Intestine

OPTN/SRTR 2020 Annual Data Report: Intestine

Abstract

Despite small increases in additions to the intestine transplant waitlist, total waitlist numbers, overall intestine transplant rates, and overall transplants performed from 2019 to 2020, the trend over the last decade is still toward less intestine transplant activity. Waitlist mortality continues to fall for pediatric populations and is relatively stable for adults. While 1-year graft survival continues to improve, there has been no noticeable improvement in 3- and 5-year graft survival. Immunosuppression practices continue to favor use of an induction agent followed by tacrolimus-based regimens. Patient survival at 5 years is currently identical for isolated intestines and liver-inclusive allograft recipients.

Introduction

Clinical intestine transplant has been a reality for around 30 years and, as availability and outcomes have improved, the number of candidates and transplants steadily increased through the 1990s and early 2000s. The emergence of intestinal rehabilitation as a specific subspecialty, in large part due to the successes of intestinal transplant programs, has demonstrated that all but the most severe cases of intestinal failure can be managed with minimal mortality, short of transplant. However, intestine transplant alone or in combination with liver transplant and, potentially, other abdominal organs can be life sustaining and offers real improvements to the quality of life for many individuals.

Nonetheless, the trend for the last 12 or 13 years has been toward fewer listings and transplants, most notably, but not uniquely, among pediatric age-groups. It seems likely that these numbers will stabilize at some point, but with advances in intestinal failure care and no noticeable improvement in post-intestine transplant conditional graft survival beyond 1 year, the number of intestine transplants each year may decline further still.

The number of intestine transplants in adults now consistently exceeds that in infants, children, and adolescents, and the number of candidate listings for adults is approaching that of the pediatric candidates. Overall, there has been no change in the indications for intestine transplant, but even among those listed for transplant, medical care seems to be influential in that, despite increasing wait times, waitlist mortality continues to fall, again most notably for children.

Information on the waiting list, transplants, and outcomes is presented for both types of transplants, referred to as intestine-liver and intestine transplants, respectively. Both types include multivisceral transplants, distinguished by inclusion or exclusion of liver.

Waiting List

The number of additions to the intestine transplant waitlist in 2020 (144) increased over the previous year (103); however, the trend over the last decade has been toward fewer additions overall. The proportion of candidates listed for intestine with liver (80) or isolated intestine (64) remains relatively constant (Figure IN 1). Among the 370 prevalent patients on the waiting list at the end of 2020, 192 (51.9%) were waiting for intestine and 178 (48.1%) for intestine-liver transplant (Figure IN 2). The shift to an increasing proportion of adult candidates for intestine transplant compared with candidates younger than 18 continues; in 2020, 56.5% of candidates on the intestine waiting list were younger than 18, and adults accounted for 43.5% of the list (Figure IN 3). The racial/ethnic distribution remained relatively consistent over time; White patients represented 59% of those waiting for an intestine transplant in 2020 (Figure IN 5). The most common etiology of intestinal failure remained short-gut syndrome (SGS; >57%), which encompasses both congenital and non-congenital SGS, as well as necrotizing enterocolitis and, probably, a large proportion of the other/unknown group (Figure IN 6). Enteropathies and intestinal pseudo-obstruction syndromes are rare and account for less than 10% of all indications for listing for intestine transplant (Figure IN 6).

Characteristics of intestine and intestine-liver candidates on the waiting list at the end of 2020 were similar with respect to race and age; most were younger than 18 years and White (Table IN 1), but pediatric patients were more likely to be listed for intestine alone, whereas adults were more likely to be listed for combined intestine and liver. Intestine transplant candidates were 54.8% female, and intestine-liver candidates were 44.3% female. Considering disease etiology, congenital and non-congenital SGS were the leading causes of disease among intestine and intestine-liver transplant candidates (Table IN 2). Prevalent intestine-liver candidates had a medical urgency of Status 1 more often than intestine candidates (54.7% vs 35.7%; Table IN 2), and if listed for retransplant, most were listed for a liver-containing allograft (Table IN 3).

Although the largest proportion of candidates were on the waitlist for less than 90 days, this proportion has fallen over the decade, and 36% of listed patients remain on the waitlist for more than 2 years (Figure IN 7). The overall intestine transplant rate halved, from a peak of 80 transplants per 100 waitlist years in 2009 to 40 transplants per 100 waitlist years by 2012, and has remained around this level in recent years (Figure IN 9). Rates varied by candidate age and were lowest for those younger than 18 years (23.5 per 100 waitlist years) (Figure IN 10). Transplant rates are similar by transplant type (intestine, intestine-liver) (Figure IN 12).

