971.53 (0.35–3.42)0.32

CI, confidence interval.

Figure 3. Comparison of the overall patient survival outcomes according to pretransplant ventilator support (A), pretransplant renal replacement therapy (B), Model for End-Stage Liver Disease (MELD) score with a cutoff of 31 (C), and retransplantation (D).

During the 10 years from January 2010 to December 2019, there were 4,395 deceased donors registered in the Korean Network for Organ Sharing (KONOS) database, which included 21 elderly donors aged between 76–79 years and 21 donors aged ≥80 years. The 42 elderly donors aged ≥76 years represent 0.96% of all deceased donors. Considering that deceased donors allocated for pediatric DDLT were excluded from our series, the proportion of elderly donors aged ≥76 years was approximately 3% of all deceased donors allocated to our patients. This proportion of elderly donors appears to be much lower than that in Western countries in which organ donation is common [1-4].

Reports on utilization and optimization of elderly donor grafts for DDLT are conflicting. Some studies advocate the use of elderly donor organs for less sick recipients [5-8]. However, other reports show that the recipient’s MELD score has no effect on outcome after receiving a graft from an elderly donor [9,10]. These studies question the use of these “high-risk” donors in “low-risk” recipients. The results of our study show that a cutoff of MELD score of 31 is not a significant risk factor for patient survival. In real-world practice in Korea, such logical matching of high-risk donors to low-risk recipients is not possible due to a serious organ shortage [11]. By contrast, those in poor general condition and requiring pretransplant ventilator support or renal replacement therapy are at significant risk of poor posttransplant outcomes, although multivariate analysis did not identify these as independent risk factors.

Some studies have examined the synergistic effects of donor age and cold ischemia time on graft survival after LT [12,13]. Prolonged cold ischemic time appears to be detrimental to the outcomes of elderly liver grafts; thus, we tried to shorten the cold and warm ischemic times as much as possible in such cases. However, we found no difference in the mean cold and warm ischemic times between the elderly study and control groups. Indeed, because the territory of South Korea is small, the cold ischemic time required for organ transportation is usually less than 4 hours. Thus, there is no need for time-saving donor-recipient matching in the current KONOS allocation system for DDLT.

Aging is characterized by a progressive decline in functions, which reduces the capacity of cells and organs to respond to intrinsic and extrinsic stimuli. Functional changes that develop with age should eventually lead to significant alterations in clinical practice. Synthetic, excretory, and metabolic changes in liver function may be affected by aging, and these effects may have clinical relevance [14]. The major age-related changes in the liver are reductions in tissue mass and blood flow. Here, we found that liver graft weight in the elderly study group was lower than that of the elderly control group. Indeed, there is an approximately 30% loss of liver volume and hepatic blood flow between the ages of 30 and 100 years [15].

Many studies show that using liver grafts from septuagenarian donors is not a contraindication to their utilization in DDLT per se [14]; however, some studies report significantly worse patient and graft survival when using liver grafts from donors older than 70 years [16-18]. Since the first reported case of successful graft from an 86-year-old donor [19], others have reported using liver grafts from octogenarian donors [2,14,20,21]; other studies have used grafts from nonagenarian donors [22-24].

Many studies of sexagenarian and septuagenarian donors demonstrate results that are similar to those obtained from younger donors. With respect to the use of octogenarian donors for DDLT, the general level of experience is less than that with grafts from younger donors. Therefore, to get good results using elderly liver grafts with no age limit, donors must be selected carefully according to strict criteria (normal liver function, good hemodynamic and pre-harvesting conditions, short intensive care unit stay, short cold and warm ischemic times, macrosteatosis <30%, absence of atherosclerosis in the hepatic artery, and absence of histological alterations in the biopsy) [14]. We think that the posttransplant results with elderly donors may improve if clinical factors are combined wisely with graft allocation. Because excellent outcomes can be achieved through strict donor selection, there may be no limit to the use of the octogenarian donors for stable patients [2].

This study has several limitations. It is a retrospective, single-center study with a relatively small number of patients. The choice as to whether to use an elderly liver graft was made on a case-by-case basis as there are no established guidelines. Further high-volume multicenter studies are necessary to validate the results of this study. In conclusion, the results of this study suggest that using an elderly donor graft might not worsen the posttransplant outcomes significantly; thus, advanced age per se may not be an absolute exclusion criterion for organ donation. Indeed, donor age factor has been considered for balancing the current supply and demand conundrum regarding liver grafts.

Conflict of Interest

No potential conflict of interest relevant to this article was reported.


This study was supported by research grant from the Korean Society for Transplantation (2021-00-01006-014).

Author Contributions

Conceptualization: SH. Data curation: CSA, KHK, DBM, TYH, GWS, DHJ, GCP. Formal analysis: YIY, SGL. Methodology: WHK, HDC, BGN, SHK. Project administration: SH. Visualization: MK, SH. Writing–original draft: MK, SH. Writing–review & editing: SH.

