Kidney

OPTN/SRTR 2020 Annual Data Report: Kidney

Abstract

The year 2020 presented significant challenges to the field of kidney transplantation. After increasing each year since 2015 and reaching the highest annual count to date in 2019, the total number of kidney transplants decreased slightly, to 23642, in 2020. The decrease in total kidney transplants was due to a decrease in living donor transplants; the number of deceased donor transplants rose in 2020. The number of patients waiting for a kidney transplant in the United States declined slightly in 2020, driven by a slight drop in the number of new candidates added in 2020 and an increase in patients removed from the waiting list owing to death-important patterns that correlated with the COVID-19 pandemic. The complexities of the pandemic were accompanied by other ongoing challenges. Nationwide, only about a quarter of waitlisted patients receive a deceased donor kidney transplant within 5 years, a proportion that varies dramatically by donation service area, from 14.8% to 73.0%. The nonutilization (discard) rate of recovered organs rose to its highest value, at 21.3%, despite a dramatic decline in the discard of organs from hepatitis C-positive donors. Nonutilization rates remain particularly high for Kidney Donor Profile Index ≥85% kidneys and kidneys from which a biopsy specimen was obtained. Due to pandemic-related disruption of living donation in spring 2020, the number of living donor transplants in 2020 declined below annual counts over the last decade. In this context, only a small proportion of the waiting list receives living donor transplants each year, and racial disparities in living donor transplant access persist. As both graft and patient survival continue to improve incrementally, the total number of living kidney transplant recipients with a functioning graft exceeded 250,000 in 2020.

Pediatric transplant numbers seem to have been impacted by the COVID-19 pandemic. The total number of pediatric kidney transplants performed decreased to 715 in 2020, from a peak of 872 in 2009. Despite numerous efforts, living donor kidney transplant remains low among pediatric recipients, with continued racial disparities among recipients. Of concern, the rate of deceased donor transplant among pediatric waitlisted candidates continued to decrease, reaching its lowest point in 2020. While this may be partly explained by the COVID-19 pandemic, close attention to this trend is critically important. Congenital anomalies of the kidney and urinary tract remain the leading cause of kidney disease in the pediatric population. While most pediatric deceased donor recipients receive a kidney from a donor with KDPI less than 35%, most pediatric deceased donor recipients had four or more HLA mismatches. Graft survival continues to improve, with superior survival for living donor recipients versus deceased donor recipients.

Introduction

Kidney transplant provides significantly more quality-of-life and survival benefits than dialysis for the treatment of end-stage kidney disease, but maximizing access to transplant, reducing access disparities, and sustaining long-term allograft survival are ongoing challenges. A national urgency to increase access to kidney transplant received unprecedented support from the federal government in the July 2019 Advancing American Kidney Health Executive Order and ensuing national policy initiatives. The COVID-19 pandemic had profound implications across kidney transplant practice in 2020, especially living donor transplant. The Annual Data Report is an opportunity to assess the state of kidney transplant and examine both positive patterns and unfavorable trends that warrant further monitoring and evaluation. Data are provided on adult and pediatric kidney transplant waiting lists, deceased and living donation, transplants, and outcomes.

Adult Kidney Transplant

Waiting List

In 2020, the number of candidates added to the waiting list declined to 37408, compared with 42935 in 2019 (Figure KI 1, Table KI 5). Listings by centers may have slowed in part due to OPTN Executive Committee COVID amnesty policies that included waiting time modifications for kidney patients not on dialysis at listing. In concert, the total number of patients on the list at any time during the year declined, following several years of stability, to 138,844, compared with 144,119 in 2019 (Figure KI 2). Amid the COVID-19 pandemic, waiting list removals due to death increased in 2020, although removals due to deteriorating medical condition declined (Table KI 6). The trend of a gradual increase in the age of candidates on the waiting list over the last 10 years persisted (Figure KI 3). Candidates 50-64 years old remained the largest age-group on the waiting list, and the proportion of candidates ≥65 years continued to rise (Figure KI 3, Table KI 1). Men composed 62% of the waiting list (Figure KI 4). Over the past 10 years, the proportion of Asian and Hispanic candidates gradually increased, accompanied by a decline in the proportion of White candidates (Figure KI 5). The proportion of candidates with a primary diagnosis of diabetes continued to rise, reaching 38.3% in 2020 (Figure KI 6).

Reflecting the decline in waiting list additions, the proportion of candidates prevalent on the waiting list and waiting less than 1 year declined slightly in 2020, but still comprises greater than half of waitlisted candidates, while 10.0% on the waitlist on January 1, 2020, have been waiting ≥5 years (Figure KI 7). The proportion of candidates with high body mass index (BMI) also continued to increase, with 27.8% of waitlisted candidates in 2020 having a BMI of 30 to <35 kg/m² and 18.0% with a BMI of ≥ 35 kg/m² (Figure KI 8). The proportion of candidates waitlisted before starting dialysis continued to increase, reaching 20.9% in 2020, although 16.7% of those waitlisted had been on dialysis for 6 or more years (Figure KI 9). More than half of waitlisted candidates had blood type O, which remains the most common type (Figure KI 10). A total of 11.4% of candidates in 2020 had a previous transplant (Figure KI 11).

The proportion of candidates willing to accept a high-Kidney Donor Profile Index (KDPI) kidney was relatively stable in 2020 compared with 2019, following a decline after implementation of the revised Kidney Allocation System (KAS) in December 2014 (Figure KI 12). Still, less than half of candidates aged 50-64 and less than two-thirds of candidates ≥65 years were willing to accept these kidneys (Figure KI 12), even though older patients are less likely than younger patients to undergo kidney transplant under the current KAS. Conversely, the proportion of candidates willing to accept a kidney from a hepatitis C virus (HCV)-positive donor continued to increase sharply, to 43.8%, correlating with availability of highly effective direct-acting antiviral agents (DAAs) and experience using DAAs to manage anticipated donor-derived infections (Figure KI 13). To date, the information on willingness to accept HCV-positive kidneys does not differentiate between donor HCV antibody (exposed) and nucleic acid (viremic) status.

Despite the COVID-19 pandemic, deceased donor kidney transplant (DDKT) rates among adult waitlisted candidates rose again in 2020, after reaching a nadir in 2014 (Figure KI 14). This increase was noted across all age (Figure KI 15), racial and ethnic (Figure KI 16), and primary kidney disease diagnosis (Figure KI 17) groups. DDKT rates were similar for white, Black, and other race patients in 2020 (18-20 per 100 waitlist years), but remained slightly lower for Asian and Hispanic candidates (14 and 16 per 100 waitlist year, respectively) (Figure KI 16). After a sharp increase in DDKT rates among patients with panel reactive antibody levels (cPRAs) of 98%-100% immediately after implementation of the revised KAS, the rate subsequently plateaued in this group and was slightly lower than the rates among patients in other cPRA groups in 2020 but still substantially higher than before the 2014 KAS revision (Figure KI 18). The DDKT rate remained slightly higher in patients with cPRAs of 80%-98%, at 19.8 transplants per 100 waitlist-years, compared with 14.8-18.6 transplants per 100 waitlist-years in the other cPRA groups (Figure KI 18). DDKT rates have increased more in blood type AB patients over the past 5 years than in those with blood types A, B, and O (Figure KI 19); rates have not increased in blood type B candidates relative to other blood types, despite the revised KAS allowing allocation of A2 and A2B kidneys to B candidates. In 2020, DDKT rates increased across the range of waiting times up to 5 years but declined among patients on the waitlist for more than 5 years (Figure KI 20). DDKT rates were similar between men and women in 2020 (Figure KI 21) and remained slightly higher among residents of nonmetropolitan than metropolitan areas (Figure KI 22).

For patients waitlisted from 2015 to 2017, 34.6% were still waiting 3 years after listing; 25.0% had undergone DDKT,14.0% had undergone living donor kidney transplant (LDKT), 6.4% died, and 20.0% were removed from the waiting list (Figure KI 23). The median time to transplant for candidates has not been calculable for more than a decade, as less than 50% of candidates on the waiting list have not undergone transplant for each year cohort since 2009. The proportion of patients listed in 2015 who underwent DDKT within 5 years continued to vary greatly by donation service area (DSA), from 14.8% in locations with long waiting times to 73.0% in regions with shorter waiting times (Figure KI 25). Considered at the state level, proportions of candidates receiving transplants within 5 years ranged from 17.8% to 53.8% (Figure KI 26).

Following a decade of decline, pretransplant mortality rose in 2020, to 5.7 deaths per 100 waitlist years, the highest value since 2012 (Figure KI 27). This increase occurred across levels of race and ethnicity, sex, reasons for kidney failure, blood type, and metropolitan/non-metropolitan residence (Figure KI 29, Figure KI 30, Figure KI 31, Figure KI 32, Figure KI 33). Waiting list mortality increased across most age-groups but remained stable among adults 18-34 years (Figure KI 28). However, waiting list mortality also varied greatly by DSA, from 0.99 to 7.76 deaths per 100 waitlist-years (Figure KI 34). Deaths within 6 months of removal from the waiting list increased dramatically in 2020, to exceed mortality in all years since 2008 (Figure KI 35), likely reflecting impacts of the pandemic. The rise in mortality within 6 months of waitlist removal occurred across groups defined by reasons for kidney failure and age, although the rise was smallest among adults 18-34 years (Figure KI 36 and Figure KI 37).

