Marcia Frellick

April 28, 2016

WASHINGTON, DC — Whether people 70 years and older should undergo lung transplantation was a matter of debate here at the International Society for Heart and Lung Transplantation 2016 Scientific Sessions.

The argument in favor centered on the decreasing gap in short-term survival between patients 70 years and older and those in their 60s. The argument against pointed to substantially worse long-term outcomes in older patients than in younger patients, and raised the issue of whether allocating lungs to older patients goes against the prudent distribution of available organs.

Selective candidates in their 70s should be eligible, said Erik Verschuuren, MD, PhD, and internist–clinical immunologist from Groningen University Medical Center in the Netherlands. "I think this is the future."

Age is relative, he added, pointing out that Yuichiro Miura, the oldest climber of Mount Everest in 2013, was 80 years old, and that in the Netherlands, the age at which a person collects a pension is "67 and climbing."

He also cited a study that demonstrated that outcomes for lung transplant patients in their 70s have improved greatly over the past 15 years, and are now close to outcomes for patients in their 60s (J Heart Lung Transplant. 2015;34:182-188).

In that study, from 2000 to 2005, 30-day survival was similar in older and younger patients (95.7% vs 93.8%; P = .65), although 3-month survival was worse in the older patients (91.2% vs 75.0%), as was 1-year survival (79.5% vs 62.5%).

However, from 2006 to 2012, there were no differences between the older and younger patients in 30-day survival (96.2% vs 96.8), 3-month survival (92.7% vs 91.9%), and 1-year survival (81.7% vs 78.6%). But survival was significantly worse in older than in younger patients at 3 years (63.7% vs 49.3%) and at 5 years (47.5% vs 28.2%).

Long-term Survival Pales for Older Patients

Any decision to transplant someone 70 years and older should be made judiciously, said Steven Hays, MD, from the University of California, San Francisco, where select patients 70 years and older undergo transplantation.

"For something to really be useful, we need to show not only that there's good survival long-term, but that it's good for our society," he explained.

He acknowledged that short-term survival for those in their 70s is improving, but wondered whether 1-year survival rates should be the goal. "And is the 60- to 69-year age group the comparator group we should be interested in?"

Dr Hays said he is troubled that long-term survival is much lower in the older patients, which raises the question of whether society gets more benefit from transplants to younger recipients.

The lung allocation score, introduced in 2005, was designed to get lungs to the patients who had the most medical urgency. But it favors an older and sicker population and is a large part of the reason for the growth in transplantation in older patients, he explained.

The number of patients older than 65 years who have undergone transplantation was almost six times higher from 2006 to 2012 than in the year leading up to 2006, he reported.

That is an issue if it affects the way we are distributing donors and, according to Dr Hays, it does. The worst-off patients are not the absolute sickest, as identified by the lung allocation score, but are actually those who have the most life-years to lose.

"An arbitrary cutoff of 70 years is not the ultimate answer, but until we find better ways to assess potential older candidates, it remains a viable marker," he said.

Frailty a Better Measure

Age thresholds are inconsistent and are often determined by individual transplant centers or on a case-by-case basis, said Jonathan Singer, MD, from the University of California, San Francisco Medical Center.

The rapid rise in elderly lung recipients in recent years has outpaced evidence-based risk-stratification tools and the guidelines that identify which older candidates will do well after lung transplantation, he told Medscape Medical News.

Dr Singer explained that his own research shows that frailty, determined by measures such as the Short Physical Performance Battery or the Fried frailty phenotype, is fairly common in those with lung disease, and might be a better way to assess eligibility for transplantation (Am J Respir Crit Care Med. 2015;192:1325-1334).

"The frailty construct is not restricted to those over 70, but extends into younger 'older candidates,' who, because of severe lung disease, are more debilitated and vulnerable to complications than age-matched healthy people," he said.

Measuring by age, older candidates have worse outcomes, he pointed out.

"For those older than 65, median survival after transplant is only about 3.5 years. That's a full 3 years shorter than in those 50 and younger," he reported. "For those 70 and older, it's even worse."

However, population-based metrics don't necessarily identify the older patients who do very well. Therefore, age is a poor predictor of individual risk, he noted.

Early studies are suggesting that frailty can get better, although researchers have not yet shown that can improve transplant outcomes, Dr Singer said.

"We all know intuitively that there are patients who aren't candidates when they walk in to meet you, but they work really hard and improve their nutritional status and their physiologic capacity for exercise and they end up being great candidates," he explained.

He reported that his research team is working to identify patients who will become better candidates with more rehabilitation.

Dr Singer, Dr Verschuuren, and Dr Hays have disclosed no relevant financial relationships.

International Society for Heart and Lung Transplantation (ISHLT) 2016 Scientific Sessions. Presented April 27, 2016.

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