OPTN/SRTR 2019 Annual Data Report: Liver

Abstract

This year was notable for changes to exception points determined by the geographic median allocation Model for End-Stage Liver Disease (MELD) and implementation of the National Liver Review Board, which took place on May 14, 2019. The national acuity circle liver distribution policy was also implemented but reverted to donor service area- and region-based boundaries after 1 week. In 2019, growth continued in the number of new waiting list registrations (12,767) and transplants performed (8,896), including living-donor transplants (524). Compared with 2018, living-donor liver transplants increased 31%. Women continued to have a lower deceased-donor transplant rate and a higher pretransplant mortality rate than men. The median waiting time for candidates with a MELD of 15-34 decreased, while the number of transplants performed for patients with exception points decreased. These changes may have been related to the policy changes that took effect in May 2019, which increased waiting list priority for candidates without exception status. Hepatitis C continued to decline as an indication for liver transplant, as the proportion of liver transplant recipients with alcohol-related liver disease and clinical profiles consistent with non-alcoholic steatohepatitis increased. Graft and patient survival have improved despite changing recipient demographics including older age, higher MELD, and higher prevalence of obesity and diabetes.

Adult Transplant

Waiting List Registration

There were 13,093 candidates on the liver transplant waiting list at the start of the year and 12,767 new registrations and 13,298 removals during the year, leaving 12,562 candidates waiting as of December 31, 2019 (Figure LI 1, Table LI 4).

The proportion of older (aged ≥65 years) candidates continued to increase, representing 20.8% of the adult waiting list in 2019, compared with 8.9% in 2009 (Figure LI 3). The number of candidates aged 50-64 years has decreased steadily over the past 6 years, although this age-group continued to make up over half (53.8%) of adults on the waiting list. The sex and racial composition of the waiting list has remained relatively unchanged: 61.8% male and 38.2% female, 68.9% white, 7.0% black, 17.5% Hispanic, and 5.0% Asian (Figure LI 4, Figure LI 5).

The proportion of candidates with a primary diagnosis of hepatitis C virus (HCV) continued to decline, making up 12.6% of new registrations, compared with 30.6% 10 years before. Meanwhile, the proportions with alcohol-related liver disease and other/unknown diagnosis continued to increase (to 31.3% and 35.6%, respectively) (Figure LI 6). The other/unknown category likely represents candidates with liver disease due to non-alcoholic steatohepatitis. The proportion of candidates with acute liver failure and cholestatic liver disease have also declined in the past 10 years, making up only 2.1% and 7.8% of new registrations, respectively, in 2019. Candidates with a primary diagnosis of hepatocellular carcinoma (HCC) comprised 10.6% of new waiting list registrations.

The severity of liver disease, based on the first active laboratory Model for End-Stage Liver Disease (MELD) during the calendar year, has increased (Figure LI 7). Most patients had an initial MELD <15 (47.1%), but an increasing proportion had an initial MELD 15-24 (36.3%), MELD 25-34 (11.3%), and MELD 40+ (2.4%). Candidates with body mass index (BMI) ≥35 kg/m² comprised 17.3% of the waiting list, representing the only BMI category with a steadily increasing trend (Figure LI 8). Candidates with a previous liver transplant made up only 3.1% of the waiting list, down from 4.5% in 2009 (Figure LI 10).

The proportion of adults willing to accept HCV-positive donors now has surpassed those unwilling to accept them (51.4% v. 48.6%, respectively), reflecting a distinct shift in attitudes compared with just 5 years before and the willingness of HCV-uninfected patients to accept HCV-positive donors in the direct-acting antiviral (DAA) era (Figure LI 11).

Waiting List Outcomes

The overall deceased-donor transplant rate among adult waiting list candidates was 61.3 per 100 waiting list-years, continuing the upward trend that started in 2013 (Figure LI 12). The increase occurred regardless of age category, sex, blood type, or place of residence (metropolitan versus non-metropolitan) (Figure LI 13, Figure LI 15, Figure LI 17, Figure LI 18). Women had a lower deceased-donor transplant rate than men (55.8 v. 64.9 per 100 waiting list-years, respectively).

