Lung Transplant Trends Shift to Older Adults, Sicker Pediatric Cases

Patients 70 years and older now account for 13% of lung transplant recipients worldwide, up from just 1% more than 2 decades ago, a shift significant enough that lung transplantation is now described as "a geriatric procedure." At the same time, the pediatric lung transplant population is shifting toward more complex patients, as cystic fibrosis (CF), which has long been the leading indication in children, is increasingly controlled by new modulator therapies that keep young patients off the transplant list.

The trends were outlined by Jens Gottlieb, MD, of the German Center for Lung Research and the Hannover Medical School, and Christian Benden, MD, MBA, director of the Lung and Heart/Lung Transplant Program at Boston Children's Hospital, during back-to-back presentations at the European Respiratory Society Congress 2026 in Barcelona, Spain.

How Aging Is Reshaping the Lung Transplant Candidate Pool

Patients 60 to 69 years old are now a large proportion of the population receiving lung transplants, and the proportion of patients 70 and older has grown 13-fold since 2004, according to the latest report from the International Society for Heart and Lung Transplantation (ISHLT).¹ The data are weighted toward North American registries, Gottlieb noted, since European transplant activity was missing from the report. Still, he said his own program's experience tracks the broader trend. Over the past 15 years, the median age of patients presenting for their first lung transplant evaluation rose by 12 years, driven largely by the loss of younger patients with CF and pulmonary hypertension.

In the United States, Gottlieb highlighted one center that is already reporting that patients 65 years and older make up two-thirds of transplant recipients. He further predicted the national median recipient age will reach 65 years within the next 1 to 2 years. Interstitial lung disease (ILD) has driven much of the increase in older recipients, alongside a smaller rise in chronic obstructive pulmonary disease (COPD), the 2 indications that, along with CF, have historically dominated lung transplant volume.

Age, Biological Risk, and Survival After Lung Transplant

Gottlieb described age as “a proxy for biological risk.” Older transplant candidates carry more frailty, sarcopenia, and comorbidities, and their immune systems function differently: the thymus gland shrinks with age, narrowing the T-cell repertoire, while telomere shortening and mitochondrial dysfunction reduce cellular replication capacity. A chronic low-grade inflammatory state can coexist with a blunted adaptive immune response, leaving older recipients more vulnerable to infection, even as their rates of acute rejection appear similar to or lower than those of younger patients. Gottlieb said older recipients may also be particularly sensitive to over-immunosuppression.

“Of course, everybody ages, but not within 5 or 10 years,” Gottlieb said of the accelerated physical decline his program has observed after transplant. “It's like a fast-forward button for the organism.”

Five-year survival after lung transplant is at around 60% overall, Gottlieb noted. The best outcomes at 5 years occur in recipients aged 35 to 50 years, according to data from the Scientific Registry of Transplant.² Survival among recipients 65 years and older is about 16% lower, though first-year outcomes are similar across age groups, he added.

A single-center study of patients 70 years and older found lower unadjusted long-term survival, but no significant difference after propensity score matching for diagnosis, procedure type, and bypass use.³ Causes of death also differ by age, Gottlieb said. While chronic lung allograft dysfunction is the leading cause among younger recipients, infection predominates in patients older than 60 years.

How Candidate Selection and Allocation Account for Age

Age is not listed as an outright contraindication to lung transplant under ISHLT consensus criteria, but it is treated as a risk factor starting with the 65-70 age group and as a high-risk factor after 70 years.⁴ Major organ allocation systems, including the lung allocation score used in many countries, tend to favor older candidates because their survival while waiting for a transplant is worse than that of younger patients. The US shifted its scoring model 3 years ago from predicting 1-year post-transplant survival to 5-year survival and now weighs medical urgency equally with likelihood of a successful outcome.

Public attitudes have not necessarily kept pace with those clinical and policy shifts, Gottlieb said. He pointed to a review of 15 studies and more than 5500 respondents in which younger age was cited as a preferred allocation criterion in about half.⁵ When the US developed its current allocation formula, he said, the general public favored prioritizing younger patients while transplant professionals favored medical urgency, a divide he linked to the field's continued reliance on younger recipients as public-facing success stories.

“Lung transplantation in older patients is increasingly relevant [and] is possible,” Gottlieb concluded, “but we have to consider individually these patients. We need a multidisciplinary assessment.”