Of the 88 candidates removed from the isolated intestine waiting list in 2020, 46 (52.3%) underwent deceased donor transplant, 4 (4.5%) died, 22 (25.0%) were removed from the list because their condition improved, and 2 (2.2%) were considered too sick to undergo transplant. No intestine transplants used a living donor allograft (Table IN 4, Table IN 5). Of outcomes for candidates listed for intestine transplant without liver in 2017, 69.4% underwent deceased donor transplant within three years, 3.4% died, 13.0% were removed from the list, and 14.2% were still waiting in 2020 (Figure IN 13). Likewise, 64 candidates were removed from the intestine-liver waiting list in 2020: 44 (68.8%) underwent deceased donor transplant, 9 (14.1%) died, 3 (4.7%) were removed from the list because their condition improved, and 3 (4.7%) were considered too sick to undergo transplant (Table IN 4, Table IN 5). Of intestine-liver candidates listed in 2017, 61.7% underwent deceased donor transplant within 3 years, 15.6% were removed from the list, 11.5% died, and 11.2% were still waiting in 2020 (Figure IN 14). Among candidates listed for intestine-liver transplant, median time to transplant saw a sizable increase, from 5.6 months for those listed in 2017-2018 to 13.5 for candidates listed in 2019-2020, whereas for isolated intestine candidates, the wait time for transplant was similar to that of previous eras, at 8.4 months (Figure IN 15).

The overall pretransplant mortality for intestinal transplant candidates was 6.5 deaths per 100 waitlist years in 2020 (Figure IN 16), and rates varied by age. Among candidates on the waiting list in 2020, pretransplant mortality was higher for adults (15.1 deaths per 100 waitlist-years) than for children (1.9 deaths per 100 waitlist-years) (Figure IN 17). Pretransplant mortality was higher for intestine-liver (10.6 deaths per 100 waitlist years) than for intestine transplant candidates (3.0 deaths per 100 waitlist years) (Figure IN 20).

Donation

Ninety-four intestines were recovered from deceased donors in 2020 (Figure IN 22). The highest proportion of intestine donors in 2020 were younger than 18 years (58.5%) (Figure IN 24). Most intestine donors were White (60.6%) (Figure IN 26). The overall rate of intestines recovered for transplant and not transplanted was 3.2% in 2020 (Figure IN 27). The most common cause of death among deceased intestine donors has always been head trauma, but in 2020, head trauma and anoxia each were the cause of death in 42.6% of intestine donors (Figure IN 29).

Transplant

The 91 intestine transplants performed in 2020 represented a small rise from 81 in 2019 (Figure IN 30), with 50 intestine-alone and 41 liver-inclusive transplants (Figure IN 31). The number of centers performing intestine transplants has remained relatively stable over the past decade (Figure IN 39). The median annual program volume was 3.5 intestine transplants in 2020; the 95th percentile of program volume was 18 transplants (Figure IN 40). In 2020, only slightly over half of intestine transplant programs performed 10 or more transplants per year, 40% performed three to nine transplants per year, and 9% of programs performed one or two transplant per year (Figure IN 41).

Throughout the 1990s and early 2000s, pediatric recipients of intestine transplants outnumbered adults; however, in the last decade, there were more adult recipients than children and adolescent recipients. Pediatric recipient counts declined from 94 in 2009 to 34 in 2020, while adult recipient counts only fell from 85 to 57 (Figure IN 32). In 2020, just over half of intestine-liver recipients were younger than 18 years (51.2% vs. 26.0% of intestine recipients) (Table IN 6). SGS was the main cause of disease leading to both intestine and intestine-liver transplant (Table IN 7). Most recipients of intestine-containing allografts in 2020 waited less than a year from listing to transplant (84% of intestine recipients and 78% of intestine-liver recipients) (Table IN 8).

Immunosuppression

Over the last decade, induction immunosuppression has been used in most intestine transplants (Figure IN 36). Tacrolimus remains the mainstay for maintenance immunosuppression, used in at least 73% of recipients, combined with corticosteroids (37.4%), mycophenolate mofetil (6.6%), or both (29.7%) (Figure IN 37).

Outcomes

For isolated intestine transplants, the clear trend over the last decade is toward improving 6- and 12-month graft survival. For transplants in 2019, only 3.3% of grafts had failed by 6 months and 6.7% by 1 year compared to 23.8% and 31.7% of transplants in 2009. However, such improvement has not been seen in 3- and 5-year graft failure, which remains consistently around 40% and 50%, respectively (Figure IN 42). Among intestine-liver transplant recipients, 42.1% had graft failure at 6 months and 47.4% at 1 year in 2019, 55.2% at 3 years in 2017, 69.0% at 5 years in 2015, and 75% at 10 years in 2010; there has been no consistent improvement in graft survival over the last 10 years for liver-inclusive allografts (Figure IN 43). For intestine transplants with or without a liver in 2013-2015, 1- and 5-year graft survival was 72.8% and 44.8%, respectively, for recipients 18 years or older and 76.0% and 61.3% for those younger than 18 years (Figure IN 44). One- and 5-year graft survival was 77.7% and 48.9%, respectively, for intestine recipients and 70.6% and 53.2%, respectively, for intestine-liver recipients (Figure IN 45). The number of recipients alive with a functioning intestine graft continued to increase, to 1217 on June 30, 2020, although we may be seeing a plateau, with essentially stable numbers of extant recipients in all groups but isolated intestine recipients younger than 18 years (Figure IN 47).