The deceased-donor transplant rate for candidates with HCC exception points remained higher than those without HCC exception (94.3 vs. 58.3 per 100 waiting list-years). Nonetheless, the transplant rate for patients with HCC exception is over 50% lower than it was 10 years before (193.4 per 100 waiting list-years). During this time period, multiple adjustments to the assignment of HCC exception points have been implemented, including standardized size and serum alpha-fetoprotein criteria, a mandatory 6-month waiting period after the initial application, a 34-point exception cap, and replacement of the “point escalator” with a static score based on median allocation MELD at transplant updated every 6 months. Compared with 2018, the deceased-donor transplant rate among patients without HCC exception increased from 50.5 to 58.3 per 100 waiting list-years (Figure LI 16).

The median waiting time (time from listing to transplant) remained low for candidates listed with the greatest medical urgency: 0.23 months for those with MELD ≥35, and 0.16 months for those listed as status 1A (Figure LI 20). The median waiting time for candidates with MELD 15-34 dropped from 8.5 to 5.6 months. Of waiting list registrants listed in 2018, 49.0% received a deceased-donor liver transplant within 1 year (Figure LI 21). Figure LI 19 shows 3-year outcomes for adults listed for liver transplant in 2016: 56.0% received a transplant (including 2.2% from a living donor), 11.3% died, and 23.3% were removed from the list without undergoing transplant, leaving 9.4% still waiting.

Geographic differences in deceased-donor transplant rates persisted, ranging from 35% to 90% at 3 years by donation service area (DSA) (Figure LI 22) and 31% to 86% by state of residence (Figure LI 23). DSA-level pretransplant mortality rates also varied, with a median of 13.3 per 100 waiting list-years (IQR 10.8-16.1) (Figure LI 33).

The overall pretransplant mortality rate in 2019 was 12.3 per 100 waiting list-years, down from a peak of 17.9 per 100 waiting list-years 5 years before (Figure LI 24). Higher rates of pretransplant mortality were observed among older age groups and those listed with higher initial laboratory MELD (Figure LI 25, Figure LI 30). Differences remained in pretransplant mortality rate by sex (11.4 per 100 waiting list-years for men, versus 13.8 for women) and by candidate residence (12.0 per 100 waiting list-years for metropolitan, versus 13.9 for non-metropolitan) (Figure LI 27, Figure LI 29). Pretransplant mortality among patients with HCV dropped from 16.8 to 8.5 per 100 waiting list-years over the past 5 years, reflecting the efficacy of DAA therapy, even among waiting list registrants (Figure LI 28). Pretransplant mortality among candidates with alcohol-related liver disease and HCC also dropped by a similar margin during that period. Candidates with acute liver failure and other/unknown etiology (usually non-alcoholic steatohepatitis) had higher rates of pretransplant mortality than other etiologies (22.4 and 15.4 per 100 waiting list years, respectively). Pretransplant mortality rate was similar between candidates with and without HCC exception, as well as between those with active and inactive status (Figure LI 31, Figure LI 32).

The most common reason for waiting list removal was deceased- or living-donor transplant (62.4%), followed by death or being too sick for transplant (18.1%), other reasons (12.0%), and condition improved and transplant no longer needed (6.7%) (Table LI 5). Deaths within 6 months after removal among waiting list candidates increased to 21.1%, compared with 16.9% in 2018, regardless of age or medical urgency category (Figure LI 34, Figure LI 35, Figure LI 36).

Donation

The number of deceased-donor livers recovered reached an all-time high of 9151 in 2019. Compared with previous years, there were no major differences in age, sex, or race (Figure LI 40, Figure LI 41, Figure LI 42). The availability of HCV-positive organs continued to increase, representing 9.7% of deceased-donor livers in 2019 (Figure LI 39, Figure LI 43).

Over the past decade, fewer pediatric (aged <18 years) livers were used for adult liver transplants, from 11.7% in 2009 to 7.7% in 2019 (Figure LI 40). This may decline further with the implementation of acuity circles and increased priority for pediatric donor livers to be allocated to pediatric recipients. Depending on the donor-specific antibodies, the allocation of pediatric donor livers to adults was 23.9% to 76.0% (Figure LI 44).