Why Pediatric Candidates Look Different Today

Benden's presentation described a parallel transformation at the other end of the age spectrum. While younger age is typically associated with better outcomes, as Gottlieb showed, they have their own unique challenges.

“Children are not small adults,” he said. “They have an excellent potential of recovery compared to the elderly, but there are some outcomes, particularly in the adolescent age group, that are as poor as the very senior people undergoing lung transplantation. The reason for that is maladherence to treatment, which is a very sad story.”

CF once accounted for roughly 60% of pediatric lung transplants in Europe and about half in the United States.⁶ These patients were largely adolescents who were managed at home on overnight noninvasive ventilation while awaiting transplant. It was historically the third most common indication for lung transplant in adults and the leading indication in children, a status it still holds today.⁷

The introduction of once-daily CF transmembrane conductance regulator modulator therapy has revolutionized management of the disease,⁸ Benden said, reversing that pattern and driving a steep, sustained decline in pediatric CF transplant volume that predates and persists beyond the COVID-19 pandemic.⁹ However, that progress has not reached everyone.

“There is a small proportion of patients that are not eligible for this kind of treatment, and we are also having an access problem because these modulators are not accessible all around the world,” Benden said, adding that no patient with CF should die without transplant being considered if it fits the overall goals of care.

As CF cases recede, pulmonary arterial hypertension has become the larger cohort of pediatric transplant candidates.⁹ Benden described these patients as often sicker and more likely to need mechanical circulatory support such as extracorporeal membrane oxygenation before transplant. A separate, heterogeneous group of children with ILD, some with underlying systemic disease requiring coordination with rheumatology, rounds out the shifting pediatric population. New international pediatric listing criteria, the first of their kind, now guide timing decisions and emphasize early referral and evaluation, attention to family and caregiver capacity, and, in select cases such as infants too sick for biopsy, consideration for transplant even without a confirmed genetic diagnosis.

“This is the future in pediatric lung transplantation…,” Benden said. “These patients are more complex. They're younger, and they're more frequently in need of pre-transplant mechanical circulatory support…. And definitely in the future, children need to be included in all these multicenter clinical research studies because we need much more data in children to support what we're doing.”

References

1. International Society for Heart and Lung Transplantation. The International Thoracic Organ Transplant (TTX) Registry of the International Society for Heart and Lung Transplantation: 2026 annual report [PowerPoint slides]. ISHLT; 2026.
2. Valapour M. Lehr CJ, Schladt DP, et al. OPTN/SRTR 2023 Annual Data Report: lung. Am J Transplant. 2025;25(2S1):S422-S489. doi:10.1016/j.ajt.2025.01.025
3. Kashem MA, Calvelli H, Warnick M, et al. A single-centre analysis of lung transplantation outcomes in recipients aged 70 or older. Eur J Cardiothorac Surg. 2024;65(6):ezae150. doi:10.1093/ejcts/ezae150
4. Leard LE, Holm AM, Valapour M, et al. Consensus document for the selection of lung transplant candidates: An update from the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2021;40(11):1349-1379. doi:10.1016/j.healun.2021.07.005
5. Tong A, Howard K, Jan S, et al. Community preferences for the allocation of solid organs for transplantation: a systematic review. Transplantation. 2010;89(7):796-805. doi:10.1097/TP.0b013e3181cf1ee1
6. Hayes D Jr, Cherikh WS, Chambers DC, et al; International Society of Heart and Lung Transplantation. The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: Twenty-second pediatric lung and heart-lung transplantation report-2019; Focus theme: Donor and recipient size match. J Heart Lung Transplant. 2019 Oct;38(10):1015-1027. doi:10.1016/j.healun.2019.08.003.
7. Benden C. Lung transplantation as standard of care for advanced cystic fibrosis lung disease. J Heart Lung Transplant. 2020;39(6):561-562. doi:10.1016/j.healun.2020.03.022
8. De Boeck K. Cystic fibrosis in the year 2020: A disease with a new face. Acta Paediatr. 2020;109(5):893-899. doi:10.1111/apa.15155
9. Avdimiretz N, Benden C. The changing landscape of pediatric lung transplantation. Clin Transplant. 2022;36(4):e14634. doi:10.1111/ctr.14634