Optimal Utilization of Donors Aged ≥65 Y in Lung Transplantation to Increase Donor Availability While Maintaining Comparable Posttransplant Outcomes

Abstract

Background: Utilizing older donors (≥65 y) in lung transplantation can greatly expand donor availability while potentially maintaining typical survival outcomes in certain subpopulations, such as older recipients, especially compared to survival with single lung transplants (which comprise ~20%-25% of US lung transplants according to recent data).

Methods: This study included US adult lung transplants from 2010 to 2021 in the Scientific Registry for Transplant Recipients. To compare patient groups defined by donor age (D < 65 or D ≥ 65) and transplant type (single or double), stratified by recipient age (R18-39, R40-64, R ≥ 65), Inverse probability of treatment weighting was used to generate Kaplan-Meier survival estimates adjusted for >15 available covariates.

Results: In R40-64, survival with D ≥ 65 double (adjusted median survival [aMS] = 7.1 [3.3-12.0] y, n = 150, P = 0.15) at least equaled survival with D < 65 single (aMS = 5.7 [2.5-10.2] y, n = 2926), whereas D ≥ 65 single use was uncommon (n = 23), and survival was highest with D < 65 double (aMS = 7.7 [3.0-13.4] y, n = 10 934, P < 0.01). In R ≥ 65, survival with D ≥ 65 double (aMS = 5.0 [2.2-10.8] y, n = 90, P = 0.53) or D ≥ 65 single (aMS = 5.3 [1.9-8.4] y, n = 73, P = 0.72) was not significantly different from survival with D < 65 single (aMS = 4.7 [2.1-8.1] y, n = 3913), whereas survival was highest with D < 65 double (aMS = 5.8 [2.0-10.2] y, n = 4209, P < 0.01). In R18-39, D ≥ 65 were uncommon (n = 15).

Conclusions: Among lung recipients aged 40-64 y, donor age ≥65 y double transplants yield survival at least matching that of donor age <65 y single transplants. Among recipients aged ≥65 y, donor age ≥65 y double or single transplants yield survival comparable to that of donor age <65 single transplants. Compared with donor age <65 y double transplants, donor age ≥65 y double transplants had only ≤10 mo shorter adjusted median survival, within recipients aged ≥40 y. Judiciously increasing utilization of donors aged ≥65 y within recipients aged ≥40 y can reduce deaths among patients needing a lung transplant by decreasing donor scarcity, while maintaining favorable posttransplant survival.

Graphical abstract

FIGURE 1.

Frequencies of single lung transplants vs donor age ≥65 lung transplants, per year from 2010 to 2021.

FIGURE 2.

Adjusted Kaplan–Meier survival curves, by donor age and transplant type group (generated via inverse probability of treatment weighting based on covariates). A, Recipients aged 40–64 y. Note: The D ≥ 65 single transplant group, in Recipients 40–64, had insufficient data (n = 23) for reliable survival estimates. B, Recipients aged ≥65 y.

FIGURE 3.

Adjusted survival probabilities at 1 and 5 y posttransplant, for 10-y donor age groups (generated via inverse probability of treatment weighting based on covariates). A, One-year survival. B, Five-year survival.

FIGURE 4.

Plot of estimated FEV₁ % predicted slopes from year 1 to 5 (based on yearly follow-up data, adjusted for baseline covariates), by donor age and transplant type.