The Survival Benefit of Accepting an Older Donor Lung Transplant Compared With Waiting for a Younger Donor Offer

BACKGROUND: Donor pool expansion is critical as lung candidates suffer high mortality, yet older donor lungs remain underutilized. We evaluated whether accepting an older donor (defined 4 ways: donor age 30-39, 40-49, 50-59, or 60-69 y) lung transplant was associated with a survival benefit over waiting for a younger donor offer. METHODS: Adult candidates who received a lung offer were identified using Scientific Registry of Transplant Recipients data, 2015-2022. Offers were categorized by donor age and candidate lung allocation score (LAS; <40, 40-55, >55). Postoffer mortality was compared between candidates for whom the offer was accepted ("acceptors") versus declined ("decliners") within each age-LAS category using weighted Cox regression. RESULTS: A total of 21 426 candidates received an offer from a donor age ≥30 y; 11 679 accepted. For LAS >55 candidates, a survival benefit was observed for acceptors of donors ages 30-39 y (weighted hazard ratio [wHR] of mortality: 0.45 0.52 0.59 ), 40-49 y (wHR: 0.61 0.70 0.79 ), and 50-59 y (wHR: 0.67 0.77 0.88 ); P < 0.001. For candidates with LAS 40-55, results suggest a survival benefit of accepting lung offers from donors age 30-39 y (wHR: 0.77 0.87 0.99 ) and 40-49 y (wHR: 0.76 0.87 0.99 ); P = 0.03. However, for candidates with LAS <40, a survival benefit was not observed for accepting any older donor transplant, with possible harm in accepting an age 50+ donor offer. CONCLUSIONS: Compared with declining and waiting for a younger donor offer, accepting an older donor lung transplant was associated with a survival advantage in candidates with high LAS in the precontinuous distribution era. Decision makers should consider these findings while recognizing potential changes in waiting time dynamics in the current era.