The organ discard rate (percentage of organs recovered for transplant and not transplanted) increased from 8.6% in 2018 to 9.6% in 2019 (Figure LI 45). This was driven by increased discard of grafts from donors aged ≥55 years and, to a lesser extent, those of donors aged 30-54 years. As expected, deceased-donor livers from older donors were less likely to be transplanted (Figure LI 46). As has been true since 2016, HCV-positive donors were not discarded more often than HCV-negative donors (Figure LI 50). Livers recovered from donors after circulatory death remained four times more likely to be discarded than livers recovered from donors after brain death (29.9% versus 7.1%, respectively) (Figure LI 52).

Amid the ongoing opioid epidemic in the United States, the proportion of donors with anoxic brain injury continued to rise, representing the leading cause of death among deceased donors (43.8%) (Figure LI 53). Head trauma and cerebrovascular accidents, respectively, were the second and third most common causes of death.

In 2019, 524 living-donor liver transplants were performed, a 31% increase over the year before (Figure LI 55, Figure LI 62). Most living donors were aged 18-54 years (Figure LI 56). An increasing proportion of living donors met criteria for obesity with a BMI ≥30 kg/m² (20.5%), although fewer than 1% of living donors had a BMI ≥35 (Figure LI 60). Right-lobe donation represented most living-donor liver transplants (71.3%) (Figure LI 59). The readmission rate for living liver donors who donated between 2014-2018 was 10.5% at 6 months and 12.5% at 12 months (Figure LI 54). Reported complications among living liver donors who donated between 2015-2019 included biliary complications (2.8%), vascular complications requiring intervention (0.8%), re-operation (2.0%), and other complications requiring intervention (6.2%) (Table LI 6). Of these same donors, 1.0% experienced Clavien Grade 1 complications, 1.5% had Clavien Grade 2, and 0.4% had Clavien Grade 3.

Transplants

In 2019, 8896 liver transplants were performed in the United States, more than in any previous year (Figure LI 61). This represented a 7.8% increase over the previous year and a 40.8% increase from 10 years earlier. The proportion of living-donor liver transplants continued to increase, making up 5.3% of all transplants in 2019 (Figure LI 62, Table LI 5). Most liver transplant recipients (69.6%) were aged >50 years, while 21.6% were ≥65 years (Figure LI 63); 8345 were adults (≥18 years), 442 (5.3%) of whom received living-donor transplants.

The number of liver transplants performed for alcohol-related liver disease and other/unknown disease (often non-alcoholic steatohepatitis) continued to rise in 2019, representing the two most common diagnoses and most transplants (65.1%) (Figure LI 66). Liver transplants for HCC, the third most common diagnosis, decreased from 16.0% to 14.0% compared with 2018. The proportion of liver transplants performed for HCV continued to fall, representing only 7.3% of transplants, down from 24.0% in 2014. Patients with HCV may still be represented among transplant recipients with a primary diagnosis of HCC.

Of adult liver transplant recipients, 63.7% were male; additionally, 70.7% were white, 16.0% were Hispanic, and 7.3% were black (Figure LI 64, Figure LI 65, Table LI 8). Coincident with the increased prevalence of non-alcoholic steatohepatitis, 37.7% were obese (BMI ≥30 kg/m²), and 30.0% had diabetes, compared with 33.6% and 25.6%, respectively, in 2009 (Table LI 9). From 2009 to 2019, the proportion of adult liver transplants covered by public insurance increased (22.4% to 30.0% for Medicare; 13.8% to 15.4% for Medicaid), while fewer transplants were covered by private insurance (59.4% to 50.8%) (Table LI 8). Regarding medical urgency, 20.4% of adults were transplanted with MELD ≥35, 18.4% with MELD 30-34, 53.0% with MELD 15-29, 5.6% with MELD <15, and 2.5% as status 1A (Table LI 9). Among adult liver transplant recipients, 34.9% waited fewer than 31 days on the waiting list, and 83.5% waited less than 1 year; 10.5% waited 1-2 years, 2.6% waited 2-3 years, and 3.4% waited ≥3 years (Table LI 10).

In 2019, 28.0% of adult liver transplant recipients had exception points, compared with 33.3% in 2018, potentially related to the policy change implemented mid-year, which changed the exception review structure and assigned fewer points for most exceptions. Of adult liver transplant recipients, 17.7% had MELD exception points for HCC, a decrease from 24.1% in 2009 and 20.4% in 2018 (Table LI 9).

