Biologic vs physiologic age in the transplant candidate

Abstract

Hematopoietic cell transplantation (HCT) remains a cornerstone of treatment of many hematologic malignancies but transplant-associated morbidity and mortality limit application to older patients. Biologic or chronologic age barriers to HCT have fallen, because patients in their 8th decade of life comprise the group with the greatest rise in transplant use over the past decade. Evaluating physiologic age or general health in older transplant candidates requires a systematic approach inclusive of functional and comorbidity assessment, which typically is accomplished through geriatric assessment (GA). GA incorporates measures of comorbidity, function, nutrition, social support, and other health-related domains to better describe physiologic age. Older allogeneic transplant patients have a surprisingly high prevalence of vulnerabilities by GA prior to transplant, and significant comorbidity or functional limitations heighten the risks of transplant-related mortality. Ultimately, incorporation of physiologic age can improve estimates of nondisease life expectancy, prognostic survival after HCT, and inform HCT candidacy. Future research on the optimal tools to characterize physiologic age and appropriate interventions in the context of transplant are needed.

Description and analysis of patients and outcomes following third‐time heart transplantation: An analysis of the United Network for Organ Sharing database from 1985 to 2017

“…Clinical factors assessed for various subsets within the population with respect to survival included older age, previous HTx events, diabetic status, and BMI. These established risk factors were compared within subsets of third‐time cardiac graft recipients . There are characteristics of these cohorts that seem to demonstrate deviations from the previously reported findings of patients with third‐time HTx.…”

“…We found those with a BMI above 30 at time of transplant (n = 7) had a 1‐, 5‐, and 10‐year survivability of less than half at all time points when compared to their counterparts with BMI under 30. Being overweight is an established risk factor that pertains to the third‐time HTx group also . One study found that substantial weight gain occurs following cardiac transplantation .…”

“…The impact of age on a heart transplant recipient's clinical outcome is a significant factor to consider . There are mixed results on the degree to which old age is a risk factor for heart transplantation .…”

“…There are mixed results on the degree to which old age is a risk factor for heart transplantation . However, various studies demonstrate younger patients have more favorable outcomes following transplantation compared to older patients, particularly in instances of re‐HTx . In the largest single‐center study on third‐time HTx recipients, the researchers found that the average age for primary and secondary HTx was 58 and 49, respectively, while the average age for third‐time HTx, however, was only 27 .…”

Allogeneic Hematopoietic Cell Transplantation in Patients Aged 50Years or Older with Severe Aplastic Anemia

“…Treatment algorithms for severe aplastic anemia (SAA) are not well characterized for older patients. For older patients treatment decisions are based not only on disease factors but also on their health and functional ability to reduce the risk of treatment-related toxicity that may contribute to morbidity and mortality [1]. For these reasons hematopoietic cell transplantation (HCT) in older patients with SAA is usually only considered as second-line treatment [2].…”