Deceased Donation

The counts of deceased donors from whom at least one kidney was recovered continued to increase in 2020, despite the disruption to transplant practice from the pandemic (Figure KI 38), particularly among donors 30 years and older (Figure KI 39). The counts of HCV-positive deceased donors from whom kidneys were recovered also rose in 2020 (Figure KI 40), continuing a trend of increase since the availability of DAAs for HCV in 2014, although the proportion was stable compared with 2019, at 10.7% (Figure KI 44). The sex, race, and ethnicity distributions of deceased kidney donors remained largely unchanged over the past decade (Figure KI 42, Figure KI 43). The proportion of pediatric kidney donors in 2020 declined to 7.0%, a nadir over observation since 2008, while the largest proportions of kidney donors were 40-54 (29.3%) and ≥55 years (24.4%) (Figure KI 41). In 2016-2020, the percentage of pediatric donor kidneys allocated to adult recipients ranged by DSA, from 73.8% to 100% (Figure KI 46). The proportion of kidneys recovered from patients who died of anoxia continued its linear increase in 2019, amid the ongoing opioid epidemic (Figure KI 45).

The proportion of deceased donor kidneys recovered but not transplanted (nonutilization) rose to 21.3% in 2020 in the context of the pandemic (Figure KI 47). The nonutilization proportion was highest for kidneys recovered from donors ≥55 years, reaching 46.7% in 2020 (Figure KI 48). Nonutilization was also higher in kidneys recovered from donors with diabetes, hypertension, or high BMI (Figure KI 49, Figure KI 52, Figure KI 53). Recovered kidneys from which biopsies were obtained continued to have stable but high proportions of discard, at 31.9% in 2020 (Figure KI 55), despite a lack of evidence that biopsy findings correlate well with posttransplant outcomes. The proportion of recovered but discarded HCV-positive kidneys declined sharply starting in 2015, and by 2020, HCV antibody-positive kidneys were discarded at nearly the same rates as HCV antibody-negative kidneys (Figure KI 57). A lower proportion of kidneys with increased infection risk were discarded than those with standard infection risk (17.0% vs 22.9%), perhaps because kidneys with high infection risk are often otherwise of high quality and low KDPI (Figure KI 58). KDPI ≥85% kidneys continued to represent most discarded kidneys, at 62.0% in 2020 (Figure KI 60). However, the average KDRI of discarded kidneys was stable in 2020, compared with the prior two years (Figure KI 62).

Living Donation

Following a recent rise in the number of LDKTs from 5538 in 2014 up to 6867 in 2019, the COVID-19 pandemic slowed the growth trajectory by prompting a nearly complete pause in living kidney donation in spring 2020. With increased availability of COVID-19 testing and adopted practices, monthly rates began to recover to prepandemic rates by summer 2020, but the disruption yielded a net decline in LDKT in 2020 to 5234 (Figure KI 73). The decline in living donor counts occurred across all donor-recipient relationship categories (Figure KI 64). Notably, both pre- and post-pandemic, only a small proportion of the waiting list receives LDKT each year, despite Health Resources and Services Administration (HRSA) initiatives to reduce financial barriers to living donors and Centers for Medicare & Medicaid Services (CMS) incentives for nephrology providers to encourage early LDKT.

The proportion of living kidney donors ≥55 years continued to rise in 2020 (Figure KI 65), correlating with better understanding of the long-term risks of kidney donation across the spectrum of donor ages and appreciation that carefully selected older donor may have low lifetime risk of complications like end-stage renal disease (ESRD). In 2020, the proportion of female living kidney donors remained stably high, at 65.1% (Figure KI 66). The racial and ethnic composition of living donors in 2020 was relatively stable compared with 2019, with 71.4% White, 14.8% Hispanic, and 7.3% Black donors (Figure KI 67). Notably, this reflects an ongoing decline in the proportion of Black living donors, from 8.7% in 2019 and from 12.0% in 2010 (Figure KI 67). The proportion of living donors who were obese, based on BMI >30 kg/m², increased slightly, to 23.5% (Figure KI 69). Most donation surgeries began as laparoscopic hand-assisted (61.9%) or pure laparoscopic (37.2%) procedures (Figure KI 68). Reported complications and hospitalizations after living-donor nephrectomy were uncommon (Figure KI 70, Figure KI 71).

Transplants

The upward trajectory in total kidney transplants was modestly slowed by the COVID-19 pandemic, with 23642 transplants in 2020, compared with 24273 in 2019 (Figure KI 72). The decline was driven by the pandemic-related impact on LDKT, as growth in DDKT continued despite the pandemic, to reach a peak of 18408 (Figure KI 73). Distributions of total kidney transplant counts in 2020 were similar to 2019 distributions across recipient age, sex, race, and cause of kidney disease (Figure KI 74, Figure KI 75, Figure KI 76, Figure KI 77). Of note, these transplant counts represent an unadjusted analysis and are not adjusted for factors such as time on dialysis and regional variation. Demographic differences in transplant recipients by organ donor type are notable, including persistent disparities in access to LDKT. While 32.2% of waitlisted candidates in 2020 were Black (Table KI 1), Black patients composed only 11.7% of LDKT recipients, versus 32.3% of DDKT recipients, in 2020 (Table KI 8). White patients composed 35.3% of the waiting list in 2020 (Table KI 1) but made up 64.3% of LDKT recipients and 39.5% of DDKT recipients (Table KI 8). Most LDKT recipients (56.0%) had private insurance at the time of transplant, while 64.8% of DDKT recipients were Medicare beneficiaries (Table KI 8). LDKT recipients tended to have less dialysis time and lower cPRAs than DDKT recipients (Table KI 9). Proportions of DDKTs versus LDKTs were similar by metropolitan and nonmetropolitan place of residence and distance from transplant centers (Table KI 8), similar to the proportions of these characteristics among waiting list patients on Dec 31, 2020 (Table KI 1). A total of 90.2% of DDKTs and 90.8% of LDKTs were performed in first-time recipients (Table KI 10). In 2020, 9.3% of deceased donors with at least one kidney transplanted were HCV antibody-positive, and 5.8% were HCV nucleic acid-positive (Table KI 11). Among living donors, 0.7% were positive for HCV antibodies, and 0.1% were HCV nucleic acid-positive (Table KI 12).

The proportions of DDKTs classified by KDPI level remained stable compared with 2019, with 23.3% in the low-KDPI group (0%-<20%), 52.9% with KDPI 35%-85%, and 7.3% with KDPI ≥85% (Figure KI 78).

Induction immunosuppression was used in 91.0% of kidney transplants, a slight decline from 92.1% in 2019 (Figure KI 79). Notably, recent reports identified a decline in use of T-cell-depleting agents early in the COVID-19 pandemic. The choice of maintenance immunosuppression at hospital discharge remained stable, with most patients receiving tacrolimus and mycophenolate mofetil-based regimens (Figure KI 80). Nearly 30% received steroid-free regimens, a relatively stable proportion, over the past decade. As noted previously, the proportion of DDKTs in recipients with peak cPRAs of 98%-100% increased sharply after the KAS revision and then gradually declined, from 12.5% in 2015 to 6.3% in 2020 (Figure KI 81). In comparison, only 1.1% of LDKT recipients in 2020 had peak cPRA of 98%-100% (Figure KI 82). As practice volume expanded, the proportion of transplants performed at centers with volumes of at least 250 transplants per year grew sharply over the past 5 years, from 13.8% in 2014 to 34.0% in 2020 (Figure KI 85).

Outcomes

Estimated glomerular filtration rate (eGFR) at 12 months, an early surrogate allograft outcome, was 45 mL/min/1.73m² or higher for 63.8% of DDKT recipients in 2019, slightly lower than the 65.6% in 2018 (Figure KI 103). Among LDKT recipients, 76.9% had 12-month eGFR of 45 mL/min/1.73m² or higher in 2019, slightly lower than the 77.7% in 2018 (Figure KI 104). Overall, 6.8% of adult kidney transplant recipients in 2018-2019 experienced acute rejection by 1 year, including 9.1% of recipients aged 18-34 and 5.9% of recipients ≥65 years (Figure KI 106). Acute rejection at 1 year occurred in 8.4% of those who received interleukin-2 (IL-2)-receptor antibody induction, compared with 6.6% who received T-cell-depleting induction and 6.4% of the small subgroup whose transplants were managed without induction (Figure KI 107).

