Long-term outcomes of lung transplantation in the elderly: an analysis using the UNOS database.

Background: Lung transplantation (LT) remains a life-saving intervention for patients with end-stage lung disease, but recipient age continues to be a key determinant of long-term outcomes. As the candidate population ages and allocation policies shift, understanding how age and donor-recipient variables impact survival is increasingly critical. This study aimed to evaluate the association between recipient age and long-term survival after LT, and to characterize age-specific differences in mortality risk factors in a national cohort. Methods: We conducted a retrospective cohort study of 30,494 adult LT recipients using data from the Scientific Registry of Transplant Recipients (SRTR) from 2006 to 2022. Recipients were stratified by age at transplant into three groups: 18-64, 65-69, and ≥70 years. Primary outcome was all-cause mortality; secondary outcomes included graft dysfunction, rejection rates, and cause of death. Kaplan-Meier and Cox proportional hazards models were used to evaluate survival risk factors. Results: Survival declined progressively with increasing age, with recipients aged ≥70 years showing significantly lower 5-year survival. Multivariable analysis identified treated rejection, low body mass index (BMI), pre-transplant intensive care unit (ICU) stay, and post-transplant dialysis as independent predictors of mortality. The impact of risk factors varied by age: rejection had less effect in older recipients, extracorporeal membrane oxygenation (ECMO) predicted mortality only in younger patients, and dialysis was significant mainly in the 65-69 years group. Importantly, donor age and sex did not significantly affect survival. Conclusions: Advanced recipient age is independently associated with reduced long-term survival after LT, and this association persists after adjustment for donor and procedural factors. The relative importance of risk predictors varies across age groups, highlighting distinct, age-dependent risk profiles that may inform candidate selection and counselling. Together, these findings underscore the need to further refine selection strategies to support the ethical and effective allocation of scarce donor lungs.