Perioperative Considerations in Older Kidney and Liver Transplant Recipients: A Review

Abstract

With the growth of the older adult population, the number of older adults waitlisted for and undergoing kidney and liver transplantation has increased. Transplantation is an important and definitive treatment for this population. We present a contemporary review of the unique preoperative, intraoperative, and postoperative issues that patients older than 65 years face when they undergo kidney or liver transplantation. We focus on geriatric syndromes that are common in older patients listed for kidney or liver transplantation including frailty, sarcopenia, and cognitive dysfunction; discuss important considerations for older transplant recipients which may impact preoperative risk stratification; and describe unique challenges in intraoperative and postoperative management for older patients. Intraoperative challenges in the older adult include using evidence-based best anesthetic practices, maintaining adequate perfusion pressure, and using minimally invasive surgical techniques. Postoperative concerns include controlling acute postoperative pain, preventing cardiovascular complications and delirium, optimizing immunosuppression, preventing perioperative kidney injury and avoiding nephrotoxicity, and rehabilitation. Future studies are needed throughout the perioperative period to identify interventions that will improve patients’ preoperative physiologic status, prevent postoperative medical complications, and improve medical and patient-centered outcomes in this vulnerable patient population.

Introduction

As the population of older adults continues to grow, the number of older adults waitlisted for and undergoing kidney and liver transplantation has increased (Figure 1). The number of adults over age 60 with end stage renal disease undergoing kidney transplantation has more than tripled over the past 30 years^1,2. Due to the aging of patients with metabolic dysfunction-associated steatotic liver disease and hepatocellular carcinoma, the upper age limit of individuals undergoing liver transplantation has increased over the last 4 decades from 50 years of age to 70 years or older^3–8. Transplantation is an important and definitive treatment for this older adult population. Older patients who undergo kidney and liver transplantation experience improved quality of life and survival compared to those with end stage organ dysfunction who do not undergo transplantation^4,9,10. In this narrative review article, we present a contemporary update of the unique preoperative, intraoperative, and postoperative issues that patients older than 65 years face when they undergo kidney or liver transplantation. We focus on geriatric syndromes that are common in older patients listed for kidney or liver transplantation, including frailty, sarcopenia, and cognitive dysfunction; discuss important considerations for older transplant recipients which may impact preoperative risk stratification; and elaborate on special challenges in intraoperative and postoperative management for these patients. Figure 2 summarizes the major perioperative issues reviewed in this article.

Figure 1.

Number of kidney, liver, and simultaneous liver and kidney transplants among aged 65 and older recipients from 2003 to 2023 by donor type and year of transplant Please note for 2023, transplant data ranged from 01/01/2023 to 11/01/2023. Source: Scientific Registry of Transplant Recipients. Request for Information. Requested on 11/21/2023.

Figure 2.

Schematic of major perioperative Issues addressed by the review

Preoperative Geriatric Concerns

• Frailty

Older age is associated with several syndromes including frailty. Frailty is defined as a loss of physiologic reserve and inability to overcome stressors^11,12. While frailty is not necessarily due to aging, it is associated with aging and organ dysfunction. Frailty is an important syndrome to identify in patients being considered for transplantation. Numerous frailty assessment instruments exist including the Fried Frailty Phenotype, Clinical Frailty Scale, and Short Physical Performance Battery test. The Fried Frailty Phenotype is frequently used by geriatricians to assess frailty by the presence of 3 or more of the following: shrinking in physical size, weakness, poor endurance and energy, slowness, and low physical activity level¹³. The Clinical Frailty Scale is based on clinical judgment and grades the patient from 1 (good health) to 7 (complete dependence)¹⁴. Available evidence suggests that the Clinical Frailty Scale is feasible with high predictive accuracy¹⁵. The Short Physical Performance Battery test evaluates lower extremity function in older adults and has been shown to be reliable and valid in diverse population¹⁶. Another frailty measurement tool called the Liver Frailty Index (LFI) has been developed and validated specifically for cirrhotic patients¹⁷. The LFI assesses patients’ grip strength, ability to perform chair stands, and balance¹⁸. It can be used to identify frailty and perioperative risk.

