Today at the International Society for Heart and Lung Transplantation (ISHLT) 46th Annual meeting and Scientific Sessions, transplant specialists Brian Keller, MD, PhD, and Thomas Egan, MD debated an ethically fraught question: How old is too old for a lung transplant?
Dr. Keller, Assistant Professor of Medicine at Harvard Medical School and Medical Director of Lung Transplantation at Massachusetts General Hospital (MGH), argued that the current upper age limit for lung transplant candidacy should remain in place-even as a growing number of adults who are 70+ years old undergo the procedure.
The age limit for lung transplantation is 70, but older patients regularly treated
Until 2014, being older than 65 was considered a contraindication for lung transplantation. However, a 2021 update to ISHLT guidelines for lung transplantation candidacy raised the age limit to 70.
"At MGH, most recipients are in their mid to upper 60s with a fairly significant number in their 70s," said Dr. Keller.
We have more older candidates for lung transplantation as a result of an aging population and advances in medical therapy for lung diseases that prolong survival and delay the need for transplantation."
Brian Keller, Massachusetts General Hospital
Allocation is an ongoing dilemma due to the severe shortage of usable donor lungs compared to the number of patients on the waitlist. In 2023, there were 3,385 new adult candidates added to the lung transplant waiting list, an increase of 37.4% over the past decade.
Dr. Keller said that the question of age and donor lungs is underpinned by societal values. "Should donor lungs go to younger patients who will likely survive longer and continue to be part of the workforce, or should they go to older patients who've already contributed to society? This question hits at two major ethical principles, utility and justice" he said.
He added that many older transplant recipients have pre-existing conditions and are at greater risk of developing cancer and cardiovascular disease as a result of their age, the transplant procedure, and immunosuppression therapy. Still, Dr. Keller acknowledged the distinction between chronological and biological age.
"There are 75-year-olds who have a biological age of 60. And there are 60-year-olds who look like they're 75 or 80 and probably shouldn't undergo lung transplantation," said Dr. Egan, Professor of Surgery, Division of Cardiothoracic Surgery, UNC, and one of the early pioneers of single and double lung transplants. "Setting a hard age limit ignores this biological variability."
Arbitrary age limits fail to consider other important factors
According to Dr. Egan, an arbitrary chronological cutoff-70, 75, or any other number-fails to reflect biological age, comorbidities, and a capacity to benefit in terms of survival and quality of life. "I don't think we can justify disqualifying people based on an arbitrary age limit," he said.
Importantly, Dr. Egan said recent research demonstrates that outcomes for carefully selected older donor lung recipients are comparable to younger patients. He cited a single‑center study that found no difference in three‑year survival between recipients over 70 and those in their '50s and '60s. In another single-institution study of 1,025 patients, short-term outcomes in older patient groups were comparable or even superior to younger cohorts. However, donor lung recipients who were 65 or older had lower long-term survival.
Survival rates post-transplant are an important consideration, according to Dr. Keller, because one- and three-year survival rates are used as a metric to assess the performance of transplant programs.
"The survival metric is tricky, because it doesn't take into consideration quality of life," he acknowledged. "I would argue that a 75‑year‑old would not be expected to live as long as a 40‑year‑old without a transplant. But is survival the right metric, or should we also be using quality of life and patient-reported outcomes? If someone gets three really good years of life, how do you weigh that versus someone who gets 10 years but with a heavy burden of complications, medical follow up, and a suboptimal quality of life?"
Dr. Egan concurred. "Lung transplantation is not just about extending life, it's about improving the quality of life that remains," he said. "From my perspective, the value of that improvement is not intrinsically less for a 75-year-old than in a 35-year-old."
He said the ultimate goal should be minimizing wait-list deaths and ensuring that organs go to candidates who will derive meaningful benefit, which is best accomplished through individualized assessment, not age cut-offs. Rather than rationing donor lungs to patients based on age, Dr. Egan said the focus should be aimed at increasing the supply and utilization of organs for transplant, including the use of lungs and other organs from sudden death victims - known as uncontrolled Donation after Circulatory Death donors (uDCDs) - assessed by ex vivo lung perfusion.
Focus should shift to increasing supply of donor organs
"If we honor the wishes of registered organ donors and invest in technologies and protocols to evaluate and rehabilitate more lungs, we can increase the donor pool instead of shrinking the candidate pool by excluding older individuals," he said.
Dr. Keller agreed. "I think in the future, if we're able to grow lungs in a lab or utilize xenotransplant organs, diminishing the lung shortage problem, I think the upper age limit argument becomes less important."
The annual meeting and scientific sessions of the ISHLT are being held from 22-25 April at the Metro Toronto Convention Centre in Toronto, ON, Canada.
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