Tuesday, December 24, 2013

Am I Too Old for a Lung Transplant?

I'd like to talk about lung transplantation again. In this post, I'll try to answer the question "Am I too old for a lung transplant?" As you will see, it's not a simple thing...

The story begins in 1998, when the International Society for Heart and Lung Transplantation (or ISHLT) published guidelines for the selection of candidates for lung transplantation. These guidelines suggested that lung transplantation be restricted to those age 65 years of age and younger. It was uncommon for anyone over the age of 65 to undergo transplantation until the mid-2000s, when lung transplant programs in the U.S. began to transplant more and more people over the age of 65. 

In 2006, the ISHLT published updated guidelines that took a more nuanced view of the issue. While these guidelines also suggested that age 65 be used as a cutoff, they also stated that it was quite reasonable to offer lung transplantation to those older than age 65 as long as they were otherwise suitable candidates from a medical perspective. 

These guidelines seem to have had a huge impact. For example, only 7% of the lung transplants performed in the United States were for adults age 65 and older. Believe it or not, in 2012, fully 27% of all lung transplants in the United States were for adults age 65 and older -- and 70% of the lung transplants performed for adults age 65 and older in 2012 were for those with Pulmonary Fibrosis. 

Here's a picture showing the growth in lung transplantation for older adults in the United States. The Red Boxes and Line represent the percentage of lung transplants performed for adults age 65 and older each year. Note the steady increase each year since 2004. These data from from the Organ Procurement and Transplantation Network.
Age at the time of lung transplantation in the United States, 1997-2010.
From Hook & Lederer, Expert Rev Respir Med 2012;6(1):51-6.

There a probably a few different reasons that more and more older adults are undergoing lung transplantation nowadays: greater availability of donor lungs, the large number of older adults with Pulmonary Fibrosis who need transplantation, and a gradual realization on the part of transplant docs and surgeons that older adults can safely undergo lung transplantation.

It is important to realize that transplant programs do continue to deny lung transplantation to older adults. One of the reasons that lung transplant programs deny lung transplantation to older adults is that, on average, older adults don't live as long after a lung transplant as younger adults. The average survival time after a lung transplant for someone in their 30s or 40s is about 6-7 years, while the average survival time for someone over age 65 is only about 3-4 years. (Check out Figures 13 and 14 here for more details).


I wrote about the way that transplant centers try to balance risk, benefit, and the equity of allocating (giving out) donor lungs in a previous post. When it comes to older age, transplant centers take into account this higher average risk of death after transplantation, but they also consider factors such as other medical problems that older adults might have and whether or not an older adult has the wherewithal to not only survive transplant surgery, but to also thrive during the recovery period. We've all met 70 year olds who looked 50, and 50 year old who looked 70. We do try to take someone's "physiological" age into account when making transplant decisions. (As an aside, one of my research interests is trying to develop simple methods of measuring physiological age in people with Pulmonary Fibrosis and other serious lung diseases).

So, while we are transplanting people now in their late 60s and early 70s (and occasional even older than 75), most people with Pulmonary Fibrosis older than 65 to 70 years old will not be a candidate for lung transplantation based on their other medical problems or based on an assessment of their ability to survive (and thrive) after transplant surgery.

Finally, new ISHLT guidelines are coming out in 2014. These guidelines might also lead to important changes in how who we consider for lung transplantation.

13 comments :

  1. Very timely post Dr David since after posting about the upcoming update, quite a discussion was started over at Inspire's PF forum. We've missed your posts here and glad you got one in before Christmas.

    Would look by the chart you provided that at least 75% of the lung transplant have been 50 years or older. And that is quite an impressive jump for the >64.

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  2. As always, your posting is informative, educational, and helpful, in accepting the realities of my situation. At this time, I have been evaluated, but am not ill enough for active listing. My sister was 70, had IPF for ten years, developed cardiac, and swallowing problems, which led to her denial.

    At this time, I remain healthy, and active, but am 65, and very much a realist. As I decline, depending upon my age, I may opt to decline the surgery. It seems that the odds of getting a transplant are relatively slim, and the longevity factor, not that great. Thanks for all of you expert input.

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  3. I would say that a pair of lungs should go to someone younger as they have not been able to live out their life. Please give us young folks a chance. =)

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  4. Loretta, I've looked into your story and am amazed at what you've been through. With your comorbitities, are you a candidate for a transplant?

