Older organs and older recipients: how ageing is reshaping transplant medicine

As the world’s population ages, organ transplantation is confronting a demographic shift that touches every stage of the process, from the operating theatre of the donor hospital to the immunosuppressive regimen of an eighty-year-old recipient. A new special issue of Transplant International, introduced by an editorial from Thierry Berney, Annelies de Weerd, Katja Kotsch, Simon Moosburner and Jasper Iske, gathers original research, reviews and viewpoints on what ageing means for transplant medicine. The editorial, published on 23 October 2026, argues that the rising number of older transplant recipients and the growing demand for organs from older donors present significant challenges that require novel considerations for both donor selection and recipient eligibility.

The central tension is well known to clinicians: older organs could help relieve the chronic shortage of donor organs, yet they are discarded more frequently because of physiological and immunological concerns. Aged recipients, meanwhile, have been shown to mount less pronounced alloimmune responses, but they face increased risks of side effects from immunosuppressive therapies and of infections. The editors also highlight emerging evidence of a biological interplay between the graft and the recipient organism when their ages differ. Taken together, these observations make ageing one of the most critical risk factors for transplant outcomes and one of the fastest-growing research fields in recent years.

One recurring theme of the special issue is that chronological age is an imperfect guide to clinical reality. The editorial notes that older chronological age does not necessarily mean older biological age, and that progress in transplant medicine and surgery has allowed transplantation to be considered for older patients with end-stage organ failure who would previously have been judged too frail. The question the editors pose is blunt: how do such patients really benefit from transplantation, and how should the ethics of donor shortage be balanced against the naturally lower life expectancy of patients who are nevertheless equally entitled to the best possible healthcare?

Several studies in the issue address that question with registry and cohort data. In a registry review from Germany, Schröter and colleagues analysed outcomes of kidney transplantation in a cohort of 572 patients stratified by age, focusing on infection burden, graft function and mortality. In recipients older than 60 years, unadjusted five-year rates of graft failure, mortality and infections were significantly higher, both overall and for specific infection types including pneumonia, urinary tract infections, invasive opportunistic infections and multidrug-resistant infections. After adjustment for confounding variables, however, only the five-year mortality rate remained higher in the older group. Older patients were more likely to have Pseudomonas aeruginosa infections, more severe herpesvirus infections and higher infection-related morbidity. The authors conclude that age alone is not a predictor of adverse events, and that post-transplant care for older recipients should focus on early infection control and pathogen-targeted surveillance.

A contrasting picture emerges from a prospective single-centre cohort study by Fayos and colleagues, who followed 712 kidney transplant recipients over eight years and stratified infection outcomes by ten-year age groups, including patients older than 80. In unadjusted analyses, each ten-year increase in age was associated with a higher incidence of overall, bacterial and opportunistic infections. After multivariate adjustment, the association remained significant for overall and bacterial infections, with the highest risk observed in patients over 70. As a potential explanation, the authors reported a decrease in circulating T-cell counts, including CD3, CD4 and CD8 cells, with each ten-year age increase. The editors suggest that the divergence from the German registry findings may be explained in part by the higher age of this cohort and differences in follow-up.

Graft loss patterns also shift with age. In a retrospective single-centre study of more than 1,700 kidney transplant recipients, Winkler and colleagues analysed causes of graft loss stratified by era and recipient age. The proportion of deaths with a functioning graft increased stepwise with age, while rejection as a cause of graft failure showed the reverse pattern, with its incidence markedly decreasing as age increased. Similar observations were made across the three time periods studied between 1995 and 2022, underscoring that the competing risks facing older and younger recipients differ in kind rather than merely in degree.

On the donor side, the special issue documents how reluctance to accept older organs persists even as donor age rises. Chotkan and colleagues examined declining donor offers in the Netherlands by analysing all offers made by the national organ allocation system between 2018 and 2023. Over that five-year period, mean donor age rose from 54 to 57 years, with donors older than 65 reaching 36 percent of the pool, while the proportion of declined offers increased from 23 to 30 percent. In multivariate analysis, donor age above 65 was one of the main factors independently associated with declining an offer, alongside donation after circulatory death and comorbidities such as hypertension and diabetes. The editors observe that older donors are still treated as marginal independently of other medical considerations, without necessarily solid evidence of poorer quality.