The incidence of first acute rejection in the first year posttransplant varied by age-group and transplant type. Among recipients in 2018-2019, incidence of acute rejection was highest in adult intestine recipients (41.2%) and lowest in adult intestine-liver recipients (35.4%) (Figure IN 48). For recipients in 2008-2018, 8.7% of intestine recipients (Figure IN 50) and 8% of intestine-liver recipients (Figure IN 51) developed posttransplant lymphoproliferative disorder within 5 years posttransplant, and rates varied by recipient and Epstein-Barr virus serostatus at transplant. Patient survival at 1 year for transplants in 2013-2015 was higher for recipients of an intestine alone (83.7% vs 75.6% for intestine-liver); however, by 5 years, the patient survival was identical, at 58.7% for both allograft types (Figure IN 52).

Figure List

Waiting list

Figure IN 1. New candidates added to the intestine transplant waiting list by liver co-listing
Figure IN 2. All candidates on the intestine transplant waiting list by liver co-listing
Figure IN 3. Distribution of candidates waiting for intestine transplant by age
Figure IN 4. Distribution of candidates waiting for intestine transplant by sex
Figure IN 5. Distribution of candidates waiting for intestine transplant by race
Figure IN 6. Distribution of candidates waiting for intestine transplant by diagnosis
Figure IN 7. Distribution of candidates waiting for intestine transplant by waiting time
Figure IN 8. Distribution of candidates waiting for intestine transplant by liver co-listing
Figure IN 9. Overall donor intestine transplant rates among waitlist candidates
Figure IN 10. Deceased donor intestine transplant rates among waitlist candidates by age
Figure IN 11. Deceased donor intestine transplant rates among waitlist candidates by race
Figure IN 12. Deceased donor intestine transplant rates among waitlisted adult candidates by liver co-listing
Figure IN 13. Three-year outcomes for candidates waiting for intestine transplant without liver, new listings in 2015-2017
Figure IN 14. Three-year outcomes for candidates waiting for intestine transplant with liver, new listings in 2015-2017
Figure IN 15. Median months to intestine transplant for waitlist candidates by liver co-listing
Figure IN 16. Overall pretransplant mortality rates among candidates waitlisted for intestine transplant
Figure IN 17. Pretransplant mortality rates among candidates waitlisted for intestine transplant by age
Figure IN 18. Pretransplant mortality rates among candidates waitlisted for intestine transplant by race
Figure IN 19. Pretransplant mortality rates among candidates waitlisted for intestine transplant by sex
Figure IN 20. Pretransplant mortality rates among candidates waitlisted for intestine transplant by liver co-listing
Figure IN 21. Overall deaths within six months after removal among intestine waitlist candidates

Deceased donation

Figure IN 22. Overall deceased intestine donor count
Figure IN 23. Deceased intestine donor count by age
Figure IN 24. Distribution of deceased intestine donors by age
Figure IN 25. Distribution of deceased intestine donors by sex
Figure IN 26. Distribution of deceased intestine donors by race
Figure IN 27. Overall percent of intestines recovered for transplant and not transplanted
Figure IN 28. Percent of intestines recovered for transplant and not transplanted by donor sex
Figure IN 29. Cause of death among deceased intestine donors

Transplant

Figure IN 30. Overall intestine transplants
Figure IN 31. Total intestine transplants by transplant type
Figure IN 32. Total intestine transplants by age
Figure IN 33. Total intestine transplants by sex
Figure IN 34. Total intestine transplants by race
Figure IN 35. Total intestine transplants by diagnosis
Figure IN 36. Induction agent use in intestine transplant recipients
Figure IN 37. Distribution of immunosuppression regimen use in intestine transplant recipients
Figure IN 38. Total HLA A, B, and DR mismatches among deceased donor intestine transplant recipients, 2016-2020
Figure IN 39. Number of centers performing adult and pediatric intestine transplants by center's age mix
Figure IN 40. Annual intestine transplant center volumes by percentile
Figure IN 41. Distribution of intestine transplants by annual center volume

Outcomes

Figure IN 42. Graft failure among transplant recipients of intestine without liver
Figure IN 43. Graft failure among transplant recipients of intestine with liver
Figure IN 44. Graft survival among deceased donor intestine transplant recipients, 2013-2015, by age
Figure IN 45. Graft survival among deceased donor intestine transplant recipients, 2013-2015, by transplant type
Figure IN 46. Graft survival among deceased donor intestine transplant recipients, 2013-2015, by metropolitan vs. non-metropolitan recipient residence
Figure IN 47. Recipients alive with a functioning intestine graft on June 30 of the year, by age at transplant and procedure
Figure IN 48. Incidence of acute rejection by 1 year posttransplant among intestine transplant recipients by age, 2017-2018
Figure IN 49. Incidence of acute rejection by 1 year posttransplant among intestine transplant recipients by induction agent 2017-2018
Figure IN 50. Incidence of PTLD among recipients of intestine transplant without liver by recipient EBV status at transplant, 2008-2018
Figure IN 51. Incidence of PTLD among recipients of intestine transplant with liver by recipient EBV status at transplant, 2008-2018
Figure IN 52. Patient survival among deceased donor intestine transplant recipients, 2013-2015, by transplant type

