“Old-for-Old” in Lung Transplantation? Insights from the ISHLT Database

Background: Lung transplantation is an established treatment strategy for patients with advanced lung disease. However, the number of transplants is limited by the scarcity of suitable donor organs. Currently, donor selection guidelines recommend the use of donors < 55 years of age, which markedly limits the available donor pool. In this study, we use the largest transplant dataset to assess how outcomes in recipients from older donors differ from those of donors < 55 years and to evaluate the interaction with older recipients.

Methods: The Registry of the International Society for Heart and Lung Transplantation (ISHLT) was queried. All adult primary lung transplants performed between 1988 and 2012 were included. All donors and recipients were divided into three groups based on age < 55, 55–64, and >64 years. Preoperative recipient and donor characteristics were compared. Kaplan-Meier analysis was used to assess survival post-transplant, and adjustment for relevant covariates was performed using Cox proportional regression analysis.

Results: During the study period, 43,155 adult primary lung transplants were performed. In this cohort, 37,887 donors were < 55 years, 4,499 were 55 to 64 years, and 769 donors were >64 years old. 2,497 transplants (15.5%) in recipients aged 55 to 64 years derived from donors >55 years with significantly older donors and recipients in Europe (p < 0.001). 5-year survival in recipients aged 55–64 years was comparable for donors < 55 years and 55–64 years and lower for those from >64 years (p = 0.0166). In recipients >64 years no significant difference in 5-year survival was observed for all donor age groups (p = 0.6166). In addition, in donors < 55 years and 55–64 years significantly better survival for double compared with single lung transplants was observed (p < 0.001). No difference was seen in donors >64years (p = 0.1321).

Conclusion: In the largest international lung transplant registry to date, recipients of 55–64 years showed comparable survival after lung transplantation from donors < 55 years and 55–64 years, however lower for donors >64 years. Therefore, the introduction of an “old-for-old” program for recipients >54 years from donors outside the standard age criteria seems feasible. In light of these data, this might further improve survival of all lung transplant recipients, potentially expanding the pool donor pool significantly.

No conflict of interest has been declared by the author(s).