Structured allocation programmes offer one way to convert older organs into successful transplants. The Eurotransplant Senior Program allocates kidneys from deceased donors aged 65 or over to recipients of the same age, who leave the general waiting list in exchange for significantly shorter waiting times, with the scheme largely based on minimising cold ischemia time by allocating organs locally. An opinion piece by Giorgakis and colleagues argued for applying an ESP-like age-matching scheme within United States allocation rules, suggesting such realignments could reduce organ discard rates, enhance long-term graft utility, ease the burden of decision-making on patients and reduce the need for re-transplants in younger patients. Langer and colleagues examined outcomes of patients transplanted under this scheme and found one-year and five-year graft and patient survival rates that were excellent and notably superior to survival on dialysis. Delayed graft function was high, at nearly 30 percent, but strongly related to prolonged cold ischemia time, and HLA mismatch was not related to graft outcomes. Notably, histology from biopsies taken immediately after reperfusion showed that the degree of glomerulosclerosis, interstitial fibrosis and tubular atrophy was associated with graft failure, while arteriolosclerosis correlated with a higher risk of primary nonfunction, suggesting pre-transplant biopsies could provide useful selection criteria.

The importance of cold ischemia time is reinforced by further studies. Matuschik and colleagues assessed the impact of cold ischemia time on delayed graft function and long-term outcomes in consecutively transplanted ESP recipients from the same donor. Cold ischemia time above 12 hours significantly increased the risk of delayed graft function; death-censored allograft survival was unaffected, but the longer ischemia tripled the risk of mortality, and the second recipient was not disadvantaged provided cold ischemia remained below 12 hours. Süsal and colleagues, in a tri-centre retrospective German study of all kidneys from donors aged 65 or over between 2006 and 2023, compared outcomes from donors with and without a history of cardiopulmonary resuscitation before brain death was declared, finding no differences in delayed graft function, one-year or five-year graft function, or five-year graft and patient survival, which suggests such donors may be suitable despite the unavoidable selection bias of retrospective designs. Maanaoui and colleagues, studying a French national cohort of more than 1,000 recipients of kidneys from donors over 70, identified donor hypertension, cold ischemia time and HLA mismatches as risk factors for graft loss, and donor serum creatinine and warm and cold ischemia times as deleterious for delayed graft function, with hypothermic machine perfusion showing a protective effect.

Machine perfusion and the biology of senescence point toward the future. A survey by Ibrahim and colleagues of all 39 liver and kidney transplant centres in Germany, with a 56 percent response rate, found that liver programmes use both hypothermic and normothermic perfusion, that kidney programmes remain largely limited to hypothermic techniques, and that most liver centres use machine perfusion selectively for marginal grafts, reporting an average 10 percent increase in organ utilisation. A national registry cohort study by Giorgakis and colleagues in the United States showed accelerated growth in donation after circulatory death liver transplantation after machine perfusion approval, with donors aged 60 or over increasing 7.8-fold, DCD livers accounting for 43 percent of transplants by 2025, and shorter waiting times without impacts on graft or patient survival. In a closing review, Buch and colleagues examined cellular senescence across the transplant process and argued that senescence burden could serve as an objective metric of organ quality and a therapeutic target, with senotherapeutic agents combined with ex vivo machine perfusion to recondition marginal organs before implantation, strategies that remain largely experimental. The editors conclude that outcomes are driven by modifiable factors such as infection burden, ischemia time, donor comorbidity and preservation strategy, that older recipients derive a survival benefit dialysis cannot match, and that replacing chronological age with robust measures of biological age may make ageing populations more opportunity than threat.

Subject of Research: Ageing donors and recipients in organ transplantation

Article Title: Editorial: Silver linings: navigating the challenges and opportunities of organ transplantation in an Ageing population

Article References: Berney, T., de Weerd, A., Kotsch, K., Moosburner, S., & Iske, J. (2026). Editorial: Silver linings: navigating the challenges and opportunities of organ transplantation in an Ageing population. Transplant International, 39, Article 17841. https://doi.org/10.3389/ti.2026.17841

Image Credits: AI Generated

DOI: 10.3389/ti.2026.17841

Keywords: organ transplantation, ageing, older donors, older recipients, kidney transplantation, cold ischemia time, machine perfusion, immunosenescence, Eurotransplant Senior Program, cellular senescence, donor allocation, graft survival