In patients with chronic kidney disease, the prevalence of frailty is 18% for those who are waitlisted and 20% for those undergoing kidney transplantation^19,20. Furthermore, in patients undergoing kidney transplantation, frailty has been associated with increased postoperative length of stay and delayed graft function²¹. Frailty at the time of kidney transplant evaluation is associated with other problems such as decreased quality of life, postoperative delirium, hospital readmission, and increased mortality¹¹. Lower extremity weakness and imbalance in kidney transplant candidates, impairments are also associated with increased post-transplant mortality²².

Frailty is prevalent in older adult patients listed for liver transplantation and predicts waitlist mortality^17,23,24. In a study of 294 patients listed for liver transplantation at a single center, 17% were identified as frail by the Fried Frailty Score²³. Each unit increase in the listed patient’s Fried Frailty Score was associated with a 45% increased risk of waitlist morality adjusted for Model for End-Stage Liver Disease²³. Additionally, for the Short Physical Performance Battery test, each unit decrease (indicating increasing frailty) was associated with increased adjusted waitlist mortality²³. In a 2-center prospective cohort study investigating older patients undergoing liver transplantation, frailty had a prevalence of 33% in older adults and was associated with increased waitlist mortality¹⁷.

It is important to identify frailty preoperatively to counsel patients and families appropriately, manage expectations, and potentially triage patients to a higher postoperative level of care if they undergo transplantation. Some problematic aspects of studying frailty is the lack of a universal frailty assessment tool and the absence of screening in the preoperative setting. Clinicians and researchers have called for using the diagnosis of frailty as a potential screen to target preoperative interventions towards improving perioperative outcomes in this high-risk older population²⁵. Although no specific evidence-based therapies currently exist to address preoperative frailty, trials are ongoing²⁶.

• Sarcopenia

Sarcopenia, the loss of skeletal muscle mass due to aging, is common in older adults and is associated with frailty. In patients requiring dialysis, sarcopenia is present in 20 to 44% of the population^27,28. Sarcopenia in chronic kidney disease correlates with worsening renal function and is attributed to malnutrition and appetite suppression, and a sedentary lifestyle²⁷. Sarcopenia in kidney transplant recipients is associated with increased mortality, graft failure, and infections²⁷.

Cirrhotic patients awaiting liver transplantation are prone to sarcopenia due to their predisposition to malnutrition, impaired use of protein as an energy source, low levels of testosterone preventing muscle growth, and increased levels of proinflammatory cytokines that accelerate muscle breakdown²⁹. The prevalence of sarcopenia in cirrhotic patients is 22 to 70%³⁰. Sarcopenia is also more prevalent in cirrhotic patients with refractory ascites³¹. Sarcopenia is associated with increased waitlist and post-transplant mortality and infectious complications in liver transplant recipients^30,32.

• Cognitive dysfunction

In addition to frailty and sarcopenia, cognitive impairment can be present in older kidney and liver transplant candidates. Preoperative cognitive screening can be done with a variety of tools such as the Mini-Cog test and should be done routinely in older adults before kidney and liver transplantation to guide decision-making^33–36. A screening tool for dementia, the Mini-Cog has a sensitivity of 76% and specificity of 89%³⁷. While dementia is a relative contraindication to transplantation, less overt levels of cognitive dysfunction may be present in older transplant candidates. In chronic kidney disease, cognitive function may decline as kidney function deteriorates³⁸. In a 2-center cohort study of 864 living and deceased donor kidney transplant recipients, the prevalence of cognitive impairment was 10% and was associated with increased all-cause graft loss and mortality after transplantation³⁹.

The differential diagnoses for impaired cognition in the older liver transplant candidate are broad and include hepatic encephalopathy, metabolic disorders, sepsis, delirium, and preexisting cognitive dysfunction. Preoperative cognitive deficits due to hepatic encephalopathy improve after liver transplantation and are not associated with waitlist mortality⁴⁰. A prospective cohort study of 34 patients found that 5 years after liver transplantation, patients with and without a history of hepatic encephalopathy demonstrated normal cognitive function and improved health-related quality of life⁴¹. In a multi-center cohort study following 1,623 ambulatory liver transplant candidates with cirrhosis, impaired cognition was associated with higher rates of frailty but did not independently predict waitlist mortality⁴².

• Malignancy

As interdisciplinary care of patients with end-stage organ disease and cancer continues to improve, more patients awaiting organ transplantation are now older and have a history of pre-transplant malignancy⁴³. However, pre-transplant malignancy confers increased perioperative risks and is associated with worse post-transplant outcomes⁴⁴. For example, immunosuppression and oncogenic viral infection after organ transplantation can cause the recurrence of pre-transplant malignancies or the development of new malignancies⁴⁵. In a study from 2004 to 2016 of primary adult kidney transplant recipients with pre-transplant malignancy, transplant recipients with pre-transplant malignancy experienced increased rates of post-transplant malignancy and decreased survival⁴⁶.