Only 301 (3.6%) of adult liver transplant recipients had a previous liver transplant in 2019, compared with 414 (7.2%) in 2009 (Table LI 10). Of all liver transplants, 787 (9.4%) were multi-organ, most of which were simultaneous liver-kidney transplants (704, compared with 347 in 2009, Figure LI 67). There were 96 split livers (1.2%), unchanged from previous years, and 712 (8.5%) livers donated after circulatory death, an increase from 285 (5.0%) in 2009 and 531 (6.9%) in 2018.

From 2017 to 2019, 9.0% of livers transplanted to adults were from donors with positive HCV antibodies, and 5.9% were positive on HCV nucleic acid testing. Of adult liver transplant recipients without a history of HCV based on a negative antibody test, 4.2% received a liver from an HCV antibody-positive donor, while 2.5% received one from a donor positive for HCV on nucleic acid testing (Table LI 11).

Geographic variability in terms of median allocation MELD among adult deceased-donor liver transplant recipients was 19 to 36 across 52 DSAs (Figure LI 70). The highest was reported in New York (NYFL), and the lowest in Arkansas (AROR). The median DSA-level MELD at transplant was 26, down from 28 in the preceding 3 years (Figure LI 71). The interquartile range was wider (IQR 24.0-29.5), suggesting persistent geographic variability.

The National Liver Review Board was recently established to better standardize exceptions. As of May 2019, each center’s median allocation MELD at transplant now determines the number of MELD exception points given to qualifying candidates. In 2019, the median proportion of patients given exception points was 25.5% at the DSA-level (IQR 21.1-33.4%) (Figure LI 72).

In 2019, 127 programs performed adult liver transplants, and the median transplant program volume increased to 55 transplants per year (IQR 24-104) (Figure LI 74). Induction therapy was used in only 28% of adult liver transplants, and 71.0% of adult liver transplant recipients received steroid-containing immunosuppressive regimens (Figure LI 68, Figure LI 69).

Outcomes

Long-term outcomes after liver transplant continued to improve. Graft failure occurred in 6.6% of deceased-donor liver transplant recipients at 6 months and 8.9% at 1 year for transplants performed in 2018, in 15.2% at 3 years for transplants performed in 2016, in 21.6% at 5 years for transplants performed in 2014, and in 42.6% at 10 years for transplants performed in 2009 (Figure LI 76). Outcomes were similar, if not better, for living-donor liver transplant recipients, with graft failure occurring in 5.9% at 6 months, 7.1% at 1 year, 13.8% at 3 years, 23.7% at 5 years, and 32.1% at 10 years (Figure LI 77). Patient survival demonstrated similar patterns, with 5.3% mortality at 6 months, 7.4% at 1 year, 13.1% at 3 years, 19.7% at 5 years, and 39.5% at 10 years (Figure LI 78).

Five-year graft survival rates among deceased-donor liver transplant recipients exceeded 75% for all age groups except those aged ≥65 years (72.3%) and for all BMI categories except <18.5 kg/m² (Figure LI 79, Figure LI 84). Five-year graft survival rates were lower for recipients of livers donated after circulatory death than for those receiving livers donated after brain death (72.6% v. 77.1%) and comparable between those with and without HCC exception points (76.6% v. 77.0%) (Figure LI 82, Figure LI 83). Whereas deceased-donor liver transplant recipients with a primary diagnosis of HCC had 5-year survival rates comparable to other disease etiologies (75.2%), living-donor liver transplant recipients with HCC demonstrated worse 5-year survival rates (61.8%) (Figure LI 80, Figure LI 88). Five-year graft survival rates for deceased-donor liver transplant recipients with HCV were comparable to other etiologies of liver disease, which may point to the effectiveness of oral DAA agents for HCV introduced in 2013. Adult patient survival after deceased-donor liver transplant largely mirrored that of graft survival (Figure LI 95, Figure LI 96, Figure LI 97, Figure LI 98).

As of June 30, 2019, 93,761 liver transplant recipients were alive with a functioning graft, 82,304 of whom received a liver transplant as adults (Figure LI 91). Within 1 year, 12.3% of liver transplant recipients in 2017-2018 experienced at least one episode of acute rejection, most often among younger recipients (Figure LI 92). About 1% of adult liver recipients developed posttransplant lymphoproliferative disorder over 5 years (Figure LI 94).