Table List

Waiting list

Table IN 1. Demographic characteristics of candidates on the intestine transplant waiting list on December 31, 2020
Table IN 2. Clinical characteristics of candidates on the intestine transplant waiting list on December 31, 2020
Table IN 3. Listing characteristics of candidates on the intestine transplant waiting list on December 31, 2020
Table IN 4. Intestine transplant waitlist activity, 2020
Table IN 5. Removal reason among intestine transplant candidates, 2020

Transplant

Table IN 6. Demographic characteristics of intestine transplant recipients, 2020
Table IN 7. Clinical characteristics of intestine transplant recipients, 2020
Table IN 8. Transplant characteristics of intestine transplant recipients, 2020

A new candidate is one who first joined the list during the given year, without having been listed in a previous year. Previously listed candidates who underwent transplant and subsequently relisted are considered new. Active and inactive patients are included. Candidates listed at more than one center are counted once per listing. New intestine-liver candidates are those listed for both organs on the same day.

Figure IN 1. New candidates added to the intestine transplant waiting list by liver co-listing
A new candidate is one who first joined the list during the given year, without having been listed in a previous year. Previously listed candidates who underwent transplant and subsequently relisted are considered new. Active and inactive patients are included. Candidates listed at more than one center are counted once per listing. New intestine-liver candidates are those listed for both organs on the same day.


Candidates on the list at any time during the year. Candidates listed at more than one center are counted once per listing.

Figure IN 2. All candidates on the intestine transplant waiting list by liver co-listing
Candidates on the list at any time during the year. Candidates listed at more than one center are counted once per listing.


Candidates waiting for transplant at any time in the given year. Active and inactive candidates are included. Candidates listed at more than one center are counted once per listing.

Figure IN 3. Distribution of candidates waiting for intestine transplant by age
Candidates waiting for transplant at any time in the given year. Active and inactive candidates are included. Candidates listed at more than one center are counted once per listing.


Candidates waiting for transplant at any time in the given year. Active and inactive patients are included. Candidates listed at more than one center are counted once per listing.

Figure IN 4. Distribution of candidates waiting for intestine transplant by sex
Candidates waiting for transplant at any time in the given year. Active and inactive patients are included. Candidates listed at more than one center are counted once per listing.


Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive patients are included.

Figure IN 5. Distribution of candidates waiting for intestine transplant by race
Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive patients are included.


Candidates waiting for transplant at any time in the given year. Active and inactive patients are included. Candidates listed at more than one center are counted once per listing.

Figure IN 6. Distribution of candidates waiting for intestine transplant by diagnosis
Candidates waiting for transplant at any time in the given year. Active and inactive patients are included. Candidates listed at more than one center are counted once per listing.


Candidates waiting for transplant at any time in the given year. Time on the waiting list is determined at the later of listing date or January 1 of the given year. Active and inactive candidates are included. Candidates listed at more than one center are counted once per listing.

Figure IN 7. Distribution of candidates waiting for intestine transplant by waiting time
Candidates waiting for transplant at any time in the given year. Time on the waiting list is determined at the later of listing date or January 1 of the given year. Active and inactive candidates are included. Candidates listed at more than one center are counted once per listing.


Candidates waiting for transplant at any time in the given year. Intestine-liver candidates were dually listed on at least one day during the year. Active and inactive patients are included. Candidates listed at more than one center are counted once per listing.

Figure IN 8. Distribution of candidates waiting for intestine transplant by liver co-listing
Candidates waiting for transplant at any time in the given year. Intestine-liver candidates were dually listed on at least one day during the year. Active and inactive patients are included. Candidates listed at more than one center are counted once per listing.


Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately.

Figure IN 9. Overall donor intestine transplant rates among waitlist candidates
Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately.


Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately. Age is determined at the later of listing date or January 1 of the given year.

Figure IN 10. Deceased donor intestine transplant rates among waitlist candidates by age
Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately. Age is determined at the later of listing date or January 1 of the given year.


Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately.

Figure IN 11. Deceased donor intestine transplant rates among waitlist candidates by race
Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately.


Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of waiting in a given year. Individual listings are counted separately. Intestine-liver co-listing is determined at the time of listing.

Figure IN 12. Deceased donor intestine transplant rates among waitlisted adult candidates by liver co-listing
Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of waiting in a given year. Individual listings are counted separately. Intestine-liver co-listing is determined at the time of listing.


Candidates listed at more than one center are counted once per listing. Removed from list includes all reasons except transplant and death. DD, deceased donor.

Figure IN 13. Three-year outcomes for candidates waiting for intestine transplant without liver, new listings in 2015-2017
Candidates listed at more than one center are counted once per listing. Removed from list includes all reasons except transplant and death. DD, deceased donor.


Candidates listed at more than one center are counted once per listing. Removed from list includes all reasons except transplant and death. DD, deceased donor.

Figure IN 14. Three-year outcomes for candidates waiting for intestine transplant with liver, new listings in 2015-2017
Candidates listed at more than one center are counted once per listing. Removed from list includes all reasons except transplant and death. DD, deceased donor.


Observations censored on December 31, 2020; Kaplan-Meier competing risk methods used to estimate time to transplant. Analysis performed once per listing. If an estimate is not plotted, 50% of the cohort listed in that year had not undergone transplant by the censoring date. Only the first transplant is counted.  IN, intestine without liver; IN-LI, intestine-liver.

