Extremes of Age Decrease Survival in Adults After Lung Transplant

Consensus document for the selection of lung transplant candidates: An update from the International Society for Heart and Lung Transplantation

“…In the larger of the two studies, survival of 4,377 lung transplant candidates with COPD in the OPTN/UNOS database was compared to that of the cohort of COPD patients that served as the validation group in the original BODE publication. (170) Median survival of patients in the fourth quartile of BODE scores (7)(8)(9)(10) was 59 months in the transplant candidate cohort and 37 months in the original BODE cohort. The poor calibration of the BODE index among transplant candidates likely reflects the marked differences in age, comorbidities, and active smoking in this carefully screened population compared to the general population included in the original validation cohort.…”

“…(2,4) There has been no endorsement of an upper age limit as an absolute contraindication, but older individuals have worse longterm survival following lung transplant. (7) The age of lung transplant recipients has increased over the past decade. In the United States (U.S.), candidates greater than 65 years of age now comprise more than 30% of the waiting list and are the age group with the highest transplant rate.…”

COUNTERPOINT: Should Every Patient With Idiopathic Pulmonary Fibrosis Be Referred for Transplant Evaluation? No

“…Survival longevity is complex but will also depend on age at LTX. 6 The decision to refer early is indeed a very sensible and practical one in the patient's best interest. It is no longer ethically or morally acceptable to place patients with IPF in "the kingdom of the near dead," a term coined in 1987 to describe the attitude of some medical practitioners to treating patients with primary pulmonary hypertension.…”

“…The mean age at diagnosis of IPF is 70 years, and one-quarter of all patients with IPF are over the age of 80 years; and although extremes of age alone are not an absolute contraindication to LTX, there is good evidence that with advancing age comes the accrual of other comorbidities, principally frailty and sarcopenia, both of which portend inferior outcomes. 6,9 The rate of malignancy, both pulmonary and extrapulmonary, inevitably increases and IPF per se is a well-known risk factor for lung cancer, which may not be able to be diagnosed before examination of the explanted organ(s). Similarly, the risk of lung cancer after LTX is significantly increased.…”

Rebuttal From Dr Glanville

“…Chronological age may be somewhat less important than biological age for the former, but this equation changes dramatically at the extremes of age. 6 Likewise the discussion regarding use of antifibrotic agents is irrelevant to referral and listing, except that it might be argued that referral could delay appropriate commencement of such medications, which outcome is indeed more likely.…”