Impact of age difference between donor and recipient on intermediate- and long-term survival in lung transplant recipients: A cohort study based on recipient age stratification

Abstract Objectives The impact of donor-recipient age difference on survival after lung transplantation (LTx) remains unclear. This study investigates effects in different recipient age groups to optimize donor-recipient matching. Methods Analyzing UNOS data (2005–2015), we stratified adult first-time LTx recipients into three age strata (18–40, 40–60, 60–80 years). Donor-recipient age difference (Δ = donor age—recipient age) was classified into Δ < 0 and Δ ≥ 0 groups; the 60–80 stratum was further divided into Δ < –10 and Δ < 0 to ≤ -10 groups. Outcomes included 5-year (primary) and 10-year patient and graft survival, with subgroup analyses by underlying pulmonary disease. Results Δ < 0 was associated with significantly better 5-year graft survival in the 18–40 and 40–60 strata (adjusted HR: 1.21 [1.02–1.44], P = 0.031 in 18–40; 1.19 [1.05–1.35], P = 0.006 in 40–60). Among recipients aged 60–80 (Δ < 0 only), Δ < −10 showed suprior 5-year patient survival compared to Δ < 0 to ≤ -10 (adjusted HR 1.23 [1.10–1.37], P < 0.001). Secondary analyses showed in 40–60, Δ < 0 had better 10-year patient survival (adjusted HR: 1.14 [1.02–1.27], P = 0.017); and in 60–80, Δ < −10 remained favorable (adjusted HR: 1.12 [1.02–1.23], P = 0.015). Subgroup analyses confirmed greater benefit younger donors in cystic fibrosis recipients aged 18–40 and 40–60, and idiopathic pulmonary fibrosis recipients aged 60–80. Conclusions Younger donors correlate with better intermediate- and long-term post-transplant survival, particularly for graft survival, supporting individualized preferential matching when clinically feasible.