Figure IN 15. Median months to intestine transplant for waitlist candidates by liver co-listing
Observations censored on December 31, 2020; Kaplan-Meier competing risk methods used to estimate time to transplant. Analysis performed once per listing. If an estimate is not plotted, 50% of the cohort listed in that year had not undergone transplant by the censoring date. Only the first transplant is counted. IN, intestine without liver; IN-LI, intestine-liver.


Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Candidates listed at more than one center are counted once per listing.

Figure IN 16. Overall pretransplant mortality rates among candidates waitlisted for intestine transplant
Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Candidates listed at more than one center are counted once per listing.


Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Candidates listed at more than one center are counted once per listing.

Figure IN 17. Pretransplant mortality rates among candidates waitlisted for intestine transplant by age
Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Candidates listed at more than one center are counted once per listing.


Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Candidates listed at more than one center are counted once per listing.

Figure IN 18. Pretransplant mortality rates among candidates waitlisted for intestine transplant by race
Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Candidates listed at more than one center are counted once per listing.


Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Candidates listed at more than one center are counted once per listing.

Figure IN 19. Pretransplant mortality rates among candidates waitlisted for intestine transplant by sex
Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Candidates listed at more than one center are counted once per listing.


Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Candidates listed at more than one center are counted once per listing. Intestine-liver co-listing is determined at the later of listing date and January 1 of the year.

Figure IN 20. Pretransplant mortality rates among candidates waitlisted for intestine transplant by liver co-listing
Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Candidates listed at more than one center are counted once per listing. Intestine-liver co-listing is determined at the later of listing date and January 1 of the year.


Denominator includes only candidates removed from the waiting list for reasons other than transplant or death while on the list.

Figure IN 21. Overall deaths within six months after removal among intestine waitlist candidates
Denominator includes only candidates removed from the waiting list for reasons other than transplant or death while on the list.


Count of deceased donors whose intestines were recovered for transplant.

Figure IN 22. Overall deceased intestine donor count
Count of deceased donors whose intestines were recovered for transplant.


Count of deceased donors whose intestines were recovered for transplant.

Figure IN 23. Deceased intestine donor count by age
Count of deceased donors whose intestines were recovered for transplant.


Deceased donors whose intestines were recovered for transplant.

Figure IN 24. Distribution of deceased intestine donors by age
Deceased donors whose intestines were recovered for transplant.


Deceased donors whose intestines were recovered for transplant.

Figure IN 25. Distribution of deceased intestine donors by sex
Deceased donors whose intestines were recovered for transplant.


Deceased donors whose intestines were recovered for transplant.

Figure IN 26. Distribution of deceased intestine donors by race
Deceased donors whose intestines were recovered for transplant.



Percentages of intestines not transplanted out of all intestines recovered for transplant.

Figure IN 27. Overall percent of intestines recovered for transplant and not transplanted
Percentages of intestines not transplanted out of all intestines recovered for transplant.



Percentages of intestines not transplanted out of all intestines recovered for transplant.

Figure IN 28. Percent of intestines recovered for transplant and not transplanted by donor sex
Percentages of intestines not transplanted out of all intestines recovered for transplant.


Deceased donors whose intestines were transplanted. CVA, cerebrovascular accident.

Figure IN 29. Cause of death among deceased intestine donors
Deceased donors whose intestines were transplanted. CVA, cerebrovascular accident.


All intestine transplant recipients, including adult and pediatric, retransplant, and multi-organ recipients.

Figure IN 30. Overall intestine transplants
All intestine transplant recipients, including adult and pediatric, retransplant, and multi-organ recipients.


All intestine transplant recipients, including adult and pediatric, retransplant, and multi-organ recipients.

Figure IN 31. Total intestine transplants by transplant type
All intestine transplant recipients, including adult and pediatric, retransplant, and multi-organ recipients.


All intestine transplant recipients, including adult and pediatric, retransplant, and multi-organ recipients.

Figure IN 32. Total intestine transplants by age
All intestine transplant recipients, including adult and pediatric, retransplant, and multi-organ recipients.


All intestine transplant recipients, including adult and pediatric, retransplant, and multi-organ recipients.

Figure IN 33. Total intestine transplants by sex
All intestine transplant recipients, including adult and pediatric, retransplant, and multi-organ recipients.


All intestine transplant recipients, including adult and pediatric, retransplant, and multi-organ recipients.

Figure IN 34. Total intestine transplants by race
All intestine transplant recipients, including adult and pediatric, retransplant, and multi-organ recipients.


All intestine transplant recipients, including adult and pediatric, retransplant, and multi-organ recipients. SGS, short-gut syndrome.

Figure IN 35. Total intestine transplants by diagnosis
All intestine transplant recipients, including adult and pediatric, retransplant, and multi-organ recipients. SGS, short-gut syndrome.


Immunosuppression at transplant reported to the OPTN.

Figure IN 36. Induction agent use in intestine transplant recipients
Immunosuppression at transplant reported to the OPTN.


Immunosuppression regimen at transplant reported to the OPTN. Tac, tacrolimus. MMF, all mycophenolate agents.