Thus, it is important to carefully screen all transplant candidates, but especially older adults, for pretransplant malignancy and consider deferring transplantation if malignancy is present. However, current pre-transplant malignancy guidelines vary considerably. Recommendations for the duration of the waiting period between when a patient is cancer-free and when they undergo transplantation also vary⁴⁷. In a systematic review of 13 clinical care practice guidelines for cancer screening in solid organ transplant recipients, recommendations were inconsistent across societies⁴⁸. Most of the clinical practice guidelines addressed kidney recipients and screening for skin cancer⁴⁸. At a 2019 consensus workshop held by the American Society of Transplantation, recommendations were made for screening specific pretransplant cancer types and to study cancer and transplant related outcomes using a multi-institutional database⁴⁹. This work would be crucial to inform preoperative screening and management of perioperative malignancies in older adults who are candidates for transplantation.

• Preoperative cardiovascular assessment and optimization

Cardiovascular complications are the primary cause of non-graft associated mortality after kidney or liver transplantation^50–53. Older age is a risk factor for heart disease, necessitating cardiovascular screening for older adult transplant candidates. Cardiovascular screening determines older transplants candidates’ perioperative risk profile and may lead to pre-transplant interventions or disqualification from transplantation. Older kidney transplant candidates should be evaluated for coronary artery disease, heart failure, valvular disease, and pulmonary hypertension⁵³. Older liver transplant candidates should be assessed for coronary artery disease, congestive heart failure, portopulmonary hypertension, arrhythmias, valvular disorders, and congenital heart disease⁵⁴.

• Interventions for preoperative coronary artery disease in older liver transplant candidates

Adult patients undergoing evaluation for liver transplantation have a high incidence of coronary artery disease with 26% of those aged 45 and older having moderate to severe coronary artery narrowing on angiography⁵⁵. Liver transplant candidates with coronary artery disease may be candidates for preoperative revascularization (e.g. percutaneous coronary intervention or coronary bypass grafting) if coagulopathy and thrombocytopenia are not prohibitive⁵⁶. Drug eluting stents have generally not been recommended in this patient population due to the requirement for dual antiplatelet therapy for a longer duration compared to bare metal stents and the concomitant increased risk of gastrointestinal bleeding^56,57. However, the duration of dual antiplatelet therapy for some newer drug eluting stents may be safely reduced to one month (the same amount of time as for bare metal stents) and may be safe to use in patients with end stage liver disease^57–59.

Atherosclerotic lesions, depending on location, number, and severity, may not be amenable to percutaneous intervention in which case coronary bypass grafting may be considered. Due to advances in intraoperative surgical and anesthetic techniques, some liver transplant candidates have successfully undergone coronary artery bypass grafting at the time of liver transplantation⁶⁰. These candidates are carefully selected by multidisciplinary teams prior to listing for liver transplantation. Staging the procedure, where the coronary bypass graft is performed prior to liver transplantation, is preferred by some cardiac surgeons. However, staging can be problematic because cardiac surgery in some patients with end stage liver disease, such as those categorized as Child-Pugh Class C, can lead to subsequent hepatic decompensation⁶⁰. Outcomes of simultaneous coronary bypass graft and liver transplantation vary by institution. 1-year survival has been reported by one center in a series of 12 patients as 62%⁶⁰. Outcomes for simultaneous coronary bypass grafting with liver transplantation are similar to outcomes for liver transplantation alone^60,61.

• Preoperative anticoagulant and antiplatelet use

Older kidney and liver transplant candidates may be on anticoagulant and antiplatelet therapies for issues such cardiovascular comorbidities before undergoing transplantation, increasing their perioperative bleeding risk. Portal vein thrombosis is an important indication for anticoagulation in liver transplant candidates. Metabolic dysfunction-associated steatohepatitis related cirrhosis, a disease process with a higher prevalence in older adults, is a risk factor for portal vein thrombosis⁶². Low molecular weight heparin is the initial drug of choice for portal vein thrombosis, and vitamin K antagonists can be used in the long-term⁶³. Currently, direct oral anticoagulants are not recommended for management of portal vein thrombosis in patients with cirrhosis because their safety and efficacy have not been determined in cirrhosis and their effects are not easily reversed at the time of liver transplantation⁶³. However, some small case series suggest direct oral anticoagulants are safe for patients with cirrhosis^63–65.

