Liver transplant (LT) is the only curative treatment for end-stage liver disease (ESLD). Globally, along with a longer life expectancy, the prevalence of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) and Hepatocellular Carcinoma (HCC) is rising in patients older than 65 years old [1–3], resulting in an increased number of liver transplants performed in this group. This trend is observed both in the United States and in Europe [4–7]. Notably, older LT candidates often show multiple comorbidities, independently from liver disease, that negatively influence post-transplant outcomes [8, 9]. Despite the increasing amount of literature addressing this topic, findings remain inconclusive. Some studies have reported poorer outcomes associated with older age, including higher graft loss and reduced survival, in particular in patients with high Model For End-Stage Stage Liver Disease (MELD) scores [10, 11]. Conversely, other works have proved that liver transplantation in selected patients aged 70 and older is safe and feasible, showing graft survival and overall survival rates similar to younger cohorts [12–14] [15]. Importantly, the guidelines from American Association for the Study of Liver Diseases and the American Society of Transplantation do not consider age over 70 years old a contraindication to LT, in the absence of significant comorbidities [16].

This heterogeneity in published results probably reflects differences found in previous analyses in study design, patient selection and institutional practices.

Emerging evidence suggests that, rather than chronological age alone, the severity of comorbidities and liver disease and the general functional status of the patients represent more reliable prognostic indicators of post-transplant outcomes, underscoring the importance of careful selection in achieving favorable results.

We present our experience with LT recipients aged ≥70 years. This study aims to describe the characteristics of our cohort of recipients aged over 70 and evaluate their post-transplant outcomes in comparison to younger recipients.

Our study shows that carefully selected LT recipients aged 70 years or older can achieve outcomes comparable to those of younger recipients, without significant differences in terms of postoperative complications, graft survival, and overall survival. The same results were obtained even after adjusted analysis eliminating preoperative differences, indicating that advanced age alone should not be considered an absolute contraindication to LT.

In recent years, LT in elderly recipients has become a prominent and pressing issue. In particular, the rising prevalence of MASLD and HCC in patients older than 65 years old has led to an increased demand for LT in this age group, and it has been demonstrated that this population can achieve promising results, reaching a 5-year overall survival of 77% [1]. However, the studies focusing on LT performed in recipients aged 70 or older are limited in the literature.

Accordingly, in our center the proportion of LT recipients aged ≥70 has increased from 1.4% in 2018 to 16.5% in 2024 (Figure 3).

Our recipients aged ≥70 years demonstrated favorable outcomes with an overall survival of 94.4% at 1 year and a 3-year and 5-year survival of 89.5% and graft survival of 94.4% at 1 year, and a 3-year and 5-year survival of 89.5%, with no difference compared to the younger cohort.

These results are consistent with those reported by Wilson et al. [12] in a multicenter cohort of 312 LT recipients aged ≥70 years, from 2007 to 2011, with a median MELD score of 15. They found a 1-year overall survival of 84.9% and similar postoperative complications, with no differences in the adjusted analysis compared to a matched cohort of patients younger than 70 years old.

However, their mid- and long-term results were less favorable, with unadjusted survival rates in the elderly cohort of 74.0% at 3 years and 64.1% at 5 years, significantly lower compared to younger recipients.

Similarly, a recent single-center study by Toiv et al. [13], reported outcomes, from 2014 to 2023, of 43 liver transplant recipients aged ≥70 years in comparison to a cohort of 956 recipients aged <70 years. The elderly group had a lower median MELD score (21.4 vs. 24.9), a higher prevalence of MASLD (51.2% vs. 23.0%) higher rates of diabetes and hyperlipidemia compared to the younger group. The elderly group had significantly longer median hospital stay (25.5 vs. 14 days), but there were no differences in overall patient or graft survival compared to the younger cohort. In the elderly group overall survival was 93% at 1 year, and 78% at 3 and 5 years. The outcomes of this study are similar to ours; however, our older cohort had lower median MELD score (13 vs. 21.4), and shorter hospital stay (14.5 vs. 25.5 days), with no difference between groups, likely as effect of selection.

Earlier series have reported similar outcomes (Table 5). A study from Mayo Clinic analyzing data from 1998 to 2004 showed comparable 5-year survival rates and no significant differences in postoperative complications between LT recipients aged ≥70 years (73%) and <60 years (76%), in two matched cohorts of 42 patients in each group [15].

Similarly, Lipshutz et al., in a series from 1988 to 2005, demonstrated comparable graft and overall survival outcomes in patients aged ≥70 years (n = 62) compared to a younger group aged between 50 and 59 years (n = 864) [14]. Mousa et.al. reported a 5- and 10-year overall survival after LT of 70.8% and 43.6% for a cohort of 162 patients over 70 years old [24]. As previously reported [3], HCC did not affect the outcomes of elderly patients after LT.

The first concern in elderly recipients is represented by early mortality.