Figure IN 37. Distribution of immunosuppression regimen use in intestine transplant recipients
Immunosuppression regimen at transplant reported to the OPTN. Tac, tacrolimus. MMF, all mycophenolate agents.


Donor and recipient antigen matching is based on OPTN antigen values and split equivalences policy as of 2018.

Figure IN 38. Total HLA A, B, and DR mismatches among deceased donor intestine transplant recipients, 2016-2020
Donor and recipient antigen matching is based on OPTN antigen values and split equivalences policy as of 2018.


Adult centers transplanted only recipients aged 18 years or older. Functionally adult centers transplanted 80% adults or more, and the remainder were children aged 15-17 years. Mixed included adults and children of any age groups. Pediatric center transplanted recipients aged 0-17 years, and a small number of adults up to age 21 years.

Figure IN 39. Number of centers performing adult and pediatric intestine transplants by center's age mix
Adult centers transplanted only recipients aged 18 years or older. Functionally adult centers transplanted 80% adults or more, and the remainder were children aged 15-17 years. Mixed included adults and children of any age groups. Pediatric center transplanted recipients aged 0-17 years, and a small number of adults up to age 21 years.


Annual volume data include recipients of all ages.

Figure IN 40. Annual intestine transplant center volumes by percentile
Annual volume data include recipients of all ages.


Based on annual volume data among recipients of all ages.

Figure IN 41. Distribution of intestine transplants by annual center volume
Based on annual volume data among recipients of all ages.


All recipients of deceased donor intestines, including multi-organ transplants.

Figure IN 42. Graft failure among transplant recipients of intestine without liver
All recipients of deceased donor intestines, including multi-organ transplants.


All recipients of deceased donor intestines, including multi-organ transplants.

Figure IN 43. Graft failure among transplant recipients of intestine with liver
All recipients of deceased donor intestines, including multi-organ transplants.


Graft survival estimated using unadjusted Kaplan-Meier methods.

Figure IN 44. Graft survival among deceased donor intestine transplant recipients, 2013-2015, by age
Graft survival estimated using unadjusted Kaplan-Meier methods.


Intestine graft survival estimated using unadjusted Kaplan-Meier methods.

Figure IN 45. Graft survival among deceased donor intestine transplant recipients, 2013-2015, by transplant type
Intestine graft survival estimated using unadjusted Kaplan-Meier methods.


Graft survival estimated using unadjusted Kaplan-Meier methods.

Figure IN 46. Graft survival among deceased donor intestine transplant recipients, 2013-2015, by metropolitan vs. non-metropolitan recipient residence
Graft survival estimated using unadjusted Kaplan-Meier methods.


Recipients are assumed to be alive with function unless a death or graft failure is recorded. A recipient may experience a graft failure and be removed from the cohort, undergo retransplant, and re-enter the cohort. IN, intestine without liver; IN-LI, intestine-liver.

Figure IN 47. Recipients alive with a functioning intestine graft on June 30 of the year, by age at transplant and procedure
Recipients are assumed to be alive with function unless a death or graft failure is recorded. A recipient may experience a graft failure and be removed from the cohort, undergo retransplant, and re-enter the cohort. IN, intestine without liver; IN-LI, intestine-liver.


Only the first reported rejection event is counted. Cumulative incidence is estimated using the Kaplan-Meier method.

Figure IN 48. Incidence of acute rejection by 1 year posttransplant among intestine transplant recipients by age, 2017-2018
Only the first reported rejection event is counted. Cumulative incidence is estimated using the Kaplan-Meier method.


Only the first reported rejection event is counted. Cumulative incidence is estimated using the Kaplan-Meier method. IL2-RA, interleukin-2 receptor agonist; TCD, T-cell depleting.

Figure IN 49. Incidence of acute rejection by 1 year posttransplant among intestine transplant recipients by induction agent 2017-2018
Only the first reported rejection event is counted. Cumulative incidence is estimated using the Kaplan-Meier method. IL2-RA, interleukin-2 receptor agonist; TCD, T-cell depleting.


Cumulative incidence is estimated using the Kaplan-Meier method. PTLD is identified as a reported complication or cause of death on the OPTN Transplant Recipient Follow-up Form or the Posttransplant Malignancy Form as polymorphic PTLD, monomorphic PTLD, or Hodgkin

Figure IN 50. Incidence of PTLD among recipients of intestine transplant without liver by recipient EBV status at transplant, 2008-2018
Cumulative incidence is estimated using the Kaplan-Meier method. PTLD is identified as a reported complication or cause of death on the OPTN Transplant Recipient Follow-up Form or the Posttransplant Malignancy Form as polymorphic PTLD, monomorphic PTLD, or Hodgkin's disease. Only the earliest date of PTLD diagnosis is considered. EBV, Epstein-Barr virus; PTLD, posttransplant lymphoproliferative disorder.


