Liver transplantation in patients over 60 years in Johannesburg, South Africa: a retrospective review of risk factors, survival outcomes and immunosuppression.

Tayob, Ahmad Ismail
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Background. Evidence on how to tailor immunosuppression therapy to account for the unique risks and altered immune mechanisms in older liver transplant recipients is lacking. Methods. Data were collected from all patients aged >=60 years undergoing liver transplantation for the first time, between 2004 and 2019. We assessed survival outcomes and rejection rates, and identified demographic and clinical predictors of these outcomes. We compared survival outcomes and immunosuppression usage between an earlier and later transplant era, to establish whether there was an improvement in survival over time, and whether prescription patterns changed as evidence emerged that older patients may require less immunosuppression. Results. The median age of the patients was 64 years, and the most common cause of liver disease was alcoholic steatohepatitis and non-alcoholic steatohepatitis. The mean MELD scores were 16,7 (SD 6,9) and the mean DRI was 2.0 (SD 0,4). Patient survival rates at 1, 3, and 5 years were 75%, 69%, and 64%, respectively. Infections were the most common cause of death. 5% of patients developed ACR. There was an increase in the risk of death for GFR categories 3a-5 unadjusted (HR 2.83 (95% CI 1.32-6.08)) and adjusted for sex, MELD score, and DRI (HR 3.47 (95% CI 1.547.84)) but no association between diabetes (HR 1.21 (95% CI 0.62-2.36)) or coronary artery disease (HR 1.46 (95% CI 0.70-3.02)) and recipient survival. Prednisone + tacrolimus + mycophenolate mofotil was the most common initial maintenance regimen. In the later transplant era, the mean prednisone dose was lower (19.8 mg verses 13.2 mg, p=0.023) and dual immunosuppression was favoured over triple (p=0.070).
A research report submitted in fulfilment of the requirements for the degree of Master of Medicine (Internal Medicine) to the Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, 2021