Policy valuations and underwriting decisions made in life settlement cases can vary depending on the life expectancy (LE) of the applicant. But for those who have undergone a solid organ transplant (SOT), those calculations are trickier.
While SOTs give a second chance of life for people with potentially fatal conditions such as kidney failure or heart disease, they rarely offer the same longevity they could expect had they not needed a transplant.
The extent of truncation, however, will depend on a variety of factors that actuaries must build into assessment models. That will include a recipient’s general health and lifestyle, the characteristics of the donated organ, the post-transplant rejection-prevention regimen and even the health centre where the procedure took place.
“Adding complexity to modelling, however, is the continued improvements in transplant techniques and procedures that are increasing the success of transplants. As well, their skills are being called upon more, as the number of people undergoing transplants increases, lifting the proportion of SOT recipients among LE assessment applicants,” said Rahul Nawander, Medical Director at Fasano Underwriting.
“It’s not a static risk, it’s a risk that’s scaling rapidly… I have seen it growing over time,” said Nawander, adding that in the past year, about 3%-5% of assessment requests that crossed his desk were from SOT recipients, a substantial leap.
“The reason we have seen it grow is that more transplants are happening.”
Last year, the US conducted a record 49,064 single-organ transplants, according to the United Network for Organ Sharing (UNOS), which matches donors to the 105,000 people on the US’ waiting list. That’s an increase of 25% over 2022 and the fifth consecutive year of increases.
The reasons for the surge are manyfold but two have stood out recently.
Health systems around the world have compressed the time it takes between removing an organ from the donor to transplanting it into a recipient. The length of time an organ can survive out of a body – the cold ischemia time (CIT) – differs with organ type. Kidneys can survive longest, with a CIT limit of 24-36 hours. Pancreases and livers about 12 hours, and hearts four to six hours.
Time savings have been achieved through coordinated transportation logistics and the creation of organ transport corridors, prioritised fast routes that allow blue-light vehicles and private air charters to carry organs at speed to transplant centres, sometimes accompanied by police. In the US, drones are also being utilised.
This has led to a reduction in the number of in-transit organ failures, enabling more people to receive a graft.
The use of artificial intelligence (AI) in matching available organs to people in need is also helping to increase the number of transplants. Matching takes into account the blood and tissue types of candidates, their health condition and factors such as age, weight, ethnicity, height and organ size.
UNOS and the Organ Procurement and Transplantation Network (OPTN) use AI to match organs with candidates on a national level.
“When we think of lists, we think of waiting in line or waiting on a first-come, first-served basis but the [organ] waiting list isn’t a list in that sense,” explained UNOS Business Architect Bonnie Felice in a video comment.
“It’s a pool of candidates awaiting organ transplants… we’re looking at information about the donor and the candidate, and we find those best matches.”
Such improvements have also enabled older candidates to receive organs, something that rarely happened to the over 60s until recently.
Actuaries assess the life expectancy of organ recipients based not only on their current age but also the age at which they received their organ, as this will determine how much more organ life they have left. But this is like hitting a moving target because organ survival rates have been lengthening over the past decades.
The key one-year survival rate – the time when new organs are most likely to be rejected – has increased dramatically in the past few decades. The American College of Surgeons said the likelihood of an organ lasting that long has increased to 95% for kidneys in 2025 from 82% in 1987, and to 90% from 63% for heart grafts. Lung transplant survivals have improved most, to 84%, from 38%.
Assessors are unlikely to feel comfortable forecasting life expectancy so soon after a procedure.
Mortality is very much front loaded in organ transplant recipients, so in the first five years many [recipients] will die but after that those people who survive will have a better survival,” said Nawander.
LE assessments are likely to be longest among recipients of organs that have better long-term survival rates. All other things being equal, kidneys have the longest; renal transplant procedures have been honed over six decades to the point where the organs can be expected to survive an average of 22 years in the US and closer to 30 years in the UK, according to academic research from 2022.
New hearts can survive an average of around 15 years, while transplanted lungs have the shortest expectancy, at nine years.
Recipients of organs from living donors can expect longer LEs, too. The median number of life years saved as a result of receiving a living-donor kidney, for instance, is 18.5 years – almost double that of deceased-donor organ recipients. In recognition of this, UNOS has established automated donor referral tools to link potential donors with candidates. This has helped reduce the proportion of deceased donor transplants.
Co-morbidities will also have an impact on assessments. Control of diabetes is critical among kidney recipients, for instance, and the presence of cardiovascular disease – the biggest killer in the US – will incur debits to valuations.
The post-transplant lifestyles of SOT recipients can also affect their assessments, especially if they have returned to bad habits that may have contributed to their need for a new organ. Liver recipients who lost their own organ through alcohol abuse, for instance, can expect a lower assessment if they return to drinking after their transplant.
Compliance with immunosuppressive and other medication to prevent organ rejection and control co-morbidities will also play a role in LEs.
The overall outlook for the LEs of SOT recipients is one of continued improvement. Advances in customised cell therapies are hoped to better prepare candidates’ bodies to receive new organs and reduce rejection risk, while targeted immunosuppression and even gene-editing techniques could also ensure organs – and their hosts – live longer.
There may be a limit on how any increase in transplants filters through to the life settlement market, however. Individuals need to hold a life insurance policy in order to sell it, and Nawander says that underwriters don’t always understand the SOT space, so some insurers won’t offer new policies to some transplant recipients, despite improvements in organ longevity.
“When I’ve met people like underwriters in the insurance industry who themselves understand the risk of most of the things, at least from the mortality perspective, I found that they had to catch up on how fast things have moved in the transplant space,” he said.