One-year death-censored graft failure after DDKT remained relatively stable for transplants in 2019, compared with 2018 (Figure KI 87). By comparison, 1-year death with function showed a slight increase compared with transplants in the prior year (3.5% vs 2.9%), a level not seen since 2010 (Figure KI 88), which may reflect an impact of the pandemic on overall patient mortality. In the most recent reporting year, 6-month, 1-year, 3-year, and 5-year LDKT death-censored graft failure were stable, while 10-year graft survival showed a small improvement (Figure KI 90). Among LKDT recipients, 6-month and 1-year death with function also showed a slight increase for transplants in 2019 over 2018 (Figure KI 91).

Among DDKTs from 2013 to 2015, 5-year graft survival was lowest among older patients and those with diabetes as the cause of kidney disease (Figure KI 92, Figure KI 93). Five-year graft survival after DDKT was 64.9% with KDPI >85%, compared with 82.5% with KDPI 21%-35%, and 83.6% with KDPI ≤20% (Figure KI 94). Five-year graft survival did not differ by donor type after circulatory death (Figure KI 95). Graft survival was lower for kidneys from which biopsy specimens were obtained at transplant (Figure KI 96); while selection likely contributes to this difference, as noted previously, the utility of procurement biopsy in informing appropriate organ use warrants further study. Among LDKT recipients, 5-year graft survival was 81.6% in those ≥65 years, compared with 90.9% in recipients 35-49 years (Figure KI 99). Five-year living donor graft survival was highest among Asian recipients and lowest among Black recipients (Figure KI 100). For both donor types, graft survival was similar in recipients who resided in metropolitan versus nonmetropolitan ZIP codes (Figure KI 98, Figure KI 102).

The total number of kidney transplant recipients alive with a functioning graft, including pediatric recipients, exceeded 250,000, reaching 255,738 in 2020 (Figure KI 105). Trends in adult patient survival generally paralleled those of graft survival (Figure KI 111 to Figure KI 119). In total, 74.3% of DDKT recipients and 83.9% of LDKT recipients aged ≥65 were alive after 5 years, compared with 95.8% and 97.8% of those aged 18-34, respectively (Figure KI 111 and Figure KI 116). Five-year patient survival was lowest among recipients with diabetes as the cause of kidney disease, at 81.1% for DDKT recipients and 88.3% of LDKT recipients (Figure KI 112 and Figure KI 117) and with KDPI ≥85 among DDKT recipients, at 75.9% (Figure KI 114).

Pediatric Kidney Transplant

Waiting List

In 2020, 1083 pediatric candidates were added to the kidney transplant waiting list (Figure KI 120). The number of prevalent pediatric candidates (listed before age 18 years) has been steadily increasing and reached 2637 in 2020 (Figure KI 121). By age, candidates 12-17 years accounted for the largest proportion of those waiting (59.5%) in 2020, compared with those 6-11 years (19.4%), and younger than 6 years (21.1%) (Figure KI 122). White candidates accounted for the largest group (42.9%) on the kidney transplant waitlist in 2020, followed by Hispanic (27.8%), Black (19.6%), and Asian candidates (6.0%) (Figure KI 123). Over the past decade, the proportion of white and Asian transplant candidates has increased, while the proportion of Black and Hispanic candidates has decreased (Table KI 14). Proportions of candidates with congenital anomalies of the kidney and urinary tract (CAKUT) as the primary cause of disease increased from 29.0% in 2010 to 38.3% in 2020, and proportions with glomerulonephritis and focal segmental glomerulosclerosis (FSGS) decreased (Table KI 15). Most pediatric candidates (71.1%) waiting as of December 31, 2020, had a cPRA less than 1% (Table KI 15). The proportion of pediatric candidates waiting for retransplant decreased over the decade, from 26.7% in 2010 to 12.7% in 2020 (Table KI 16). Multi-organ listing remained uncommon; only 1.6% of pediatric candidates were awaiting multi-organ transplant at the end of 2020 (Table KI 16).

Sixty-five percent of pediatric candidates on the waiting list had been waiting for less than 1 year (Figure KI 126). Of the 941 candidates removed from the waiting list in 2020 (Table KI 17), 563 (59.8%) received a deceased donor kidney, 248 (26.4%) received a living donor kidney, 21 (2.2%) died, 5 (0.5%) were removed from the list because their condition improved, and 8 (0.9%) were considered too sick to undergo transplant (Table KI 18). Among patients newly listed from 2015 to 2017, 51.5% underwent deceased donor transplant within 3 years, 26.0% underwent living donor transplant, 14.1% were still waiting, 7.3% were removed from the list for other reasons, and 1.2% died (Figure KI 128). Of concern, the rate of deceased donor transplant among pediatric waitlisted candidates continued to decrease to its lowest point in 2020, at 34.1 transplants per 100 waitlist-years, compared with a peak of 51.8 transplants per 100 waitlist-years in 2009 (Figure KI 129). While this may be partly explained by the COVID-19 pandemic, continued attention to this topic is critically important. Post-KAS, transplant rates changed based on recipient age (Figure KI 130). In 2020, transplant rates were highest for candidates 1-5 years (43.9 per 100 waitlist-years), followed by candidates younger than 1 year (39.0), 6-11 years (33.9), and 12-17 years (31.1), though the rate among candidates younger than 1 was variable due to small numbers of transplants performed in this age-group (Figure KI 130). The KAS priority for highly sensitized candidates continued to result in higher transplant rates than pre-KAS for highly sensitized pediatric candidates in 2020 (Figure KI 132). In contrast to mortality among candidates waiting for other organs, pretransplant mortality among pediatric kidney transplant candidates remained low, at 1.4 deaths per 100 waitlist-years in 2020, with very little variation by age and race (Figure KI 134, Figure KI 135, Figure KI 136). This compares to a pretransplant mortality rate of 5.7 deaths per 100 waitlist years among adult kidney transplant candidates in 2020 (Figure KI 27).

Transplant

Transplant numbers were impacted by the COVID-19 pandemic. The total number of pediatric kidney transplants performed decreased to 715 in 2020, from a peak of 872 in 2009 (Figure KI 138). Living donor kidney transplants continued to decline to the lowest point in the past decade, to 222 in 2020, accounting for 31.0% of all transplants (Figure KI 139). Children younger than 6 years made up the largest group of living donor kidney recipients (40.2%) (Figure KI 142).

In 2020, 32 programs performed only pediatric kidney transplants, compared with 134 performing only adult transplants and 61 performing transplants in both adults and children (Figure KI 143). Looking at transplant center volume, 22.0% of transplants in candidates younger than 18 years were performed at programs with a volume of five or fewer pediatric transplants that year (Figure KI 144). Most pediatric recipients who underwent transplant between 2018 and 2020 were 11-17 years, 60.1% among deceased donor recipients and 50.1% among living donor recipients (Table KI 19). The racial distribution was notably different for deceased and living donor transplant recipients; 67.8% of living donor recipients were White, 7.5% were Black, 18.7% were Hispanic, and 4.3% were Asian. In contrast, 35.8% of deceased donor recipients were White, 22.7% were Black, 32.9% were Hispanic, and 5.2% were Asian (Table KI 19). Private insurance was more common among living donor recipients (54.4%), while Medicare/Medicaid was more common among deceased donor recipients (66.4%) (Table KI 19). Most deceased donor recipients (95.2%) underwent transplant with a kidney from a donor with KDPI less than 35% (Table KI 21). Most pediatric recipients of a deceased donor kidney (83.4%) had four or more HLA mismatches, versus only 27.5% of living donor recipients (Figure KI 147).

The combination of a donor who was positive for cytomegalovirus and a pediatric recipient who was negative occurred in 36.7% of deceased donor transplants (Table KI 22) and 29.2% of living donor transplants (Table KI 23). The combination of a donor who was positive for Epstein-Barr virus (EBV) and a pediatric recipient who was negative occurred in 38.1% Table KI 22) of deceased donor transplants and in 51.8% of living donor transplants (Table KI 23).

Immunosuppressive Medication Use

Almost all (94.3%) pediatric kidney transplant recipients reported some induction use in 2020 (Figure KI 145). The most common maintenance immunosuppression regimens at hospital discharge were tacrolimus, mycophenolate mofetil (MMF), and steroids (54.1%), followed by tacrolimus and MMF in 36.8% (Figure KI 146).

Outcomes

Graft failure after kidney-alone deceased donor transplant in pediatric recipients was 1.9% at 6 months and 2.8% at 1 year for transplants in 2018-2019, 6.4% at 3 years for transplants in 2016-2017, 15.2% at 5 years for transplants in 2014-2015, and 32.1% at 10 years for transplants in 2010-2011 (Figure KI 150). Corresponding graft failure after living donor transplant was 0.8% at 6 months and 1.6% at 1 year for transplants in 2018-2019, 2.7% at 3 years for transplants in 2016-2017, 8.2% at 5 years for transplants in 2014-2015, and 21.7% at 10 years for transplants in 2010-2011 (Figure KI 153). For the cohort of recipients who underwent transplant in 2013-2015, 1- and 5-year graft survival was 96.2% and 83.1%, respectively, for deceased donor recipients and 97.0% and 92.4%, respectively, for living donor recipients (Figure KI 157). In the 2018-2019 cohort, the overall incidence of acute rejection within the first year was 10.7%, with some variation by age; it was highest for those 11-17 years (11.7%) (Figure KI 158). Short-term renal function, measured by eGFR, improved substantially over the past decade. Proportions of living donor and deceased donor recipients from 2019 with eGFR 60 mL/min/1.73 m² or higher 12 months posttransplant were 66.8% and 70.1%, respectively (Figure KI 148, Figure KI 149). Incidence of posttransplant lymphoproliferative disorder among EBV-negative recipients from 2008-2018 was 3.8% at 5 years posttransplant, compared with 0.7% among EBV-positive recipients (Figure KI 159). Overall, 5-year patient survival among pediatric deceased donor kidney transplant recipients in 2013-2015 was very high, at 97.0% (Figure KI 161), with little variability by age (Figure KI 162).