Anticoagulation and antiplatelet use pose a challenge for the perioperative team but should not preclude transplantation. The best way to manage anticoagulants and antiplatelets prior to kidney and liver transplantation—whether to hold, reverse, bridge, continue, or wait—has not been determined and centers have differing practices. Uninterrupted anticoagulation and antiplatelet therapy in kidney transplant recipients were found to be safe in a single-center retrospective study⁶⁶. Based on a systematic review of 6 lower quality studies, dual antiplatelet therapy use at the time of kidney transplantation is associated with modestly increased risk of postoperative hemorrhage compared to single antiplatelet therapy⁶⁷. The increased risk of postoperative hemorrhage did not lead to increased surgical intervention for hemorrhage. Postoperative cardiovascular events were not significantly different in the 2 groups⁶⁷. In a case series of 4 patients who underwent liver transplantation while treated with direct oral anticoagulants, some patients required perioperative blood product transfusions, but none required prothrombin complex concentrate⁶⁹. The case series suggests that liver transplantation may be successfully performed without reversing direct oral anticoagulants⁶⁹.

• Prehabilitation

Prehabilitation aims to improve transplant candidates’ physical, psychological, and metabolic status using nutrition, exercise, education, and psychosocial interventions⁷¹. Preoperative interventions in the form of exercise regimens, nutritional supplementation, or psychological support have been trialed in older non-transplant surgical patients and transplant candidates with positive results^70,72,73. Specifically, after two months of prehabilitation, kidney transplant candidates improved their physical activity by 64% and experienced a shorter postoperative length of stay for recipients⁷⁴. Other studies demonstrate improvement in older kidney transplant candidates’ exercise and cardiopulmonary function with preoperative prehabilitation^70,75. In a 2022 systematic review, prehabilitation for liver transplant candidates was safe, feasible, and associated with improved aerobic and functional capacity in 1,094 patients while they were awaiting liver transplantation⁷⁶.

Intraoperative Considerations

Intraoperative anesthesia management of older adults undergoing kidney or liver transplantation should follow best practices regarding medication management, positioning, fluid management, and hemodynamic management for older adults. For medication management of older adults, polypharmacy and potentially deliriogenic medications should ideally be avoided. However, for transplant patients, polypharmacy, the concurrent use of 5 or more medications, is unavoidable because transplant recipients require numerous medications such as immunosuppressants, steroids, and antibiotics⁷⁷. Since polypharmacy is unavoidable, the anesthesiology team should focus on avoiding the use of medications associated with adverse postoperative outcomes including postoperative delirium⁷⁸. These medications include benzodiazepines, anticholinergics, ketamine, and potentially inappropriate medications included in the American Geriatrics Society’s Beers^® Criteria^78–82.

When positioning older kidney and liver transplant recipients, the intraoperative team should support pressure points because older adults are susceptible to skin and nerve injuries and pressure ulcers⁸³. Older liver transplant candidates are prone to tissue edema and anasarca, requiring careful positioning. Maintaining normal temperature and hydration status avoids elevated oxygen consumption, impaired drug clearance, and reduces the risk of electrolyte abnormalities.

For older adult patients, aging is associated with increased sensitivity to volatile anesthetic agents. Thus, the minimum alveolar concentration for inhaled volatile anesthetics should be adjusted for age and closely monitored⁸⁴. Level 1 evidence in the form of independent randomized controlled trials have shown that electroencephalography-based monitoring is helpful for anesthetic titration to decrease the rate of postoperative delirium and postoperative cognitive dysfunction^85,86. Avoidance of excessive depth of anesthesia by using age-adjusted doses of intravenous and inhaled anesthetics may be helpful to prevent delirium in older adult kidney and liver transplant recipients, although a causal relationship has not been established in this population specifically^85–88.

Maintaining adequate perfusion pressure is important in older adults due to older patients’ inability to physiologically overcome hypotension. Age-related changes in cerebral and renal autoregulation lead to the inability for older adults to compensate for low mean arterial pressures, making them susceptible to cerebral and myocardial ischemia and acute kidney injury⁸⁹. Many older patients have diastolic dysfunction and require sinus rhythm to maintain adequate left ventricular filling⁹⁰.