Pediatric Transplant

Summary

As has been true in the past, 60% of all children listed for liver transplant in 2019 were aged 5 years or younger, and the highest rate of pretransplant mortality persisted for children aged younger than 1 year. This rate was persistently higher than rates for all adults, despite use of split and other technical variant grafts, high rates of exception scores, and living donation. Children are undergoing transplant at higher acuity than in the past, as evidenced by higher MELD/pediatric end-stage liver disease (PELD) scores and listings at status 1A and 1B. Higher acuity at transplant is likely due to lack of access to suitable donor organs, as dictated by current policy, which has been compensated for by persistent trends toward use of partial or split liver grafts and ABO-incompatible grafts. Despite higher illness severity scores at transplant, graft and patient survival posttransplant have improved over time.

Waiting List

In 2019, 686 new candidates were added to the pediatric liver transplant waiting list (Figure LI 104). The number of prevalent candidates (on the list on December 31 of the given year) continued a slow decrease to 462 overall (Table LI 16). Children aged younger than 1 year (29.9%) and 1-5 years (29.9%) made up the largest age groups, followed by ages 12-17 (24.4%) and 6-11 years (15.8%) (Figure LI 106). White candidates continued to make up the largest racial/ethnic group on the waiting list in 2019 (48.7%), followed by Hispanic (24.3%), Black (16.1%), and Asian candidates (7.6%) (Figure LI 107). For pediatric liver waitlist candidates from 2009 to 2019, sex, race, diagnosis, and geographic distributions changed little (Table LI 13, Table LI 14). Medical urgency has changed over time, with an increase in the proportions listed as status 1A and 1B. The proportion of candidates on the waiting list with exception status increased notably, to 27.6% in 2019, compared with 13.9% a decade earlier (Table LI 14). Waiting time shifted such that 55.0% of candidates waited less than 1 year in 2019, compared with 45.1% in 2009 (Table LI 15). Proportions of candidates listed for multi-organ transplants including liver have increased over time. Proportions of liver-kidney transplant candidates have increased from 1.3% to 3.1% over the past decade. The proportion of liver-pancreas-intestine transplant candidates increased from 7.9% in 2009 to 13.3% in 2019 (Table LI 15). Among candidates removed from the waiting list in 2019, 65.2% underwent deceased donor transplant, 11.1% underwent living donor transplant, 3.9% died, 11.7% were removed from the list because their condition improved, and 2.0% were considered too sick to undergo transplant (Table LI 17). Among newly listed candidates in 2016, 67% underwent deceased donor transplant within 3 years, 9% underwent living donor transplant, 5% died, 14% were removed from the list, and 5% were still waiting (Figure LI 109). In 2019, the rate of deceased donor transplants among pediatric candidates continued to increase, reaching 100.2 per 100 waitlist-years compared with 67.5 in 2008 (Figure LI 110). Transplant rates were highest for candidates aged younger than 1 year, 148.4 per 100 waitlist-years. The lowest rates were for candidates aged 12 to 17 years, 57.8 per 100 waitlist-years (Figure LI 111). Regarding medical urgency status, as expected, transplant rates were highest for status 1A (516.8 per 100 waitlist-years) and status 1B candidates (480.4 per 100 waitlist-years) (Figure LI 114). Among candidates listed with MELD/PELD scores, rates were similar for those with MELD/PELD 35 or higher and MELD/PELD 30-34, 154.6 and 172.3 transplants per 100 waitlist years, respectively, compared with 78.1 for those with MELD/PELD below 15 (Figure LI 113). Pretransplant mortality remained stable at 6.9 deaths per 100 waitlist-years in 2019 (Figure LI 116). The pretransplant mortality rate was highest for candidates aged younger than 1 year at 12.1 deaths per 100 waitlist-years in 2019, and lowest for candidates aged 1-5 years, at 3.9 deaths per 100 waitlist-years (Figure LI 117).