Figure List

Waiting list

Deceased donation

Living donation

Figure KI 64. Number of living kidney transplants by donor relation
Figure KI 65. Living kidney donors by age
Figure KI 66. Living kidney donors by sex
Figure KI 67. Living kidney donors by race
Figure KI 68. Intended living kidney donor procedure type
Figure KI 69. BMI among living kidney donors
Figure KI 70. Rehospitalization among living kidney donors, 2015-2019
Figure KI 71. Kidney complications among living kidney donors, 2015-2019

Transplant

Figure KI 72. Overall kidney transplants
Figure KI 73. Total kidney transplants by donor type
Figure KI 74. Total kidney transplants by age
Figure KI 75. Total kidney transplants by sex
Figure KI 76. Total kidney transplants by race
Figure KI 77. Total kidney transplants by diagnosis
Figure KI 78. Kidney transplants by kidney donor profile index (KDPI)
Figure KI 79. Induction agent use in adult kidney transplant recipients
Figure KI 80. Immunosuppression regimen use in adult kidney transplant recipients
Figure KI 81. Peak C/PRA at time of kidney transplant in adult deceased donor recipients
Figure KI 82. Peak C/PRA at time of kidney transplant in adult living donor recipients
Figure KI 83. Total HLA A, B, and DR mismatches among adult kidney transplant recipients, 2016-2020
Figure KI 84. Annual adult kidney transplant center volumes by percentile
Figure KI 85. Distribution of adult kidney transplants by annual center volume

Outcomes

Pediatric transplant

Table List

Figure KI 60. Percent of kidneys recovered for transplant and not transplanted by KDPI
Percentages of kidneys not transplanted out of all kidneys recovered for transplant, by KDPI classification. The reference population for the KDRI to KDPI conversion is all deceased donor kidneys recovered for transplant in the US in 2019. KDPI, kidney donor profile index; KDRI, kidney donor risk index.

**Figure KI 61. Donor-specific components of the kidney donor risk index**
Donors with at least one transplanted kidney. The donor-specific components of the kidney donor risk index are shown, except for donor height. CVA, cerebrovascular accident; DCD, donation after circulatory death; SCr, serum creatinine.

**Figure KI 62. Average kidney donor risk index**
Kidneys recovered for transplant. Kidney donor risk index is computed using only donor-specific components, and is not converted to KDPI.

**Figure KI 63. Average kidney donor risk index by biopsy status**
Kidneys recovered for transplant. Kidney donor risk index is computed using only donor-specific components, and is not converted to KDPI. Kidneys are classified as biopsied if either of the donor's kidneys was biopsied.

**Figure KI 64. Number of living kidney transplants by donor relation**
As reported on the OPTN Living Donor Registration Form.

**Figure KI 69. BMI among living kidney donors**
Donor height and weight reported on the OPTN Living Donor Registration Form.

**Figure KI 70. Rehospitalization among living kidney donors, 2015-2019**
Cumulative hospital readmission. The discharge time point is recorded at the earliest of discharge or 6 weeks after donation.

**Figure KI 71. Kidney complications among living kidney donors, 2015-2019**
Complications reported on the OPTN Living Donor Registration and Living Donor Follow-up Forms at each time point. Complications include readmission, re-operation, vascular complications, and other complications requiring intervention. Multiple complications may be reported at any time point.

**Figure KI 72. Overall kidney transplants**
All kidney transplant recipients, including adult and pediatric, retransplant, and multi-organ recipients.

**Figure KI 77. Total kidney transplants by diagnosis**
All kidney transplant recipients, including adult and pediatric, retransplant, and multi-organ recipients. GN, glomerulonephritis; CKD, cystic kidney disease.

Figure KI 78. Kidney transplants by kidney donor profile index (KDPI)
All adult recipients of deceased donor kidneys, including multi-organ transplants. The reference population for the KDRI to KDPI conversion is all deceased donor kidneys recovered for transplant in the US in 2019. Kidneys recovered en-bloc are counted once. KDPI, kidney donor profile index; KDRI, kidney donor risk index.

**Figure KI 79. Induction agent use in adult kidney transplant recipients**
Immunosuppression at transplant reported to the OPTN.

**Figure KI 80. Immunosuppression regimen use in adult kidney transplant recipients**
Immunosuppression regimen at transplant reported to the OPTN. Tac, tacrolimus. MMF, all mycophenolate agents.

**Figure KI 81. Peak C/PRA at time of kidney transplant in adult deceased donor recipients**
Peak c/PRA is used. c/PRA was used for 2010 and later. c/PRA was not consistently calculated and is set to missing for transplant recipients in 2009.

**Figure KI 83. Total HLA A, B, and DR mismatches among adult kidney transplant recipients, 2016-2020**
Donor and recipient antigen matching is based on OPTN antigen values and split equivalences policy as of 2019.

**Figure KI 84. Annual adult kidney transplant center volumes by percentile**
Annual volume data are limited to recipients aged 18 years or older.

**Figure KI 85. Distribution of adult kidney transplants by annual center volume**
Based on annual volume data among recipients aged 18 or older.

**Figure KI 86. Graft failure among adult deceased donor kidney transplant recipients**
Estimates are unadjusted, computed using Kaplan-Meier methods. Recipients are followed to the earliest of kidney graft failure; kidney retransplant; return to dialysis; death; or 6 months, 1, 3, 5, or 10 years posttransplant. All-cause graft failure (GF) is defined as any of the prior outcomes prior to 6 months, 1, 3, 5, or 10 years, respectively.

**Figure KI 87. Death-censored graft failure among adult deceased donor kidney transplant recipients**
Estimates are unadjusted, computed using Kaplan-Meier competing risk methods. Recipients are followed to the earliest of kidney graft failure; kidney retransplant; return to dialysis; death; or 6 months, 1, 3, 5, or 10 years posttransplant. Death-censored graft failure (DCGF) is defined as a return to dialysis, reported graft failure, or kidney retransplant.

**Figure KI 92. Graft survival among adult deceased donor kidney transplant recipients, 2013-2015, by age**
Graft survival estimated using unadjusted Kaplan-Meier methods.

Figure KI 94. Graft survival among adult deceased donor kidney transplant recipients, 2013-2015, by KDPI
Graft survival estimated using unadjusted Kaplan-Meier methods. The reference population for the KDRI to KDPI conversion is all deceased donor kidneys recovered for transplant in the US in 2019. KDPI, kidney donor profile index.

**Figure KI 95. Graft survival among adult deceased donor kidney transplant recipients, 2013-2015, by DCD status**
Graft survival estimated using unadjusted Kaplan-Meier methods. DCD, donation after circulatory death; DBD, donation after brain death.

**Figure KI 96. Graft survival among adult deceased donor kidney transplant recipients, 2013-2015, by biopsy status**
Graft survival estimated using unadjusted Kaplan-Meier methods. Kidneys are classified as biopsied if either of the donor's kidneys was biopsied.

GFR (mL/min/1.73 m<sup>2</sup>) estimated using the Chronic Kidney Disease Epidemiology Collaboration equation, and computed for patients alive with graft function at 12 months posttransplant. — **Figure KI 103. Distribution of eGFR at 12 months posttransplant among adult deceased donor kidney transplant recipients**
GFR (mL/min/1.73 m²) estimated using the Chronic Kidney Disease Epidemiology Collaboration equation, and computed for patients alive with graft function at 12 months posttransplant.

**Figure KI 105. Recipients alive with a functioning kidney graft on June 30 of the year, by age at transplant**
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.

**Figure KI 106. Incidence of acute rejection by 1 year posttransplant among adult kidney transplant recipients by age, 2018-2019**
Only the first reported rejection event is counted. Cumulative incidence is estimated using the Kaplan-Meier method.

**Figure KI 107. Incidence of acute rejection by 1 year posttransplant among adult kidney transplant recipients by induction agent, 2018-2019**
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 KI 108. Posttransplant diabetes among adult kidney transplant recipients**
Percentage of adult deceased donor kidney recipients who were nondiabetic at transplant and developed diabetes posttransplant. Posttransplant diabetes is reported on the Transplant Recipient Follow-up Form. Death and graft failure are treated as competing events.

**Figure KI 110. Incidence of PTLD among adult kidney transplant recipients by recipient EBV status at transplant, 2014-2018**
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.