Maintaining hemodynamic stability is particularly challenging during liver transplantation when hemorrhage, anhepatic physiology, and postreperfusion injury can lead to hypotension, arrhythmias, and shock. In almost 4% of liver transplants, intraoperative cardiac arrest can occur, mostly due to pulmonary thromboembolism or postreperfusion injury^91,92. In a single center’s experience with 1,238 liver transplantation cases, higher Model for End-Stage Liver Disease score was found to be a risk factor for intraoperative cardiac arrest⁹¹. Increasing age was not found to be a risk factor for intraoperative cardiac arrest in liver transplantation⁹¹. If, however, an older liver transplant recipient was to experience an intraoperative cardiac arrest, the prognosis is likely to be unfavorable. Despite advances in perioperative cardiac arrest management such as the use of rescue mechanical circulatory support, outcomes for cardiac arrest in older adults are poor in general and may lead to intraoperative mortality or subsequent withdrawal of support^93–95.

Surgical considerations for older adult patients have included the preferential use of minimally invasive techniques to help decrease postoperative pain, improve pulmonary function, and promote recovery⁹⁶. While the quality of the evidence supporting the practice is low, minimally invasive techniques for kidney transplantation (i.e. laparoscopic and robotic-assisted techniques) may be particularly beneficial for older transplant patients^97,98. Advances in surgical techniques for liver transplantation have improved outcomes over time and allowed sicker patients to undergo transplantation, although specific techniques for older adults have not been developed⁹⁹.

Postoperative Concerns

• Acute postoperative pain

Careful control of postoperative pain is important; both overuse of opioids and inadequate pain control are associated with postoperative delirium in older patients. Postoperative cognitive decline is also more common in older adults with persistent post-surgical pain¹⁰⁰. Insufficient evidence exists to recommend routine regional nerve blocks, however regional anesthesia techniques may be helpful in older kidney transplant recipients by decreasing the need for opioids. Truncal nerve blocks such as the transversus abdominus plane block and quadratus lumborum block can help control pain after kidney transplantation and may decrease patients’ opioid use^101,102. Similarly for liver transplant recipients, the subcostal transversus abdominal plane block may be helpful in controlling postoperative pain¹⁰³. Multimodal analgesia can help minimize opioid use in the older kidney and liver transplant patient and may prevent delirium, although definitive evidence is lacking¹⁰⁴. Many agents (e.g., gabapentinoids and nonsteroidal anti-inflammatory medications) may have higher risks, or be relatively contraindicated, in both older populations and people at risk of organ dysfunction¹⁰⁵.

• Cardiovascular complications

Ischemic heart disease is a leading cause of mortality in older kidney transplant recipients and older age predicts cardiovascular events after liver transplantation^106,107. Myocardial infarction, clinically significant arrhythmias, and acute heart failure, occur in up to 41% of the older liver transplant recipient population and are the leading cause of death within 6 months of transplantation^107,108. Optimization of the cardiovascular system immediately after liver transplantation is important and practices such as continuation of beta-blocker therapy (once patients are hemodynamically stable and no longer on vasopressors), controlling blood pressure and heart rate, maintaining fluid status, and normalizing electrolytes, are important.

• Delirium

Delirium is another leading postoperative complication in older adult surgical patients and is associated with adverse postoperative outcomes. In kidney transplant recipients, delirium had a prevalence of up to 20% in older adults and was associated with frailty¹⁰⁹. Postoperative delirium in kidney transplant recipients has been associated with increased postoperative length of stay, discharge to an institution, graft loss, and mortality¹⁰⁹. Postoperative delirium in liver transplant recipients is more complex because this patient population has multiple predisposing factors for delirium, alternative potential causes of cognitive symptoms (e.g. hepatic encephalopathy), and is not extensively studied. Prevalence of delirium after liver transplantation has been reported as 17% to 25%^110,111. Delirium in liver transplant recipients has been associated with increased intensive care unit and hospital length of stay but not mortality^111–113.

Interventions to prevent and treat delirium in the postoperative period emphasize non-pharmacologic therapies such as frequent orientation, early mobility, cognitive aids, and maintenance of sleep-wake cycles¹¹⁴. Efforts to use dexmedetomidine to decrease delirium in liver transplant recipients have been unsuccessful¹¹⁵. More studies are needed to study effective interventions to prevent and treat delirium in the older adult kidney and liver transplant population.

