As liver transplants significantly increase among older patients, nonalcoholic steatohepatitis has become the most common reason for the procedure in this population, according to a study published in Hepatology Communications.

“Another study from our team, which in publication in Clinical Gastroenterology and Hepatology, suggests that the proportion of elderly patients in need of liver transplantation in the U.S. is sharply increasing,” study author Zobair M. Younossi MD, MPH, president of Inova Medicine Services and professor and chairman of the department of medicine at Inova Fairfax Medical Campus in Virginia, told Healio. “At present, NASH is the most common indication for liver transplantation among the elderly. The outcomes of these patients have been improving in the past two decades so that three in four [patients] can expect to live at least 5 years posttransplant.”
Registry of Transplant Recipients to identify 31,209 LT candidates, aged 65 years or older, to evaluate on-list and posttransplant outcomes. Among the common etiologies were NASH (31%), hepatitis C (23%) and alcohol liver disease (18%). In addition, 30% of candidates had hepatocellular carcinoma.

infographic on NASH rates increasing in older patients
According to researchers, the proportion of adult LT candidates 65 years and older significantly increased (P < .0001) from 9% (2002-2005) to 23% (2018-2020); similarly, the proportion of NASH among older patients increased from 13% to 39% during those study periods. Of those, 54% underwent LT.

Results from multivariate analysis indicated that more recent years of listing, older age, male sex, higher Model for End-Stage Liver Disease (MELD) score and HCC (all P < .01) were independent predictors of an increased chance for receiving a transplant in patients 65 years and older.

In addition, posttransplant mortality was higher in older patients compared with younger LT recipients; however, this mortality rate decreased over time. Independent predictors of higher posttransplant mortality in older LT recipients included earlier years of transplantation, older age, male sex, higher MELD score, history of type 2 diabetes, retransplantation and HCC at baseline or follow-up (all P < .01).

“We found that elderly patients in need of a liver transplant are increasingly being considered for the procedure,” Younossi and colleagues concluded. “Further research is

needed to improve both on-list and posttransplant management of patients of advanced age in order to meet the growing demand for this complex treatment among the aging population with liver disease.”

PERSPECTIVE

Jamile’ Wakim-Fleming, MD

Fatty liver disease is rapidly increasing, and rates have doubled in the past 5 years compared with 15 years earlier, for both genders and for all ages. With this increase, a parallel rise in complications has been observed, including liver failure and liver cancer, as well as increased rates of liver transplantations to save life.

The seminal study by Younossi and colleagues looked specifically at LT rates in an older age group, drawing data from the Scientific Registry of Transplant Recipients. More than 31,000 individuals aged 65 years and older, listed for LT between 2002 and 2020, were studied and assessed for frequency of transplant, cause of liver disease and mortality outcomes. Data comparisons were made between earlier listing vs. recent listing.

The authors showed that the proportion of older patients listed for LT is increasing and that the most common cause of their liver disease is fatty liver and liver cancers. They also found that mortality from LT is higher in the older group, but that the mortality rates have been declining over time. Deterioration and removal from the transplant list have increased over time.

Findings from this study are very important and serious, as they demonstrate that more people are affected by fatty liver disease, more people aged 65 years and older need LT and more people are deteriorating and removed from the transplant list.

Knowing that fatty liver is usually a preventable disease and that the health consequences can be dire and costly, one may draw the conclusion that prevention is crucial. We need to prevent the progression of the fatty steatotic livers before complications occur, by increasing awareness of the disease, disseminating education and knowledge among clinicians and the public, and instituting a prompt diagnosis and early intervention.

Jamile’ Wakim-Fleming, MD
Director, Fatty Liver Disease Program
Digestive Disease & Surgery Institute
Cleveland Clinic