**Figure KI 111. Patient survival among adult deceased donor kidney transplant recipients, 2013-2015, by age**
Patient survival estimated using unadjusted Kaplan-Meier methods.

Figure KI 114. Patient survival among adult deceased donor kidney transplant recipients, 2013-2015, by KDPI
Patient survival estimated using unadjusted Kaplan-Meier methods. The reference population for the KDRI to KDPI conversion is all deceased donor kidneys recovered for transplant in the US in 2019. KDPI, kidney donor profile index.

**Figure KI 115. Patient survival among adult deceased donor kidney transplant recipients, 2013-2015, by biopsy status**
Patient survival estimated using unadjusted Kaplan-Meier methods. Kidneys are classified as biopsied if either of the donor's kidneys was biopsied.

**Figure KI 121. All pediatric candidates on the kidney transplant waiting list**
Candidates listed at more than one center are counted once per listing; age determined at first listing.

**Figure KI 123. Distribution of pediatric candidates waiting for kidney transplant by race**
Candidates waiting for transplant any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive candidates are included.

**Figure KI 124. Distribution of pediatric candidates waiting for kidney transplant by diagnosis**
Candidates waiting for transplant any time in the given year. Candidates listed at more than one center are counted once per listing. Diagnosis categories follow North American Pediatric Renal Trials and Collaborative Studies recommendations. Active and inactive candidates are included. FSGS, focal segmental glomerulosclerosis; CAKUT, congenital anomalies of the kidney and urinary tract.

**Figure KI 126. Distribution of pediatric candidates waiting for kidney transplant by waiting time**
Candidates waiting for transplant any time in the given year. Candidates listed at more than one center are counted once per listing. Time on the waiting list is determined at January 1 of the given year. Candidates listed in the given year are considered to have been listed less than 1 year. Active and inactive candidates are included.

**Figure KI 127. Distribution of pediatric candidates waiting for kidney transplant by C/PRA**
Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Peak c/PRA is used. c/PRA was used for 2010 and later. c/PRA was not consistently calculated and set to missing for transplant recipients in 2009. Active and inactive candidates are included.

**Figure KI 128. Three-year outcomes for newly listed pediatric candidates waiting for kidney transplant, 2015-2017**
Pediatric candidates who joined the waitlist in 2016. Candidates listed at more than one center are counted once per listing. DD, deceased donor; LD, living donor.

**Figure KI 129. Overall deceased donor kidney transplant rates among pediatric waitlist candidates**
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.

**Figure KI 138. Overall pediatric kidney transplants**
All pediatric kidney transplant recipients, including retransplant, and multi-organ recipients.

**Figure KI 141. Pediatric kidney transplants from living donors by relation**
Relationship of living donor to recipient is as indicated on the OPTN Living Donor Registration Form.

**Figure KI 142. Percent of pediatric kidney transplants from living donors by recipient age**
All pediatric living kidney transplant recipients, including retransplant, and multi-organ recipients.

**Figure KI 143. Number of centers performing pediatric and adult kidney 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.

**Figure KI 144. Pediatric kidney recipients at programs that perform 5 or fewer pediatric transplants annually**
Age groups are cumulative.

GFR (mL/min/1.73 m<sup>2</sup>) estimated using the bedside Schwartz equation, and computed for patients alive with graft function at 12 months posttransplant. Equation: eGFR = 0.413*Height(cm)/Creatinine (mg/dL). — **Figure KI 148. Distribution of eGFR at 12 months posttransplant among pediatric deceased donor kidney-alone transplant recipients**
GFR (mL/min/1.73 m²) estimated using the bedside Schwartz equation, and computed for patients alive with graft function at 12 months posttransplant. Equation: eGFR = 0.413*Height(cm)/Creatinine (mg/dL).

**Figure KI 156. Graft survival among pediatric deceased donor kidney transplant recipients, 2013-2015, by age**
Recipient survival estimated using unadjusted Kaplan-Meier methods.

**Figure KI 160. Patient death among pediatric kidney transplant recipients**
All pediatric recipients of deceased donor kidneys, including multi-organ transplants. Estimates are unadjusted, computed using unadjusted Kaplan-Meier methods.

**Table KI 1. Demographic characteristics of adults on the kidney transplant waiting list on December 31, 2010, December 31, 2015 and December 31, 2020**
Candidates waiting for transplant on December 31 of the given year, regardless of first listing date. Distance is computed from candidate's home zip code to the transplant center.
Characteristic	2010, N	2010, Percent	2015, N	2015, Percent	2020, N	2020, Percent
Age: 18-34 years	9327	10.1%	9354	8.8%	7834	8.1%
Age: 35-49 years	25,922	28.2%	27,249	25.6%	22,898	23.5%
Age: 50-64 years	39,864	43.4%	46,672	43.9%	42,377	43.6%
Age: ≥ 65 years	16,798	18.3%	23,149	21.8%	24,133	24.8%
Sex: Female	37,912	41.2%	42,035	39.5%	37,091	38.1%
Sex: Male	53,999	58.8%	64,389	60.5%	60,151	61.9%
Race/ethnicity: White	35,806	39.0%	39,044	36.7%	34,351	35.3%
Race/ethnicity: Black	31,419	34.2%	35,991	33.8%	31,272	32.2%
Race/ethnicity: Hispanic	16,482	17.9%	20,470	19.2%	20,315	20.9%
Race/ethnicity: Asian	6978	7.6%	9271	8.7%	9603	9.9%
Race/ethnicity: Other/unknown	1226	1.3%	1648	1.5%	1701	1.7%
Geography: Metropolitan	78,814	85.8%	92,376	86.8%	85,027	87.4%
Geography: Non-metro	13,097	14.2%	14,048	13.2%	12,215	12.6%
Distance: < 50 miles	61,500	66.9%	70,502	66.2%	64,394	66.2%
Distance: 50-<100 miles	13,678	14.9%	16,189	15.2%	15,528	16.0%
Distance: 100-<150 miles	6570	7.1%	7809	7.3%	6594	6.8%
Distance: 150-<250 miles	6057	6.6%	7071	6.6%	5886	6.1%
Distance: ≥ 250 miles	3440	3.7%	4412	4.1%	4570	4.7%
Distance: Unknown	666	0.7%	441	0.4%	270	0.3%
All candidates	91,911	100.0%	106,424	100.0%	97,242	100.0%

**Table KI 2. Clinical characteristics of adults on the kidney transplant waiting list on December 31, 2010, December 31, 2015 and December 31, 2020**
Candidates waiting for transplant on December 31 of the given year, regardless of first listing date. CKD, cystic kidney disease; GN, glomerulonephritis. *Diabetes status based on diagnosis and comorbid conditions.
Characteristic	2010, N	2010, Percent	2015, N	2015, Percent	2020, N	2020, Percent
Diagnosis: Diabetes	29,747	32.4%	37,890	35.6%	37,612	38.7%
Diagnosis: Hypertension	23,314	25.4%	25,198	23.7%	20,333	20.9%
Diagnosis: GN	13,428	14.6%	15,239	14.3%	13,626	14.0%
Diagnosis: CKD	7833	8.5%	9273	8.7%	8494	8.7%
Diagnosis: Other	17,589	19.1%	18,824	17.7%	17,177	17.7%
Diabetes*	38,574	42.0%	47,930	45.0%	45,778	47.1%
Blood type: A	26,404	28.7%	30,100	28.3%	26,202	26.9%
Blood type: B	14,818	16.1%	17,633	16.6%	16,219	16.7%
Blood type: AB	2674	2.9%	2849	2.7%	2378	2.4%
Blood type: O	48,015	52.2%	55,842	52.5%	52,443	53.9%
CPRA: < 1%	47,976	52.2%	65,699	61.7%	60,071	61.8%
CPRA: 1-< 20%	11,232	12.2%	9223	8.7%	9209	9.5%
CPRA: 20-< 80%	14,672	16.0%	15,786	14.8%	16,138	16.6%
CPRA: 80-< 98%	6616	7.2%	6323	5.9%	5288	5.4%
CPRA: 98-100%	8243	9.0%	8846	8.3%	6462	6.6%
CPRA: Unknown	3172	3.5%	547	0.5%	74	0.1%
All candidates	91,911	100.0%	106,424	100.0%	97,242	100.0%