• Immunosuppression

Because aging is associated with decreased immune responses and altered pharmacodynamics and pharmacokinetics for medications, older kidney and liver transplant recipients have unique requirements for immunosuppression¹¹⁶. Immunosenescence accompanies older age and is due to decreases in the adaptive and innate immune responses and increased systemic inflammation¹¹⁶. Drug absorption, distribution in body compartments, and excretion are also impaired in older patients¹¹⁶. Calcineurin inhibitors such as tacrolimus and cyclosporine are problematic for older adults because of their association with nephrotoxicity, delirium, and other neurocognitive problems after transplantation. Additionally, older transplant recipients are at higher risk for adverse responses to immunosuppression including infection and malignancy¹¹⁷. Older transplant recipients require close follow-up for maintenance of immunosuppression post-transplant and tailored regimens.

Older kidney transplant recipients benefit from tailored immunosuppression strategies with lower-intensity regimens which minimize steroids¹¹⁸. High quality evidence supports minimization of corticosteroids for adult kidney transplant recipients^119,120. In a randomized controlled trial of 386 low- to moderate-immune risk adult kidney recipients receiving maintenance immunosuppression with tacrolimus and mycophenolate mofetil with or without corticosteroids, corticosteroid withdrawal was not associated with increased long-term allograft failure from any cause¹²⁰. Additionally, in a national database study of Medicare-insured kidney transplant recipients and outcomes associated with their immunosuppression regimens, steroid-sparing regimens were associated with lower acute rejection rates in older kidney transplant recipients¹¹⁸. However, older kidney recipients who received mammalian target of rapamycin inhibitor and cyclosporine-based maintenance immunosuppression are associated with higher risk of adverse outcomes¹¹⁸.

While it has been suggested that older liver transplant recipients should also receive reduced immunosuppression regimens, some contradictory evidence exists. Older liver transplant recipients may require the same level of immunosuppression as younger recipients for the first year after transplantation. In a single-center retrospective cohort study of 143 liver transplant recipients maintained on similar immunosuppression regimens, recipients 60 years and older experienced similar incidence of rejection within 1 year as well as similar 1 year incidence of infection, malignancy, and patient survival as younger patients¹²¹. Other authors have proposed a lower-intensity immunosuppression regimen for older adult liver transplant recipients with lower exposure to calcineurin inhibitors and a shorter course of corticosteroids although evidence supporting this approach is lacking¹²².

• Rehabilitation

Due to their predisposition to preoperative deconditioning, older kidney and liver transplant recipients are likely to need inpatient rehabilitation after transplantation. In kidney transplant recipients of all ages, frailty scores worsen initially after transplantation and subsequently improve by the third month after surgery¹²³. Preoperative frailty persists in most patients after liver transplantation and the degree of pre-transplant frailty in this population predicts posttransplant robustness¹²⁴. Rehabilitation is an important intervention and appears to be safe and feasible in liver transplant recipients¹²⁵. Exercise training is beneficial in solid organ transplant recipients and rehabilitation may help mitigate cardiovascular risk in older kidney and liver transplant recipients¹²⁶.

• Quality of Life

As the survival of older adults undergoing transplantation has improved, more authors are investigating patient-centered outcomes such as quality of life after transplantation. Observational studies show that quality of life improves in older adult kidney transplant recipients to a greater degree than for older adults who undergo dialysis⁹. Additionally, functional status decreases in many older dialysis patients⁹. Older dialysis patients are also at a higher risk from suffering from serious falls⁹. Quality of life also improves after liver transplantation, although studies specifically investigating older adults are lacking^127,128. In a single-center retrospective study, quality of life in adult patients more than 10 years after liver transplantation resembled the general population except in the domain of mental health¹²⁷. In a single-center retrospective study of outpatients after liver transplantation, quality of life was similar to population data however liver transplant recipients had a lower return to work rate¹²⁹.

