OPTN/SRTR 2020 Annual Data Report: Introduction

Introduction to the OPTN/SRTR 2020 Annual Data Report

The OPTN/SRTR 2020 Annual Data Report (ADR) presents the status of the solid organ transplant system in the United States from 2009 to 2020. Organ-specific chapters are presented for kidney, pancreas, liver, intestine, heart, and lung transplant. Each organ-specific chapter is organized to present waitlist information, donor information (both deceased and living, as appropriate), transplant information, and patient outcomes. Data pertaining to pediatric patients are generally presented separately from the adult data. In addition to the organ-specific chapters, you will find chapters dedicated to deceased organ donation and the COVID-19 pandemic. The data presented in the ADR are descriptive in nature. In other words, most tables and figures present raw data without statistical adjustment for possible confounding or changes over time. Therefore, the reader should keep in mind the observational nature of the data when attempting to draw inferences before trying to ascribe a cause to any observed patterns or trends. This introduction provides a brief overview of trends in waitlist and transplant activity. More detailed descriptions can be found in the respective organ-specific chapters.

Trends in Kidney Transplant

In 2020, 141,341 adult and pediatric candidates were on the kidney waiting list at some point (Figure INT 1), a decrease of 3.6% from 2019. Notably, however, the size of the kidney waiting list in 2020 was about the same as it was in 2013 (139,616), marking the end of a 5-year period of relatively little change, and in stark contrast to the 16.1% growth in the waiting list from the previous 5-year period (2010 to 2014). Of the 141,341 candidates on the waiting list, only 65.3% (92,420) were in active status at some point during the year, a slight decrease from 67.2% in 2019. This shows a continuing trend of about one-third of the waiting list being inactive at any given time (Figure INT 3). The number of new candidates added to the kidney waiting list in 2020 declined to 38,492. This is a 12.4% decline from 43,968, ending an upturn that began in 2018 (Figure INT 5). The number of kidney transplants also declined in 2020 to 23,642, a 2.5% decline from 2019. This marks the end of a 6-year period of rising numbers of kidney transplants, of which there were 24,273 in 2019 - 10.3% more than in 2018 and 30.5% more than in 2015 (Figure INT 7). These transplants included 5234 from living donors and 18,408 from deceased donors in 2020 (Figure KI 73). This marks a 23.7% decline in living donor transplants and a 5.7% increase in deceased donor transplants from 2019. The decline in living donor transplants is likely due to the COVID-19 pandemic; the number has not been this low in the past decade. The growth in number of deceased donor transplants represents a continued rise from 2012 and represents a 57.7% increase since 2012. Despite these advances, the proportion of kidneys from deceased donors recovered for the purpose of transplant but ultimately not transplanted remains at about 20%, similar to 2019 (Figure INT 9). Among transplant recipients from 2013 to 2015, 1-year patient survival was 97.1% and 5-year patient survival was 88.8% (Figure INT 10).

Trends in Pancreas Transplant

The demand for pancreas transplant has continued to decline, likely due to improvements in the medical treatment of diabetes. Since 2008, the number of candidates on the waiting list for pancreas-alone or pancreas-after-kidney transplant has declined every year, from 2108 in 2009 to 999 in 2020 (Figure INT 2). The number of candidates waiting for a combined kidney-pancreas transplant declined from 3858 in 2009 to 3054 in 2020, with declines in all but 2 years: 2012 and 2019. The year 2019 marked the first increase since 2012 in total number of candidates on the combined kidney-pancreas waiting list, from 3023 in 2018 to 3141 in 2019. Trends were similar in the number of new additions to the pancreas transplant waiting list, with declines to 307 and 1315 for pancreas-alone and pancreas-after-kidney in 2020, respectively (Figure INT 6). The numbers of candidates having at least 1 active day on the waiting list for pancreas-alone transplants and for kidney-pancreas transplants were 359 and 1795, respectively (Figure INT 4). The total number of pancreas transplants performed in the United States declined to 962 in 2020; this represents a 5.2% decline from 2019 (Figure INT 8). Most pancreata continue to be transplanted as part of a simultaneous pancreas-kidney transplant. The 962 pancreas transplants in 2020 included 87 pancreas-alone, 48 pancreas-after-kidney, and 827 simultaneous pancreas-kidney (Figure PA 48). Patient survival after pancreas transplant is similar to that after kidney transplant and higher than that for all other organs. In the cohort of recipients from 2013 to 2015, 1-year patient survival was 96.0% and 5-year patient survival was 89.7% (Figure INT 10).