In a nationwide Korean study from Gil et al. [25], who analyzed 9415 LT from 2007 to 2016 and included 84 recipients older than 70 years (47 Deceased Donor Liver Transplant and 37 Living Donor Liver Transplant), reported that in-hospital mortality increased significantly with age beyond 60 years old. Specifically, post-liver transplant in-hospital mortality of recipients over 70, adjusted for baseline liver disease, was 4.2 times higher than in patients aged between 51 and 55 years (20.2% vs. 4.8%), and almost 3 times higher after adjusting for perioperative complications. They also reported increasing costs with age [25].

Similarly, Gomez Gavara et al. [6], indicated age over 65 years as an independent prognostic factor for mortality and graft loss. They analyzed data of 10,172 liver recipients (1,062 older than 65 years old) from European Liver Transplant Registry (ELTR) and showed worse overall patient survival in recipients over 65 years (85% at 1 year, 71% at 3 years, 59% at 5 years and 55% at 10 years) and worse graft survival (84% at 1 year, 71% at 3 years, 59% at 5 years and 55% at 10 years), confirmed after PSM. However, in their subgroup analysis, they identified transplant indication as a major prognostic factor in elderly patients. In this group, while outcomes for HCC were similar to younger patients, alcohol-related cirrhosis showed worse 5 and 10-year survival of 47% and 33%, attributed to frailty and sarcopenia.

In our study, due to accurate selection, no increased mortality was observed in the elderly group.

MELD score has a prominent influence on postoperative outcomes and remains an important variable in assessing candidacy for LT in patients over 70 years. Sharpton et al. [10] analyzed UNOS database that included all adult LT from 2005 to 2010, of which 343 were recipients older than 70 years old. They evaluated the combined effect of recipient’s age and MELD at the time of LT and reported a poor 1-year graft survival of 56% for recipients ≥70 and MELD ≥28.

However, in the same age group, MELD ≤20 and MELD between 20 and 27 showed better outcomes, with one-year graft survival rates of 85% and 75%, respectively, with no significant interaction between recipient age and MELD <28. Considering a lower median MELD in our older cohort, our results emphasize that, rather than age alone, liver disease severity should guide eligibility.

Moreover, cardiac risk is a critical prognostic factor in elderly recipients, as emerged by the series of Audet et al. [26]. In their study, recipients ≥65 years old (n = 34) showed higher mortality compared to younger controls. In the elderly group, 50% had a history of coronary artery disease (CAD), and the mortality rate due to cardiac causes was significantly higher. One and 3-year survival rates were 87% and 81.5%. As previously reported [14], cardiovascular events represent a major cause of mortality in older LT recipients and accurate cardiological screening is necessary to identify high-risk candidates.

In current literature, there are no strictly defined criteria for the exclusion of elderly patients from LT. Previous studies, as discussed above, have identified factors associated with increased post-transplant mortality risk: high MELD scores ≥28, the presence of CAD and high comorbidity burden, expressed as mCCI >1 [17].

At our center the selection process for elderly recipients is based on a case-by-case evaluation, taking into account the benefits and risks associated with transplantation, the general health status, comorbidities, and perioperative risk. However, as reflected by our elderly cohort characteristics, selection is oriented to minimize these high-risk factors. Accordingly, in our elderly cohort, only 2 patients had history of CAD and only 4 patients had MELD score ≥28. Moreover, our elderly cohort showed a low comorbidity burden, with 81.6% of the elderly patients having mCCI <2.

Several limitations must be acknowledged to interpret our results appropriately. First, this is a retrospective single-center analysis with a relatively small number of elderly recipients. Given the design of our study, our purpose was not to draw definitive conclusions but to contribute to the ongoing research with additional data from our experience. Additionally, as recipient selection was based on a multidisciplinary board evaluation, the process did not rely on objective or reproducible selection criteria. Although our outcomes are quite favorable, they may be the result of careful local selection practices and may not be reproduced by other centers.

Second, this study includes only patients who received LT and therefore does not account for patients aged ≥70 years who were evaluated but ultimately excluded from liver transplantation. Because data on declined candidates were not systematically recorded during the study period, we were unable to analyze the characteristics in this group and the reasons for exclusion.

Third, frailty and sarcopenia were not consistently assessed in our cohort and were therefore not included in the comparative analysis. The modified Charlson Comorbidity Index (mCCI) was used as a surrogate measure of comorbidity burden, but this does not replace validated frailty metrics. Sarcopenia, as a surrogate marker of frailty, has been associated with unfavorable outcomes following liver transplantation [22]; however, as shown in our results, variability in cut-off thresholds across studies limits its reliability as a standalone clinical parameter.

Finally, long-term outcomes such as 10-year overall and graft survival could not be evaluated, as the follow-up period was limited to 5 years.

These limitations highlight the need for prospective, multicenter studies with standardized data collection and reproducible selection criteria for elderly candidates; future research should incorporate sarcopenia in combination with objective and functional frailty assessments, evaluate both accepted and declined candidates, and include quality of life assessment [7] to better define transplant candidacy in patients ≥70 years.