    However, I'm not quite 63...and I haven't been able to live out my life. My father is 90. Should I not expect another 20 to 30 years? Obviously as a young person you have your bias as I do being of the older side. To date, I've not had any heroic efforts taken on my behalf to extend my life as you have. So I could argue that you've had your chance having your life extended and now it is someone else's turn.

    But those philosophical debates are what need to be taken out of the equation and instead, as the doctors are doing, is looking at whose life is about to expire and whether they can benefit from a transplant. It is not up to you or I or the doctors to decide how many years we are allowed to live in order to have been able to live out our lives!

    I wish all the best for you.

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  5. Two sisters get lung transplants from same donor at Houston Methodist Hospital

    For months, 71-year-old Irma Myers-Santana and her younger sister, Anna Williamson, 69, had been debating who more urgently needed a lung transplant, each wanting the other to go first.

    http://www.startribune.com/lifestyle/health/241415561.html
    http://abclocal.go.com/ktrk/story?section=news/local&id=9401425

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    1. That is so great!! I am going to share this on Twitter and Facebook.

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    2. Another interesting aspect is that the sisters are Jehovah Witnesses and the surgery had to be without transfusion and apparent Houston Methodist is the only hospital in the US that will do so.

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  6. Dear Dr Lederer, my mother is 75 years old and has pulmonary fibrosis (hypersensitivity pneumonitis to be precise) and she is now permanently on oxygen (24/7). She has absolutely no other medical conditions and was very fit, healthy and active, physiologically like a 60 year old until this condition happened and has almost paralysed her now. Is there absolutely any way whatsoever she could have a lung transplant and if so would it only increase her life span by 3-4 years as you mention in your article above? She is on all the obvious medications and we live in London, UK. Is there absolutely anything we can do to help increase her years of survival. Please help, I'm desperate for her!

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    1. Sorry for the late reply. I am not entirely familiar with the criteria used to select folks for lung transplantation in the UK. Please talk to your doctors about whether or not a transplant is a good option for your mother. Here is a list of lung transplant programs in the UK:

      Freeman Hospital, Newcastle upon Tyne
      Papworth Hospital, Cambridge
      Harefield Hospital, London
      Queen Elizabeth Hospital, Birmingham
      Wythenshawe Hospital, Manchester

      Please share my best wishes with your mother.

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  7. This is what my sister who is 69 years old was told yesterday by her doctor. You can have a trachea, have a feeding tube put in, be put in a home (not hers) and live your life. The other option was to take her off the ventilator, give her morphine so she feels no pain and wait for her to die. Not his exact words. He said she is to old for a transplant. The average time after the operation is 3 to 4 years. Well that is plenty and more than what he suggests.

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    1. My grandson who was just one week from turning 11 passed away due to a tragic accident last month. We just found out that his lungs went to a 65 yr old male. I was shocked to see this. I know only God knows how much time each of us has and it isn't up to us to say how long any other person should live. But as his grandmother I feel that his organs should have gone to children who needed them much more than someone who has already had their chance at life. I know lots of you won't agree with me, but I have my opinion and you have yours. It certainly makes me reconsider being a donor.

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    2. I am so sorry for you loss. There are no words I could write that would lessen the pain you and your family must be feeling. I hope your grandson did not suffer.

      I completely understand and relate to your concerns about the donation situation you described. You are not alone -- There are many who agree with you. Perhaps it is time for the lung transplant community to address and reconsider the ethics of transplanting older adults. You might find this article relevant: http://www.nejm.org/doi/full/10.1056/NEJMp1307792.

      Please share my condolences with your family. Your grandson is in my thoughts today.

      Dave Lederer

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  8. Dr Lederer,

    I"m a 65 year old male diagnosed with pulmonary fibrosis 3 yrs ago. I just came across your blog and read with interest medications that can possibly cause this disease. I also have CAD and take bistolic as part of my blood pressure regimen. Since I started using this drug in 2008 nodules began to appear followed a couple of years later with pulmonary fibrosis.My cardiologist is concerned with my heart and doesn't believe bistolic is an issue. I'm connecting the dots but not being a medical professional, my opinion is pure conjecture. Would you be concerned if a patient of yours was taking bistolic? For information purposes I'm on a treadmill
    2 miles everyday.
    Thank You

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