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This chapter addresses the following Geriatric Fellowship Curriculum Milestone: #9


Learning Objectives

  • Learn aging-associated changes in hepatic function, epidemiology, genetics, pathogenesis, and pathology of common hepatic diseases in older adults.

  • Understand the prevalence, common clinical presentations, diagnosis, and treatment of hepatotropic viruses, autoimmune hepatitis, and drug-induced injury in older patients.

  • Learn the appropriate indications and limitations of liver transplantation in older adults.

Key Clinical Points

  1. Older adults are more prone to hepatic injury due to aging-associated changes, including a reduction in regenerative capacity, functional hepatocyte volume, and hepatic blood flow.

  2. Patients with metabolic syndrome are at high risk for developing nonalcoholic fatty liver disease (NAFLD).

  3. Administration of chemotherapy or immunosuppressive drugs can lead to reactivation of hepatitis B and rarely to acute liver failure.

  4. Drug induced liver injury occurs more frequently in older patients and tends to be more severe.

  5. Alcohol-related liver disease and chronic hepatitis C are the two most common causes of end-stage liver disease in older patients.


The liver is remarkable in its ability to preserve its function despite advanced age. Older patients are at an increased risk of more severe hepatic injury when exposed to hepatic insults. This increased risk is likely related to the liver’s age-related decrease in regenerative capacity. We will review the hepatic changes that are known to occur with aging and their pathologic consequences of liver disease in older patients (Table 91-1).


As will be discussed multiple times in this chapter, most of the therapies available for younger patients are safe and appropriate for use in the geriatric population. However, older patients with advanced pancreatic, liver, or biliary disease may not be eligible for curative treatments in some circumstances. For example, due to comorbid disease, few patients over 70 years of age meet entry criteria for liver transplantation. Similarly, geriatric patients with newly diagnosed neoplasms of the pancreas or hepatobiliary system may not tolerate the extensive surgery that may be appropriate in a younger patient. Palliative care for patients with advanced pancreatic and hepatobiliary disease has become a well-recognized subspecialty and provides valuable therapies and counseling to alleviate suffering near the end of life.


For a number of years, liver volume was thought to decrease with age. More recently, it was determined that liver volume remains unchanged ...

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