Simultaneous Liver and Kidney Transplantation in Older Adults

Simultaneous liver and kidney transplantation is indicated in patients with end-stage renal disease with cirrhosis and symptomatic portal hypertension or patients listed for liver transplantation who also have renal dysfunction¹³⁰. Older adults with end stage liver disease and renal dysfunction are increasingly being considered for simultaneous liver kidney transplantation due to improvements in survival from better surgical techniques, patient selection, and perioperative care. Simultaneous liver and kidney recipients aged 65 years and older at a single center experienced similar patient and graft survival compared to simultaneous liver and kidney recipients younger than 65 years and liver transplantation alone recipients aged 65 years and older¹³¹. Based on the risk model developed by Croome and colleagues, they found that older adults can undergo successful simultaneous liver and kidney transplantation if they are not on mechanical ventilation immediately prior to transplantation and if they are not 70 yrs or older with a Model for End-Stage Liver Disease score 30 and higher¹³¹. Understanding how older adults tolerate the physiologic stress of simultaneous liver and kidney transplantation and being able to predict older patients’ graft survival will help interdisciplinary transplant teams prudently allocate scarce organs to this unique patient population.

Discussion

Perioperative care of older adults undergoing kidney and liver transplantation is challenging and requires continuing education and collaboration among the different disciplines involved in each phase of patient care. Consistent and routine assessments for frailty, sarcopenia, cognitive function would help risk stratify patients and triage patients to interventions such as prehabilitation. Optimization and intervention for preoperative cardiovascular comorbidities is important for older transplant candidates at high risk for perioperative cardiovascular complications. Determining best practices for perioperative anticoagulation and antiplatelet therapy would help standardize practices across centers and could allow more candidates to become eligible for transplantation. Recommendations for intraoperative care originate from knowledge work on non-transplant older adult patients regarding monitoring, positioning, and anesthetic management. Optimizing perfusion pressure is important to preserve cardiac function and prevent kidney injury. The postoperative phase is an opportunity for interdisciplinary collaboration to prevent and treat delirium, tailor immunosuppression to each recipient, and improve patient-centered outcomes. Table 1 summarizes opportunities for future inquiry for each of the perioperative phases.

Table 1.

Opportunities for Future Inquiry

Area of Concern	Ideas for Future Inquiry
Preoperative phase
Frailty, Sarcopenia, Cognitive dysfunction	Implementation of standardized and routine frailty and cognitive screening
Malignancy	Consensus on pre-transplant malignancy screening and management
Anticoagulation	Determine whether to continue or hold anticoagulants and antiplatelets at the time of transplantation
Prehabilitation	Identify candidates for prehabilitation using screening for frailty and cognitive dysfunction Determine best practices for physical activity, nutrition, and cognitive interventions
Intraoperative phase
Perfusion Pressure	Identify intraoperative hemodynamic goals for older adults undergoing kidney and liver transplantation which optimizes cardiac function and prevents kidney injury
Postoperative phase
Acute pain	Determine whether regional anesthesia can improve pain, mobility, and other patient outcomes Determine whether opioid sparing techniques can decrease opioid consumption and improve patient outcomes
Delirium	Investigate whether patient care pathways or Enhanced Recovery After Surgery protocols can prevent delirium in older transplant patients
Immunosuppression	Determine the short and long-term impact of lower-intensity and steroid sparing immunosuppression regimens for older transplant recipients
Quality of Life	Determine the impact of transplantation on patient-centered outcomes such as quality of life

Perioperative pathways have been successfully used in the management of surgical patients and may be beneficial if applied to the complex care of older adult transplant candidates¹³². Enhanced recovery pathways, for example, have been developed for liver transplantation and may be helpful in improving outcomes for older adult liver transplant recipients¹³³. Similarly, kidney transplant enhanced recovery pathways have been developed and decrease patients’ postoperative length of stay in the hospital¹³⁴. Another component of geriatric pathways is geriatric co-management, the model where geriatricians work together with primary surgical teams to manage patients. It has improved outcomes in vascular surgery, orthopedic surgery, and surgical oncology patients. Geriatric co-management may have a role in the care of older kidney and liver candidates and transplant recipients by ensuring best practices are delivered and coordinating the complex interprofessional care that these vulnerable patients require^135–137.

In conclusion, perioperative management of older adults undergoing kidney and liver transplant is becoming more important as this population grows and is becoming increasingly complex. Successful outcomes depend on evidence-based practices and a team approach as the input of many disciplines and professions are needed to manage older kidney and liver transplant candidates and recipients. This article highlights major perioperative issues faced by older patients undergoing kidney and liver transplantation with the goal of educating readers and stakeholders on challenges faced by older patients. We highlight important issues and suggest opportunities for future inquiry to advance knowledge, improve patient care, and bring attention to this challenging and growing patient population.