**Table KI 3. Listing characteristics of adults on the kidney transplant waiting list on December 31, 2010, December 31, 2015 and December 31, 2020**
Candidates waiting for transplant on December 31 of the given year, regardless of first listing date. KDPI, kidney donor profile index. *Prior to 2014, includes willingness to accept expanded criteria donor (ECD) kidney. KDPI >85% is local non-zero HLA mismatch only.
Characteristic	2010, N	2010, Percent	2015, N	2015, Percent	2020, N	2020, Percent
Transplant history: First	77,267	84.1%	91,995	86.4%	85,744	88.2%
Transplant history: Retransplant	14,644	15.9%	14,429	13.6%	11,498	11.8%
Wait time: < 1 year	29,985	32.6%	29,603	27.8%	28,643	29.5%
Wait time: 1-< 2 years	21,623	23.5%	23,140	21.7%	22,960	23.6%
Wait time: 2-< 3 years	14,675	16.0%	18,089	17.0%	15,422	15.9%
Wait time: 3-< 4 years	9854	10.7%	12,453	11.7%	9924	10.2%
Wait time: 4-< 5 years	5954	6.5%	8328	7.8%	6891	7.1%
Wait time: ≥ 5 years	9820	10.7%	14,811	13.9%	13,402	13.8%
Will accept KDPI*>85%	43,009	46.8%	50,539	47.5%	43,742	45.0%
Tx type: Kidney alone	88,870	96.7%	103,158	96.9%	94,266	96.9%
Tx type: Kidney-pancreas	2341	2.5%	2084	2.0%	1821	1.9%
Tx type: Kidney-liver	597	0.6%	982	0.9%	869	0.9%
Tx type: Kidney-heart	92	0.1%	185	0.2%	267	0.3%
Tx type: Other	11	0.0%	15	0.0%	19	0.0%
All candidates	91,911	100.0%	106,424	100.0%	97,242	100.0%

**Table KI 4. Reasons for inactive status among new adult kidney transplant listings, 2020**
Candidates first listed as inactive. Each listing is counted separately. LD, living donor.
Reasons for inactive status	N	Percent
Candidate work-up incomplete	7225	69.5%
Insurance issues	701	6.7%
Too well	662	6.4%
Too sick	561	5.4%
Candidate choice	327	3.1%
COVID-19 Precaution	281	2.7%
Weight inappropriate	234	2.2%
Candidate for LD transplant only	228	2.2%
Transplant pending	120	1.2%
Medical non-compliance	32	0.3%
Inappropriate substance abuse	20	0.2%
Candidate could not be contacted	5	0.0%
Unknown	3	0.0%
Physician/surgeon unavailable	3	0.0%

**Table KI 5. Kidney transplant waitlist activity among adults**
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	2018	2019	2020
Patients at start of year	101,339	100,972	101,195
Patients added during year	40,157	42,935	37,408
Patients removed during year	40,456	42,638	41,371
Patients at end of year	101,040	101,269	97,232

**Table KI 6. Removal reason among adult kidney transplant candidates**
Removal reason as reported to the OPTN. Candidates with death dates that precede removal dates are assumed to have died waiting.
Removal reason	2018	2019	2020
Deceased donor transplant	14,942	16,754	17,797
Living donor transplant	6145	6605	4986
Transplant outside US	59	64	47
Patient died	4472	4193	5232
Patient refused transplant	455	396	302
Improved, transplant not needed	197	205	180
Too sick for transplant	4433	4257	3850
Other	9753	10,164	8977

**Table KI 7. Living kidney donor deaths in the first year after donoation, 2016-2020, by number of days after donation**
Living kidney donors. Number of deaths reported to OPTN or Social Security Administration. Donation-related deaths are included in the Medical category.
Cause	0-30 days	31-90 days	91-365 days
Suicide	0	2	2
Accident/homicide	0	0	5
Overdose	1	1	0
Medical	0	0	1
Cancer	0	0	0
Unknown	0	1	1
TOTAL	1	4	9

**Table KI 8. Demographic characteristics of adult kidney transplant recipients, 2020**
Kidney transplant recipients, including retransplants. Distance is computed from recipient's home zip code to the transplant center.
Characteristic	Deceased, N	Deceased, Percent	Living, N	Living, Percent	All, N	All, Percent
Age: 18-34 years	2023	11.3%	814	16.2%	2837	12.4%
Age: 35-49 years	4619	25.8%	1333	26.6%	5952	26.0%
Age: 50-64 years	7213	40.3%	1872	37.4%	9085	39.6%
Age: ≥ 65 years	4060	22.7%	993	19.8%	5053	22.0%
Sex: Female	6989	39.0%	1839	36.7%	8828	38.5%
Sex: Male	10,926	61.0%	3173	63.3%	14,099	61.5%
Race/ethnicity: White	7072	39.5%	3225	64.3%	10,297	44.9%
Race/ethnicity: Black	5786	32.3%	588	11.7%	6374	27.8%
Race/ethnicity: Hispanic	3348	18.7%	796	15.9%	4144	18.1%
Race/ethnicity: Asian	1396	7.8%	337	6.7%	1733	7.6%
Race/ethnicity: Other/unknown	313	1.7%	66	1.3%	379	1.7%
Insurance: Private	4597	25.7%	2809	56.0%	7406	32.3%
Insurance: Medicare	11,611	64.8%	1890	37.7%	13,501	58.9%
Insurance: Medicaid	1223	6.8%	208	4.2%	1431	6.2%
Insurance: Other government	354	2.0%	74	1.5%	428	1.9%
Insurance: Unknown	130	0.7%	31	0.6%	161	0.7%
Geography: Metropolitan	15,299	85.4%	4369	87.2%	19,668	85.8%
Geography: Non-metro	2616	14.6%	643	12.8%	3259	14.2%
Distance: < 50 miles	11,539	64.4%	3302	65.9%	14,841	64.7%
Distance: 50-<100 miles	3029	16.9%	770	15.4%	3799	16.6%
Distance: 100-<150 miles	1442	8.0%	348	6.9%	1790	7.8%
Distance: 150-<250 miles	980	5.5%	255	5.1%	1235	5.4%
Distance: ≥ 250 miles	781	4.4%	304	6.1%	1085	4.7%
Distance: Unknown	144	0.8%	33	0.7%	177	0.8%
All recipients	17,915	100.0%	5012	100.0%	22,927	100.0%

**Table KI 9. Clinical characteristics of adult kidney transplant recipients, 2020**
Kidney transplant recipients, including retransplants. CKD, cystic kidney disease; GN, glomerulonephritis.
Characteristic	Deceased, N	Deceased, Percent	Living, N	Living, Percent	All, N	All, Percent
Diagnosis: Diabetes	6002	33.5%	1244	24.8%	7246	31.6%
Diagnosis: Hypertension	3986	22.2%	798	15.9%	4784	20.9%
Diagnosis: GN	2769	15.5%	1152	23.0%	3921	17.1%
Diagnosis: CKD	1706	9.5%	837	16.7%	2543	11.1%
Diagnosis: Other	3452	19.3%	981	19.6%	4433	19.3%
Blood type: A	6270	35.0%	1981	39.5%	8251	36.0%
Blood type: B	2531	14.1%	683	13.6%	3214	14.0%
Blood type: AB	892	5.0%	169	3.4%	1061	4.6%
Blood type: O	8222	45.9%	2179	43.5%	10,401	45.4%
Dialysis time: None	2740	15.3%	1796	35.8%	4536	19.8%
Dialysis time: < 1 year	1357	7.6%	997	19.9%	2354	10.3%
Dialysis time: 1-< 3 years	3686	20.6%	1201	24.0%	4887	21.3%
Dialysis time: 3-< 5 years	3621	20.2%	395	7.9%	4016	17.5%
Dialysis time: ≥ 5 years	6511	36.3%	623	12.4%	7134	31.1%
CPRA: < 1%	11,027	61.6%	3607	72.0%	14,634	63.8%
CPRA: 1-< 20%	1592	8.9%	489	9.8%	2081	9.1%
CPRA: 20-< 80%	2892	16.1%	680	13.6%	3572	15.6%
CPRA: 80-< 98%	1222	6.8%	177	3.5%	1399	6.1%
CPRA: 98-100%	1181	6.6%	57	1.1%	1238	5.4%
CPRA: Unknown	1	0.0%	2	0.0%	3	0.0%
All recipients	17,915	100.0%	5012	100.0%	22,927	100.0%

**Table KI 10. Transplant characteristics of adult kidney transplant recipients, 2020**
Kidney transplant recipients, including retransplants. DBD, donation after brain death; DCD, donation after circulatory death; KDPI, kidney donor profile index. DCD status and KDPI scores apply to deceased donor transplants only.
Characteristic	Deceased, N	Deceased, Percent	Living, N	Living, Percent	All, N	All, Percent
Wait time: None (preemptive)	149	0.8%	73	1.5%	222	1.0%
Wait time: < 1 year	8015	44.7%	3013	60.1%	11,028	48.1%
Wait time: 1-< 3 years	4889	27.3%	1516	30.2%	6405	27.9%
Wait time: 3-< 5 years	2623	14.6%	308	6.1%	2931	12.8%
Wait time: ≥ 5 years	2239	12.5%	102	2.0%	2341	10.2%
KDPI: ≤ 20%	4181	23.3%
KDPI: 21-34%	2947	16.4%
KDPI: 35-85%	9480	52.9%
KDPI: > 85%	1307	7.3%
DCD status: DBD	13,220	73.8%
DCD status: DCD	4695	26.2%
DGF: None	12,866	71.8%	4870	97.2%	17,736	77.4%
DGF: Yes	5049	28.2%	142	2.8%	5191	22.6%
Transplant history: First	16,157	90.2%	4549	90.8%	20,706	90.3%
Transplant history: Retransplant	1758	9.8%	463	9.2%	2221	9.7%
Tx type: Kidney only	16,028	89.5%	5012	100.0%	21,040	91.8%
Tx type: Kidney-pancreas	819	4.6%	0	0.0%	819	3.6%
Tx type: Kidney-liver	763	4.3%	0	0.0%	763	3.3%
Tx type: Kidney-heart	284	1.6%	0	0.0%	284	1.2%
Tx type: Kidney-lung	11	0.1%	0	0.0%	11	0.0%
Tx type: Other	10	0.1%	0	0.0%	10	0.0%
All recipients	17,915	100.0%	5012	100.0%	22,927	100.0%