  1. Paterno F, Wima K, Hoehn RS, Cuffy MC, Diwan TS, Woodle SE, et al. Use of elderly allografts in liver transplantation. Transplantation 2016;100:153-8.
    Pubmed CrossRef
  2. Gastaca M, Guerra M, Alvarez Martinez L, Ruiz P, Ventoso A, Palomares I, et al. Octogenarian donors in liver transplantation. Transplant Proc 2016;48:2856-8.
    Pubmed CrossRef
  3. Jiménez-Romero C, Caso Maestro O, Cambra Molero F, Justo Alonso I, Alegre Torrado C, Manrique Municio A, et al. Using old liver grafts for liver transplantation: where are the limits? World J Gastroenterol 2014;20:10691-702.
    Pubmed KoreaMed CrossRef
  4. Cascales-Campos PA, Ramírez P, González-Sánchez MR, Alconchel F, Martínez-Insfran LA, Sánchez-Bueno F, et al. Orthotopic liver transplantation with elderly donors (over 80 years of age): a prospective evaluation. Transplant Proc 2018;50:3594-600.
    Pubmed CrossRef
  5. Ozhathil DK, Li YF, Smith JK, Tseng JF, Saidi RF, Bozorgzadeh A, et al. Impact of center volume on outcomes of increased-risk liver transplants. Liver Transpl 2011;17:1191-9.
    Pubmed CrossRef
  6. Kim DY, Moon J, Island ER, Tekin A, Ganz S, Levi D, et al. Liver transplantation using elderly donors: a risk factor analysis. Clin Transplant 2011;25:270-6.
    Pubmed CrossRef
  7. Segev DL, Maley WR, Simpkins CE, Locke JE, Nguyen GC, Montgomery RA, et al. Minimizing risk associated with elderly liver donors by matching to preferred recipients. Hepatology 2007;46:1907-18.
    Pubmed CrossRef
  8. Cameron AM, Ghobrial RM, Yersiz H, Farmer DG, Lipshutz GS, Gordon SA, et al. Optimal utilization of donor grafts with extended criteria: a single-center experience in over 1000 liver transplants. Ann Surg 2006;243:748-55.
    Pubmed KoreaMed CrossRef
  9. Anderson CD, Vachharajani N, Doyle M, Lowell JA, Wellen JR, Shenoy S, et al. Advanced donor age alone does not affect patient or graft survival after liver transplantation. J Am Coll Surg 2008;207:847-52.
    Pubmed CrossRef
  10. Schaubel DE, Sima CS, Goodrich NP, Feng S, Merion RM. The survival benefit of deceased donor liver transplantation as a function of candidate disease severity and donor quality. Am J Transplant 2008;8:419-25.
    Pubmed CrossRef
  11. Min SI, Ahn C, Han DJ, Kim SI, Chung SY, Lee SK, et al. To achieve national self-sufficiency: recent progresses in deceased donation in Korea. Transplantation 2015;99:765-70.
    Pubmed CrossRef
  12. Cassuto JR, Patel SA, Tsoulfas G, Orloff MS, Abt PL. The cumulative effects of cold ischemic time and older donor age on liver graft survival. J Surg Res 2008;148:38-44.
    Pubmed CrossRef
  13. Reese PP, Sonawane SB, Thomasson A, Yeh H, Markmann JF. Donor age and cold ischemia interact to produce inferior 90-day liver allograft survival. Transplantation 2008;85:1737-44.
    Pubmed CrossRef
  14. Mooney H, Roberts R, Cooksley WG, Halliday JW, Powell LW. Alterations in the liver with ageing. Clin Gastroenterol 1985;14:757-71.
  15. Wynne HA, Cope LH, Mutch E, Rawlins MD, Woodhouse KW, James OF. The effect of age upon liver volume and apparent liver blood flow in healthy man. Hepatology 1989;9:297-301.
    Pubmed CrossRef
  16. Busquets J, Xiol X, Figueras J, Jaurrieta E, Torras J, Ramos E, et al. The impact of donor age on liver transplantation: influence of donor age on early liver function and on subsequent patient and graft survival. Transplantation 2001;71:1765-71.
    Pubmed CrossRef
  17. Lai Q, Melandro F, Levi Sandri GB, Mennini G, Corradini SG, Merli M, et al. Use of elderly donors for liver transplantation: has the limit been reached? J Gastrointestin Liver Dis 2011;20:383-7.
  18. Fouzas I, Sgourakis G, Nowak KM, Lang H, Cicinnati VR, Molmenti EP, et al. Liver transplantation with grafts from septuagenarians. Transplant Proc 2008;40:3198-200.
    Pubmed CrossRef
  19. Wall W, Grant D, Roy A, Asfar S, Block M. Elderly liver donor. Lancet 1993;341:121.
  20. Jiménez Romero C, Moreno González E, Colina Ruíz F, Palma Carazo F, Loinaz Segurola C, Rodríguez González F, et al. Use of octogenarian livers safely expands the donor pool. Transplantation 1999;68:572-5.
    Pubmed CrossRef
  21. Petridis I, Gruttadauria S, Nadalin S, Viganò J, di Francesco F, Pietrosi G, et al. Liver transplantation using donors older than 80 years: a single-center experience. Transplant Proc 2008;40:1976-8.
    Pubmed CrossRef
  22. Romagnoli J, Urbani L, Catalano G, Costa A, Marciano E, Filipponi F, et al. Liver transplantation using a 93-year-old donor. Transplant Proc 2001;33:3797.
  23. Grazi GL, Cescon M, Ravaioli M, Corti B, Pinna AD. Successful liver transplantation from a 95-year-old donor to a patient with MELD score 36 and delayed graft arterialization. Am J Transplant 2008;8:725-6.
    Pubmed CrossRef
  24. Karpen SJ. Growing old gracefully: caring for the 90-year-old liver in the 40-year-old transplant recipient. Hepatology 2010;51:364-5.
    Pubmed CrossRef