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TO THE EDITORS:

We thank Dr. Perkins1 for lending his perspective on the complicated issue of performing transplantation for elderly patients with hepatocellular carcinoma, and we submit that the frequency with which transplant selection committees face this issue is greater than what most readers appreciate. Because the publicly available Scientific Registry of Transplant Recipients database does not further stratify patients older than 65 years, we have returned to the Standard Transplant Analysis and Research files2 and have determined that the actual percentage of septuagenarians undergoing liver transplantation with respect to the entire liver transplant database is 1.52% (ie, 1602 of 105,405 patients). With the rough figure of 1.5%, septuagenarians account for approximately 90 transplants per year (if we assume that roughly 6000 transplants are performed annually). In fact, in the most recent year for which data are available, 143 septuagenarians underwent transplantation. This is double the figure quoted for the increase in liver transplants to be expected from proposed changes in organ allocation policy. For example, liver simulated allocation modeling predicts 77 fewer deaths per year across all regions if a wholesale regional distribution policy is enacted.3 With the controversy surrounding recent changes in organ allocation as a backdrop, certainly the fate of 90 to 140 transplants per year is worth discussing.

Often, as Perkins points out,1 the decision to approve an elderly patient for liver transplantation is framed in terms of the justice-versus-utility equation. In these cases, we agree with Perkins that the availability of other treatment options and a particular recipient's expected survival (both with and without liver transplantation) must be taken into consideration. In our study,4 we revealed that on the national stage, elderly liver transplant recipients (≥70 years) have a 5-year survival rate of only 55.2%. However, in contrast to younger cohorts, a diagnosis of hepatocellular carcinoma in this age group does not appear to influence survival (the rates are equally poor). Because survival is no different for elderly cohorts with and without hepatocellular carcinoma, on the basis of current United Network for Organ Sharing policy (which does not limit transplantation at the extremes of age), we have concluded that as long as chronological age does not eliminate an individual's transplant candidacy, a tumor diagnosis should not prejudice the granting of Model for End-Stage Liver Disease exception points for elderly recipients otherwise falling within accepted criteria for transplantation.

However, we believe that Perkins1 may have misinterpreted our intentions. Basing our conclusions on current policy does not in any way speak to the policy's wisdom or signal support for the aggressive pursuit of liver transplantation in patients at advanced age. In fact, we are in agreement with Perkins that if patients in the same elderly subgroup were to undergo radiofrequency ablation, there would be lower cost expenditures, less morbidity, and similar, or perhaps even greater survival. In our article,4 we were merely attempting to frame the issue in the context of the national data and as a logical extension of allocation policy as it is currently written. In doing so, we hope that the availability of these data will be of use to members of transplant selection committees, policy makers, and others tasked with determining the eligibility of transplant recipients.

REFERENCES

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  • 1
    Perkins JD. Treatment of an elderly patient with hepatocellular carcinoma: counseling from the patient's point of view. Liver Transpl 2012; 18: 391-394.
  • 2
    Ioannou GN, Perkins JD, Carithers RLJr. Liver transplantation for hepatocellular carcinoma: impact of the MELD allocation system and predictors of survival. Gastroenterology 2008; 134: 1342-1351.
  • 3
    Organ Procurement and Transplantation Network. Proposal to create regional distribution of livers for MELD/PELD candidates. http://optn.transplant.hrsa.gov/PublicComment/pubcommentPropSub_239.pdf. Accessed July 2012.
  • 4
    Schwartz JJ, Pappas L, Thiesset HF, Vargas G, Sorensen JB, Kim RD, et al. Liver transplantation in septuagenarians receiving Model for End-Stage Liver Disease exception points for hepatocellular carcinoma: the national experience. Liver Transpl 2012; 18: 423-433.

Jason Schwartz M.D.*, Heather Thiesset M.P.H.†, Terry Box M.D.‡, William Hutson M.D.§, John Sorensen, M.D.†, * Division of Surgical Transplantation Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, † Departments of General Surgery (Section of Transplantation), ‡ Medicine, University of Utah Salt Lake City, UT, § Division of Gastroenterology and Hepatology University of Maryland School of Medicine College Park, MD.