Joe Gammalo had been contending with pulmonary fibrosis, a scarring of the lungs, for more than a decade when he came to the Cleveland Clinic in 2008 seeking a lung transplant.
“It had gotten to the point where I was on oxygen all the time and in a wheelchair,” he told me in an interview. “I didn’t expect to live.”
Lung transplants are a dicey proposition, involving a huge surgical procedure, arduous follow-up, the lifelong use of potent immunosuppressive drugs and high rates of serious side effects. “It’s not like taking out an appendix,” said Dr. Marie Budev, the medical director of the clinic’s lung transplant program.
Only 50 to 57 percent of all recipients live for five years, she noted, and they will still die of their disease. But there’s no other treatment for pulmonary fibrosis.
Some medical centers would have turned Mr. Gammalo away. Because survival rates are even lower for older patients, guidelines from the International Society for Heart and Lung Transplantation caution against lung transplants for those over 65, though they set no age limit.
But “we are known as an aggressive, high-risk center,” said Dr. Budev. So Mr. Gammalo was 66 when he received a lung; his newly found buddy, Clyde Conn, who received the other lung from the same donor, was 69.
You can’t mistake the trend: A graying population and revised policies determining who gets priority for donated organs, have led to a rising proportion of older adults receiving transplants.
My colleague Judith Graham has reported on the increase in heart transplants, but the pattern extends to other organs, too.
The number of kidney transplants performed annually on adults over 65 tripled between 1998 and last year, according to data from the Scientific Registry of Transplant Recipients. In 2001, 7.4 percent of liver transplant recipients were over 65; last year, that rose to 13 percent.
The rise in elderly lung transplant candidates is particularly dramatic because, since 2005, a “lung allocation score” puts those at the highest mortality risk, rather than those who’ve waited longest, at the top of the list.
In 2001, about 3 percent of those on the wait list and of those transplanted were over 65; last year, older patients represented almost 18 percent of wait-listed candidates and more than a quarter of transplant recipients. (Medicare pays for the surgery, though patients face co-pays and considerable out-of-pocket costs, including for drugs and travel.)
The debate has grown, too: When the number of adults awaiting transplants keeps growing, but organ donations stay flat, is it desirable or even ethical that an increasing proportion of recipients are elderly?
Dr. Budev, who estimated that a third of her program’s patients are over 65, votes yes. As long as a program selects candidates carefully, “how can you deny them a therapy?” she asked. So the Cleveland Clinic has no age limit. “We feel that everyone should have a chance.”
At the University of Michigan, by contrast, the age limit remains 65, though Dr. Kevin Chan, the transplant program’s medical director, acknowledged that some fit older patients get transplanted.
“You can talk about this all day — it’s a tough one,” Dr. Chan said. Younger recipients have greater physiologic reserve to aid in the arduous recovery; older ones face higher risk of subsequent kidney failure, stroke, diabetes and other diseases, and, of course, their lifespans are shorter to begin with.
Donated lungs, fragile and prone to injury, are a particularly scarce commodity. Last year, surgeons performed 16,055 kidney transplants, 5,805 liver transplants and 1,949 heart transplants. Only1,830 patients received lung transplants.
“What if there’s a 35-year-old on a ventilator who needs the lung just as much?” Dr. Chan said. “Why should a 72-year-old possibly take away a lung from a 35-year-old?” Yet, he acknowledged, “it’s easy to look at the statistics and say, ‘Give the lungs to younger patients.’ At the bedside, when you meet this patient and family, it’s a lot different.”
These questions about who deserves scarce resources — those most likely to die without them? or those most likely to live longer with them? — will persist as the population ages. They’re also likely to arise when the International Society for Heart and Lung Transplantation begins working towards revised guidelines this spring. (I’d also like to hear your take, below.)
Lots of 65- and 75-year-olds are very healthy. Yet transplants themselves can cause harm and there’s no backup, like dialysis. Without the transplant, they die. But when the transplant goes wrong, they also die.
More than four years post-transplant, the Cleveland Clinic’s “lung brothers” are success stories. Mr. Conn, who lives near Dayton, Ohio, can’t walk very far or lift more than 10 pounds, but he works part time as a real-estate appraiser and enjoys cruises with his wife.
Mr. Gammalo, a onetime musician, has developed diabetes, like nearly half of all lung recipients. But he went onstage a few weeks back to sing “Don’t Be Cruel” with his son’s rock band, “a highlight of both our lives,” he said.
Yet when I asked Mr. Conn, now 73, how he felt about having priority over a younger but healthier person, he paused. “It’s a good question,” he said, to which he had no answer.
Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”
