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 said. "I didn’t expect to live." Lung transplants are a dicey proposition, involving a huge surgical procedure, arduous follow–up, the lifelong use of immunosuppressive drugs and high rates of serious side effects. "It’s not like removing an appendix," said Dr Marie Budev, medical director of the clinic’s lung transplant program.

Only 50 to 57 per cent 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 centres would have turned Gammalo away. 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 centre," said Dr Budev. So 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.

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 per cent of liver transplant recipients were over 65; last year, that rose to 13 per cent.

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 per cent of those on the wait list and of those transplanted were over 65; last year, older patients represented almost 18 per cent of wait–listed candidates and more than a quarter of transplant recipients.

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. Cleveland Clinic has no age limit. "We feel 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 scarce commodity. Last year, surgeons performed 16,055 kidney transplants, 5,805 liver transplants and 1,949 heart transplants. Only 1,830 patients received lung transplants.