**Table KI 11. Adult deceased donor kidney donor-recipient serology matching, 2018-2020**
Donor serology is reported on the OPTN Donor Registration Form and recipient serology on the OPTN Transplant Recipient Registration Form. There may be multiple fields per serology. Any evidence for a positive serology is treated as positive for that serology. Donor HCV NAT data are shown by recipient HCV antibody status. CMV, cytomegalovirus; EBV, Epstein-Barr virus; HBsAg, hepatitis B surace antigen; HCV, hepatitis C virus; HIV, human immunodeficiency virus; NAT, nucleic acid test.
Donor	Recipient	CMV	EBV	HBsAg	HCV antibody	HCV NAT
D-	R-	13.5%	0.8%	97.6%	86.2%	89.3%
D-	R+	25.1%	8.0%	1.2%	3.2%	3.5%
D-	R unk	0.4%	0.4%	1.0%	1.3%	1.4%
D+	R-	18.6%	5.4%	0.1%	7.7%	4.6%
D+	R+	41.5%	82.5%	0.0%	1.4%	1.1%
D+	R unk	0.5%	2.7%	0.0%	0.2%	0.1%
D unk	R-	0.2%	0.0%	0.0%	0.0%	0.0%
D unk	R+	0.3%	0.2%	0.0%	0.0%	0.0%
D unk	R unk	0.0%	0.0%	0.0%	0.0%	0.0%

**Table KI 12. Adult living donor kidney donor-recipient serology matching, 2018-2020**
Donor serology is reported on the OPTN Donor Registration Form and recipient serology on the OPTN Transplant Recipient Registration Form. There may be multiple fields per serology. Any evidence for a positive serology is treated as positive for that serology. Donor HCV NAT data are shown by recipient HCV antibody status. CMV, cytomegalovirus; EBV, Epstein-Barr virus; HBsAg, hepatitis B surface antigen; HCV, hepatitis C virus; HIV, human immunodeficiency virus; NAT, nucleic acid test.
Donor	Recipient	CMV	EBV	HBsAg	HCV antibody	HCV NAT
D-	R-	25.1%	1.4%	96.2%	94.1%	85.8%
D-	R+	20.3%	6.8%	0.9%	1.8%	1.7%
D-	R unk	0.5%	0.2%	0.8%	1.3%	1.3%
D+	R-	17.7%	6.5%	0.2%	0.7%	0.1%
D+	R+	32.6%	81.7%	0.0%	0.0%	0.0%
D+	R unk	0.6%	1.5%	0.0%	0.0%	0.0%
D unk	R-	1.5%	0.2%	1.9%	1.9%	10.9%
D unk	R+	1.7%	1.7%	0.0%	0.0%	0.2%
D unk	R unk	0.0%	0.1%	0.0%	0.0%	0.1%

**Table KI 13. Reasons for inactive status among new pediatric kidney transplant listings, 2020**
Candidates first listed as inactive. Each listing is counted separately. LD, living donor.
Reasons for inactive status	N	Percent
Candidate work-up incomplete	383	53.2%
Too well	111	15.4%
Candidate for LD transplant only	106	14.7%
Candidate choice	46	6.4%
Too sick	22	3.1%
Insurance issues	15	2.1%
Weight inappropriate	15	2.1%
COVID-19 Precaution	12	1.7%
Medical non-compliance	7	1.0%
Transplant pending	2	0.3%
Candidate could not be contacted	1	0.1%

**Table KI 14. Demographic characteristics of pediatric candidates on the kidney transplant waiting list on December 31, 2010, December 31, 2015, and December 31, 2020**
Candidates aged younger than 18 years waiting for transplant on December 31 of given year, regardless of first listing date. Age calculated at snapshot. Candidates listed as children who turned 18 before the cohort date are excluded. Distance is computed from candidate's home zip code to the transplant center.
Characteristic	2010, N	2010, Percent	2015, N	2015, Percent	2020, N	2020, Percent
Age: < 1 year	2	0.3%	7	0.7%	1	0.1%
Age: 1-5 years	162	20.9%	240	23.4%	211	19.0%
Age: 6-10 years	132	17.0%	194	18.9%	244	21.9%
Age: 11-17 years	480	61.9%	585	57.0%	656	59.0%
Sex: Female	290	37.4%	425	41.4%	399	35.9%
Sex: Male	486	62.6%	601	58.6%	713	64.1%
Race/ethnicity: White	288	37.1%	415	40.4%	497	44.7%
Race/ethnicity: Black	206	26.5%	203	19.8%	198	17.8%
Race/ethnicity: Hispanic	247	31.8%	327	31.9%	301	27.1%
Race/ethnicity: Asian	23	3.0%	59	5.8%	75	6.7%
Race/ethnicity: Other/unknown	12	1.5%	22	2.1%	41	3.7%
Geography: Metropolitan	675	87.0%	889	86.6%	961	86.4%
Geography: Non-metro	101	13.0%	137	13.4%	151	13.6%
Distance: < 50 miles	510	65.7%	647	63.1%	708	63.7%
Distance: 50-<100 miles	119	15.3%	170	16.6%	160	14.4%
Distance: 100-<150 miles	59	7.6%	90	8.8%	77	6.9%
Distance: 150-<250 miles	45	5.8%	52	5.1%	93	8.4%
Distance: ≥ 250 miles	33	4.3%	57	5.6%	68	6.1%
Distance: Unknown	10	1.3%	10	1.0%	6	0.5%
All candidates	776	100.0%	1026	100.0%	1112	100.0%

**Table KI 15. Clinical characteristics of pediatric candidates on the kidney transplant waiting list on December 31, 2010, December 31, 2015, and December 31, 2020**
Candidates aged younger than 18 years waiting for transplant on December 31 of the given year, regardless of first listing date. Candidates listed as children who turned 18 before the cohort date are excluded. FSGS, focal segmental glomerulosclerosis; GN, glomerulonephritis; CAKUT, congenital anomalies of the kidney and urinary tract.
Characteristic	2010, N	2010, Percent	2015, N	2015, Percent	2020, N	2020, Percent
Diagnosis: FSGS	93	12.0%	102	9.9%	82	7.4%
Diagnosis: GN	87	11.2%	75	7.3%	57	5.1%
Diagnosis: CAKUT	225	29.0%	400	39.0%	426	38.3%
Diagnosis: Other	371	47.8%	449	43.8%	547	49.2%
Blood type: A	234	30.2%	306	29.8%	377	33.9%
Blood type: B	136	17.5%	160	15.6%	180	16.2%
Blood type: AB	18	2.3%	32	3.1%	29	2.6%
Blood type: O	388	50.0%	528	51.5%	526	47.3%
CPRA: < 1%	483	62.2%	665	64.8%	791	71.1%
CPRA: 1-< 20%	54	7.0%	100	9.7%	93	8.4%
CPRA: 20-< 80%	80	10.3%	125	12.2%	133	12.0%
CPRA: 80-< 98%	68	8.8%	47	4.6%	36	3.2%
CPRA: 98-100%	64	8.2%	84	8.2%	59	5.3%
CPRA: Unknown	27	3.5%	5	0.5%	0	0.0%
All candidates	776	100.0%	1026	100.0%	1112	100.0%

**Table KI 16. Listing characteristics of pediatric candidates on the kidney transplant waiting list on December 31, 2010, December 31, 2015, and December 31, 2020**
Candidates aged younger than 18 years waiting for transplant on December 31 of the given year, regardless of first listing date. Candidates listed as children who turned 18 before the cohort date are excluded.
Characteristic	2010, N	2010, Percent	2015, N	2015, Percent	2020, N	2020, Percent
Transplant history: First	569	73.3%	846	82.5%	971	87.3%
Transplant history: Retransplant	207	26.7%	180	17.5%	141	12.7%
Wait time: < 1 year	440	56.7%	564	55.0%	580	52.2%
Wait time: 1-< 2 years	146	18.8%	229	22.3%	233	21.0%
Wait time: 2-< 3 years	84	10.8%	116	11.3%	138	12.4%
Wait time: 3-< 4 years	50	6.4%	58	5.7%	66	5.9%
Wait time: 4-< 5 years	27	3.5%	17	1.7%	31	2.8%
Wait time: ≥ 5 years	29	3.7%	42	4.1%	64	5.8%
Tx type: Kidney alone	763	98.3%	1000	97.5%	1095	98.5%
Tx type: Kidney-pancreas	1	0.1%	0	0.0%	1	0.1%
Tx type: Kidney-liver	8	1.0%	22	2.1%	13	1.2%
Tx type: Kidney-heart	2	0.3%	3	0.3%	2	0.2%
Tx type: Other	2	0.3%	1	0.1%	1	0.1%
All candidates	776	100.0%	1026	100.0%	1112	100.0%