Cumulative incidence is estimated using the Kaplan-Meier method. PTLD is identified as a reported complication or cause of death on the OPTN Transplant Recipient Follow-up Form or the Posttransplant Malignancy Form as polymorphic PTLD, monomorphic PTLD, or Hodgkin

Figure IN 51. Incidence of PTLD among recipients of intestine transplant with liver by recipient EBV status at transplant, 2008-2018
Cumulative incidence is estimated using the Kaplan-Meier method. PTLD is identified as a reported complication or cause of death on the OPTN Transplant Recipient Follow-up Form or the Posttransplant Malignancy Form as polymorphic PTLD, monomorphic PTLD, or Hodgkin's disease. Only the earliest date of PTLD diagnosis is considered. EBV, Epstein-Barr virus; PTLD, posttransplant lymphoproliferative disorder.


Patient survival estimated using unadjusted Kaplan-Meier methods.

Figure IN 52. Patient survival among deceased donor intestine transplant recipients, 2013-2015, by transplant type
Patient survival estimated using unadjusted Kaplan-Meier methods.


Table IN 1. Demographic characteristics of candidates on the intestine transplant waiting list on December 31, 2020
Candidates waiting for intestines with and without liver on December 31, 2020, regardless of first listing date. Distance is computed from candidate's home zip code to the transplant center.
Characteristic IN, N IN, Percent IN-LI, N IN-LI, Percent
Age: < 6 years 73 63.5% 49 46.2%
Age: 6-17 years 21 18.3% 20 18.9%
Age: 18-34 years 11 9.6% 26 24.5%
Age: 35-49 years 9 7.8% 11 10.4%
Age: 50-64 years 1 0.9% 0 0.0%
Sex: Female 63 54.8% 47 44.3%
Sex: Male 52 45.2% 59 55.7%
Race/ethnicity: White 65 56.5% 62 58.5%
Race/ethnicity: Black 22 19.1% 21 19.8%
Race/ethnicity: Hispanic 20 17.4% 20 18.9%
Race/ethnicity: Asian 5 4.3% 3 2.8%
Race/ethnicity: Other/unknown 3 2.6% 0 0.0%
Geography: Metropolitan 103 89.6% 80 75.5%
Geography: Non-metro 12 10.4% 26 24.5%
Distance: < 50 miles 27 23.5% 28 26.4%
Distance: 50-<100 miles 7 6.1% 12 11.3%
Distance: 100-<150 miles 7 6.1% 9 8.5%
Distance: 150-<250 miles 16 13.9% 16 15.1%
Distance: ≥ 250 miles 52 45.2% 33 31.1%
Distance: Unknown 6 5.2% 8 7.5%
All candidates 115 100.0% 106 100.0%



Table IN 2. Clinical characteristics of candidates on the intestine transplant waiting list on December 31, 2020
Candidates waiting for intestines with and without liver on December 31, 2020, regardless of first listing date. SGS, short-gut syndrome.
Characteristic IN, N IN, Percent IN-LI, N IN-LI, Percent
Diagnosis: Necrotizing enterocolitis 14 12.2% 5 4.7%
Diagnosis: Congenital SGS 23 20.0% 19 17.9%
Diagnosis: Non-congenital SGS 30 26.1% 36 34.0%
Diagnosis: Pseudo-obstruction 16 13.9% 2 1.9%
Diagnosis: Enteropathies 3 2.6% 4 3.8%
Diagnosis: Other/unknown 29 25.2% 40 37.7%
Blood type: A 40 34.8% 32 30.2%
Blood type: B 15 13.0% 10 9.4%
Blood type: AB 4 3.5% 2 1.9%
Blood type: O 56 48.7% 62 58.5%
IN medical urgency: Status 1 41 35.7% 58 54.7%
IN medical urgency: Non-urgent 31 27.0% 20 18.9%
IN medical urgency: Inactive 43 37.4% 28 26.4%
All candidates 115 100.0% 106 100.0%



Table IN 3. Listing characteristics of candidates on the intestine transplant waiting list on December 31, 2020
Candidates waiting for intestines with and without liver on December 31, 2020, regardless of first listing date.
Characteristic IN, N IN, Percent IN-LI, N IN-LI, Percent
Transplant history: First 105 91.3% 85 80.2%
Transplant history: Retransplant 10 8.7% 21 19.8%
Wait time: < 1 year 37 32.2% 41 38.7%
Wait time: 1-< 2 years 12 10.4% 15 14.2%
Wait time: 2-< 3 years 12 10.4% 11 10.4%
Wait time: 3-< 4 years 9 7.8% 11 10.4%
Wait time: 4-< 5 years 10 8.7% 5 4.7%
Wait time: ≥ 5 years 35 30.4% 23 21.7%
Tx type: Intestine only 97 84.3% 0 0.0%
Tx type: Intestine-liver 0 0.0% 1 0.9%
Tx type: Intestine-pancreas 15 13.0% 0 0.0%
Tx type: Intestine-pancreas-liver 0 0.0% 97 91.5%
Tx type: Intestine-pancreas-liver-kidney 0 0.0% 8 7.5%
Tx type: Other 3 2.6% 0 0.0%
All candidates 115 100.0% 106 100.0%



Table IN 4. Intestine transplant waitlist activity, 2020
Candidates listed at more than one center are counted once per listing. Candidates who are listed, undergo transplant, and are relisted are counted more than once. Candidates are not considered to be on the list on the day they are removed; counts on January 1 may differ from counts on December 31 of the prior year. Candidates listed for multi-organ transplants are included.
Waiting list state IN IN-LI
Patients at start of year 135 91
Patients added during year 65 82
Patients removed during year 88 64
Patients at end of year 112 109