Trends in Liver Transplant

The number of adult and pediatric candidates on the liver waiting list has remained fairly consistent since 2008, ranging from a high of 28,625 in 2011 to a low of 26,031 in 2019 (Figure INT 1). The year 2020 marked the fourth consecutive year of declines in the liver waiting list. Although the total number of candidates on the liver waiting list has been slowly declining in recent years, the number of additions to it had been slowly increasing until 2019 (Figure INT 5). In 2020, only 22.6% of these candidates had at least 1 active day on the waiting list. In 2020 (Figure INT 3), 13,026 candidates were added to the waiting list, a 3.2% decrease over the previous year (Figure INT 6.) The number of transplants increased to 8906 in 2020, which is about the same as it was in 2019 (8896) (Figure INT 7). This reflects 8415 deceased donor transplants in 2020 (a record number), which is about the same as in 2019 (8372), and a 6% decline in living donor transplants from 524 to 491 in 2020 (Figure LI 61). Liver-alone transplants made up 89.9% of the adult liver transplants performed in 2020, with 9.1% being simultaneous liver-kidney transplants and the remaining 1% consisting of other multiorgan combinations (Table LI 10). The proportion of livers recovered for transplant but not transplanted was 9.4% in 2020 (Figure INT 9). Recipient survival from 2013 to 2015 was 91.4% at 1 year and 81.2% at 5 years (Figure INT 10).

Trends in Intestine Transplant

In 2020, 371 candidates were on the waiting list for an intestine transplant for at least 1 day (Figure INT 2) and 145 new candidates were added to the intestine waiting list (Figure INT 6). Only 280 candidates had at least 1 active day on the waiting list (Figure INT 4). The number of intestine transplants remained small, with 91 performed in 2020 (Figure INT 8). This represents a 49% decline in yearly intestine transplants since 2009. Among intestine transplant recipients from 2013 to 2015, 1-year survival was 80.8% and 5-year survival was 60.0% (Figure INT 10).

Trends in Heart Transplant

The first full year of the new heart allocation system, which incorporates 6 medical urgency statuses rather than the previous 3-tier system, was 2019. In 2020, there were 8473 candidates on the heart waiting list for at least 1 day, which represents a 2% decline from 2019 (8650 candidates) (Figure INT 2). Of these patients, 4674 were newly added to the list in 2020 (Figure INT 6). In 2020, 7464 candidates had at least 1 active day on the waiting list (Figure INT 4). The number of heart transplants performed in 2020 reached a record high of 3715, a 3.2% increase over 2019 (Figure INT 8). Among the cohort of recipients from 2013 to 2015, 1-year patient survival was 90.7% and 5-year survival was 80.6% (Figure INT 10).

Trends in Lung Transplant

The year 2020 saw 2597 lung transplants performed (Figure INT 8) among 4208 patients who were on the waiting list at some point (Figure INT 2), 3866 of whom were active at least 1 day (Figure INT 4). New listings in 2020 accounted for 2755 of the 4809 candidates on the list (Figure INT 6). The 2759 lung transplants performed in 2019 represent a record high, and in 2020 that decreased by 5.8%. Among recipients from 2013 to 2015, 1-year survival was 87.5% and 5-year survival was 60.1% (Figure INT 10).

Summary

In 2020, a record number of total solid organ transplants were performed in the United States. Since 2010, we have witnessed growth in the number of kidney transplants (+33%), liver transplants (+58%), heart transplants (+65%), and lung transplants (+43%). Both pancreas and intestine transplants have seen a decline, of 21% and 49%, respectively, over the same period. Demand for transplants continues to rise. Newly listed candidates for kidney transplants in 2020 declined compared to 2019 for kidney, pancreas, liver, heart, and lung transplants, which is likely due to the COVID-19 pandemic. Despite this decline in newly listed candidates, the waitlist additions outpace the number of transplants performed for all organs. The kidney waiting list is about sixfold greater than the number of transplants performed, the liver list is threefold greater than the number of liver transplants performed, and the heart and lung lists are each about double the number of transplants performed. Each organ-specific chapter of this ADR presents a much more detailed look at the status of organ donation and transplant in the United States.

Figure List

Intro

Figure INT 1. All candidates on the kidney or liver waiting list
Figure INT 2. All candidates on the waiting list for organs other than isolated kidney or liver
Figure INT 3. Candidates active on the kidney or liver waiting list
Figure INT 4. Candidates active on the waiting list for organs other than isolated kidney or liver
Figure INT 5. New candidates added to the kidney or liver waiting list during the year
Figure INT 6. New candidates added to the waiting list during the year for organs other than isolated kidney or liver
Figure INT 7. Total counts of kidney or liver transplants
Figure INT 8. Total counts of transplants for organs other than isolated kidney or liver
Figure INT 9. Rates of organs recovered for transplant and not transplanted
Figure INT 10. Patient survival among all transplant recipients, 2013-2015, by organ