**Table KI 17. Kidney transplant waitlist activity among pediatric candidates**
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	2018	2019	2020
Patients at start of year	1533	1548	1553
Patients added during year	1047	1030	1083
Patients removed during year	1031	1025	941
Patients at end of year	1549	1553	1695

**Table KI 18. Removal reason among pediatric kidney transplant candidates**
Removal reason as reported to the OPTN. Candidates with death dates that precede removal dates are assumed to have died waiting.
Removal reason	2018	2019	2020
Deceased donor transplant	577	610	563
Living donor transplant	297	262	248
Transplant outside US	1	0	1
Patient died	24	19	21
Patient refused transplant	0	3	2
Improved, transplant not needed	10	6	5
Too sick for transplant	9	10	8
Other	113	115	93

**Table KI 19. Demographic characteristics of pediatric kidney transplant recipients, 2018-2020**
Pediatric kidney transplant recipients, including retransplants. Distance is computed from recipient's home zip code to the transplant center.
Characteristic	Deceased, N	Deceased, Percent	Living, N	Living, Percent	All, N	All, Percent
Age: 1-5 years	286	19.1%	233	31.6%	519	23.2%
Age: 6-10 years	312	20.8%	135	18.3%	447	20.0%
Age: 11-17 years	899	60.1%	369	50.1%	1268	56.8%
Sex: Female	611	40.8%	279	37.9%	890	39.8%
Sex: Male	886	59.2%	458	62.1%	1344	60.2%
Race/ethnicity: White	536	35.8%	500	67.8%	1036	46.4%
Race/ethnicity: Black	340	22.7%	55	7.5%	395	17.7%
Race/ethnicity: Hispanic	492	32.9%	138	18.7%	630	28.2%
Race/ethnicity: Asian	78	5.2%	32	4.3%	110	4.9%
Race/ethnicity: Other/unknown	51	3.4%	12	1.6%	63	2.8%
Insurance: Private	370	24.7%	401	54.4%	771	34.5%
Insurance: Medicare	378	25.3%	109	14.8%	487	21.8%
Insurance: Medicaid	616	41.1%	176	23.9%	792	35.5%
Insurance: Other government	111	7.4%	42	5.7%	153	6.8%
Insurance: Unknown	22	1.5%	9	1.2%	31	1.4%
Geography: Metropolitan	1247	83.3%	621	84.3%	1868	83.6%
Geography: Non-metro	250	16.7%	116	15.7%	366	16.4%
Distance: < 50 miles	919	61.4%	442	60.0%	1361	60.9%
Distance: 50-<100 miles	243	16.2%	121	16.4%	364	16.3%
Distance: 100-<150 miles	130	8.7%	59	8.0%	189	8.5%
Distance: 150-<250 miles	111	7.4%	67	9.1%	178	8.0%
Distance: ≥ 250 miles	82	5.5%	41	5.6%	123	5.5%
Distance: Unknown	12	0.8%	7	0.9%	19	0.9%
All recipients	1497	100.0%	737	100.0%	2234	100.0%

**Table KI 20. Clinicial characteristics of pediatric kidney transplant recipients, 2018-2020**
Pediatric kidney transplant recipients, including retransplants. Diagnosis categories follow North American Pediatric Renal Trials and Collaborative Studies recommendations. FSGS, focal segmental glomerulosclerosis; GN, glomerulonephritis; CAKUT, congenital anomalies of the kidney and urinary tract.
Characteristic	Deceased, N	Deceased, Percent	Living, N	Living, Percent	All, N	All, Percent
Diagnosis: FSGS	181	12.1%	72	9.8%	253	11.3%
Diagnosis: GN	129	8.6%	64	8.7%	193	8.6%
Diagnosis: CAKUT	477	31.9%	251	34.1%	728	32.6%
Diagnosis: Other	710	47.4%	350	47.5%	1060	47.4%
Blood type: A	435	29.1%	271	36.8%	706	31.6%
Blood type: B	167	11.2%	110	14.9%	277	12.4%
Blood type: AB	48	3.2%	23	3.1%	71	3.2%
Blood type: O	847	56.6%	333	45.2%	1180	52.8%
Dialysis time: None	427	28.5%	302	41.0%	729	32.6%
Dialysis time: < 1 year	308	20.6%	176	23.9%	484	21.7%
Dialysis time: 1-< 3 years	466	31.1%	175	23.7%	641	28.7%
Dialysis time: 3-< 5 years	144	9.6%	32	4.3%	176	7.9%
Dialysis time: ≥ 5 years	152	10.2%	52	7.1%	204	9.1%
CPRA: < 1%	1134	75.8%	560	76.0%	1694	75.8%
CPRA: 1-< 20%	140	9.4%	70	9.5%	210	9.4%
CPRA: 20-< 80%	164	11.0%	87	11.8%	251	11.2%
CPRA: 80-< 98%	30	2.0%	13	1.8%	43	1.9%
CPRA: 98-100%	29	1.9%	5	0.7%	34	1.5%
CPRA: Unknown	0	0.0%	2	0.3%	2	0.1%
All recipients	1497	100.0%	737	100.0%	2234	100.0%

**Table KI 21. Transplant characteristics of pediatric kidney transplant recipients, 2018-2020**
Pediatric kidney transplant recipients, including retransplants. DBD, donation after brain death; DCD, donation after circulatory death; DGF, delayed graft function; KDPI, kidney donor profile index. DCD status and KDPI scores apply to deceased donor transplants only.
Characteristic	Deceased, N	Deceased, Percent	Living, N	Living, Percent	All, N	All, Percent
Wait time: None (preemptive)	7	0.5%	26	3.5%	33	1.5%
Wait time: < 1 year	1033	69.0%	544	73.8%	1577	70.6%
Wait time: 1-< 3 years	369	24.6%	140	19.0%	509	22.8%
Wait time: 3-< 5 years	64	4.3%	21	2.8%	85	3.8%
Wait time: ≥ 5 years	24	1.6%	6	0.8%	30	1.3%
KDPI: ≤ 20%	1151	76.9%
KDPI: 21-34%	274	18.3%
KDPI: 35-85%	71	4.7%
KDPI: > 85%	1	0.1%
DCD status: DBD	1421	94.9%
DCD status: DCD	76	5.1%
DGF: None	1393	93.1%	714	96.9%	2107	94.3%
DGF: Yes	104	6.9%	23	3.1%	127	5.7%
Transplant history: First	1402	93.7%	692	93.9%	2094	93.7%
Transplant history: Retransplant	95	6.3%	45	6.1%	140	6.3%
Tx type: Kidney only	1425	95.2%	737	100.0%	2162	96.8%
Tx type: Kidney-pancreas	2	0.1%	0	0.0%	2	0.1%
Tx type: Kidney-liver	52	3.5%	0	0.0%	52	2.3%
Tx type: Kidney-heart	11	0.7%	0	0.0%	11	0.5%
Tx type: Other	7	0.5%	0	0.0%	7	0.3%
All recipients	1497	100.0%	737	100.0%	2234	100.0%

**Table KI 22. Pediatric deceased donor kidney donor-recipient serology matching, 2018-2020**
Donor serology is reported on the OPTN Donor Registration Form and recipient serology on the OPTN Transplant Recipient Registration Form. There may be multiple fields per serology. Any evidence for a positive serology is treated as positive for that serology. CMV, cytomegalovirus; EBV, Epstein-Barr virus.
Donor	Recipient	CMV	EBV
D-	R-	26.5%	5.8%
D-	R+	14.1%	7.9%
D-	R unk	0.7%	0.1%
D+	R-	36.7%	38.1%
D+	R+	21.0%	46.7%
D+	R unk	0.4%	1.1%
D unk	R-	0.5%	0.1%
D unk	R+	0.1%	0.1%
D unk	R unk	0.0%	0.0%

**Table KI 23. Pediatric living donor kidney donor-recipient serology matching, 2018-2020**
Donor serology is reported on the OPTN Donor Registration Form and recipient serology on the OPTN Transplant Recipient Registration Form. There may be multiple fields per serology. Any evidence for a positive serology is treated as positive for that serology. CMV, cytomegalovirus; EBV, Epstein-Barr virus.
Donor	Recipient	CMV	EBV
D-	R-	38.0%	6.4%
D-	R+	9.6%	3.3%
D-	R unk	0.4%	0.1%
D+	R-	29.2%	51.8%
D+	R+	16.4%	33.9%
D+	R unk	0.4%	1.8%
D unk	R-	4.5%	1.6%
D unk	R+	1.4%	1.1%
D unk	R unk	0.1%	0.0%