Table IN 5. Removal reason among intestine transplant candidates, 2020
Removal reason as reported to the OPTN. Candidates with death dates that precede removal dates are assumed to have died waiting.
Removal reason IN IN-LI
Deceased donor transplant 46 44
Living donor transplant 0 0
Patient died 4 9
Patient refused transplant 1 0
Improved, transplant not needed 22 3
Too sick for transplant 2 3
Other 13 5



Table IN 6. Demographic characteristics of intestine transplant recipients, 2020
Intestine transplant recipients, including retransplants. Distance is computed from recipient's home zip code to the transplant center.
Characteristic IN, N IN, Percent IN-LI, N IN-LI, Percent
Age: < 18 years 13 26.0% 21 51.2%
Age: 18-34 years 14 28.0% 9 22.0%
Age: 35-49 years 13 26.0% 5 12.2%
Age: 50-64 years 9 18.0% 4 9.8%
Age: ≥ 65 years 1 2.0% 2 4.9%
Sex: Female 25 50.0% 14 34.1%
Sex: Male 25 50.0% 27 65.9%
Race/ethnicity: White 31 62.0% 22 53.7%
Race/ethnicity: Black 13 26.0% 12 29.3%
Race/ethnicity: Hispanic 4 8.0% 5 12.2%
Race/ethnicity: Asian 1 2.0% 2 4.9%
Race/ethnicity: Other/unknown 1 2.0% 0 0.0%
Insurance: Private 27 54.0% 16 39.0%
Insurance: Medicaid 7 14.0% 17 41.5%
Insurance: Unknown 16 32.0% 8 19.5%
Geography: Metropolitan 45 90.0% 31 75.6%
Geography: Non-metro 5 10.0% 10 24.4%
Distance: < 50 miles 22 44.0% 17 41.5%
Distance: 50-<100 miles 5 10.0% 3 7.3%
Distance: 100-<150 miles 4 8.0% 4 9.8%
Distance: 150-<250 miles 5 10.0% 4 9.8%
Distance: ≥ 250 miles 12 24.0% 12 29.3%
Distance: Unknown 2 4.0% 1 2.4%
All recipients 50 100.0% 41 100.0%



Table IN 7. Clinical characteristics of intestine transplant recipients, 2020
Intestine transplant recipients, including retransplants. SGS, short-gut syndrome. MELD scores are given for intestine-liver candidates.
Characteristic IN, N IN, Percent IN-LI, N IN-LI, Percent
Diagnosis: Necrotizing enterocolitis 1 2.0% 4 9.8%
Diagnosis: Congenital SGS 1 2.0% 7 17.1%
Diagnosis: Non-congenital SGS 31 62.0% 12 29.3%
Diagnosis: Pseudo-obstruction 5 10.0% 1 2.4%
Diagnosis: Other/unknown 12 24.0% 17 41.5%
Blood type: A 11 22.0% 16 39.0%
Blood type: B 8 16.0% 9 22.0%
Blood type: AB 1 2.0% 2 4.9%
Blood type: O 30 60.0% 14 34.1%
Medical condition: Hospitalized in ICU 0 0.0% 5 12.2%
Medical condition: Hospitalized, not ICU 5 10.0% 10 24.4%
Medical condition: Not hospitalized 43 86.0% 26 63.4%
Medical condition: Hospitalization unknown 2 4.0% 0 0.0%
IN medical urgency: Status 1 45 90.0% 32 78.0%
IN medical urgency: Non-urgent 5 10.0% 9 22.0%
LI medical urgency: Status 1A 7 17.1%
LI medical urgency: MELD/PELD ≥ 35 11 26.8%
LI medical urgency: MELD/PELD 30-34 7 17.1%
LI medical urgency: MELD/PELD 15-29 13 31.7%
LI medical urgency: MELD/PELD < 15 3 7.3%
All recipients 50 100.0% 41 100.0%



Table IN 8. Transplant characteristics of intestine transplant recipients, 2020
Intestine transplant recipients, including retransplants.
Characteristic IN, N IN, Percent IN-LI, N IN-LI, Percent
Wait time: < 31 days 10 20.0% 11 26.8%
Wait time: 31-60 days 3 6.0% 5 12.2%
Wait time: 61-90 days 7 14.0% 6 14.6%
Wait time: 3-< 6 months 10 20.0% 4 9.8%
Wait time: 6-< 12 months 12 24.0% 6 14.6%
Wait time: 1-< 2 years 5 10.0% 4 9.8%
Wait time: ≥ 2 years 3 6.0% 5 12.2%
Donor type: Deceased 50 100.0% 41 100.0%
Transplant history: First 46 92.0% 31 75.6%
Transplant history: Retransplant 4 8.0% 10 24.4%
Tx type: Intestine only 41 82.0% 0 0.0%
Tx type: Intestine-liver-pancreas 0 0.0% 35 85.4%
Tx type: Other 9 18.0% 6 14.6%
All recipients 50 100.0% 41 100.0%