Transplant

The number of pediatric liver transplants has remained remarkably stable, with 551 transplants in 2019 (Figure LI 120), of which 79 (14.3%) were living donor liver transplants (Figure LI 121). Recipients aged younger than 6 years underwent the highest proportion of transplants from living donors, 18.1% (Figure LI 124). In 2019, 22 programs were performing pediatric-only liver transplants, compared with 88 performing adult-only transplants and 33 performing transplants in both adults and children (Figure LI 125). In 2019, 6.2% of transplants in candidates aged 0-10 years, 7.8% in those aged younger than 15 years, and 8.9% in those aged younger than 18 years were performed at programs with volumes of five or fewer pediatric transplants in that year (Figure LI 126). In 2019, 20.3% of liver transplants in pediatric recipients were split-liver transplants, compared with 14.4% a decade ago (Figure LI 127). The proportion of pediatric transplant recipients who underwent transplant by exception was 74.7%, compared with 28.7% among adult recipients (Figure LI 128). Among pediatric transplant recipients 2017-2019, percentages with exception points by DSA ranged from 28.6% to 100% (Figure LI 129). Despite use of exception scores, split grafts, and living donors, rates of pretransplant mortality were highest of all age groups for candidates aged younger than 1 year.

Over the past decade, recipient age, sex, and racial distributions have changed little, although fewer recipients were aged younger than 1 year (25.8% in 2017-2019 compared with 30.3% in 2007-2009) (Table LI 18). Cholestatic biliary atresia remained the leading cause of liver failure (33.5%) (Table LI 19). Most pediatric liver transplant recipients were not hospitalized before transplant (64.3%) and fewer were in the intensive care unit, 17.4% in 2017-2019 versus 25.6% in 2007-2009. Regarding medical urgency status, over the past decade, proportions of recipients undergoing transplant at status 1B increased. The proportion undergoing transplant with a MELD/PELD of 30 or higher increased from 29.1% to 44.4% over the past 10 years. MELD/PELD exception use increased from 27.5% in 2007-2009 to 47.9% in 2017-2019. Types of liver transplant procedures in pediatric recipients changed little over the past decade; 61.2% of patients received a whole liver in 2017-2019 and 19.5% received a partial liver (i.e., less than a whole liver was transplanted, possibly from a living donor, and the remainder of the liver was discarded) (Table LI 20). Use of split livers increased from 15.5% in 2007-2009 to 19.3% in 2017-2019. ABO-incompatible liver transplants occurred in 5.4% of recipients in 2017-2019, increased from 3.5% in the earlier era. Over the past decade, proportions of pediatric liver transplant recipients undergoing a liver-alone transplant increased from 84.2% in 2007-2009 to 91.5% in 2017-2019 (Table LI 20).

Immunosuppression and Outcomes

In 2019, 61% of pediatric liver transplant recipients received no induction therapy (Figure LI 130). The most commonly used initial immunosuppression regimens were tacrolimus, MMF, and steroids (39.4%) and tacrolimus and steroids (33.9%) (Figure LI 131).

Graft survival continued to improve over the past decade among pediatric recipients of deceased donor and living donor livers. Graft failure occurred in 6.2% at 6 months and in 7.8% at 1 year among deceased donor liver transplants performed in 2018, in 13.9% at 3 years for transplants performed in 2016, in 15.9% at 5 years for transplants performed in 2014, and in 24.8% at 10 years for transplants performed in 2009 (Figure LI 133). Graft failure occurred in 6.5% of recipients at 6 months and in 6.5% at 1 year posttransplant among living donor transplants performed in 2018, in 6.5% at 3 years for transplants performed in 2016, in 9.6% at 5 years for transplants performed in 2014, and in 17.6% at 10 years for transplants performed in 2009 (Figure LI 134). By age, 5-year graft survival was 81.1% for recipients aged younger than 1 year, 82.4% for ages 1-5 years, 85.3% for ages 6-10 years, and 85.5% for ages 11-17 years (Figure LI 135). Five-year graft survival was 83.5% for recipients who underwent transplant with MELD/PELD below 15 (Figure LI 137). In 2017-2018, incidence of acute rejection by 1 year posttransplant was 25.4% overall, varying from 21.3% in recipients aged younger than 1 year to 29.4% in those aged 1-5 years (Figure LI 139). Incidence of posttransplant lymphoproliferative disorder was 4.7% at 5 years posttransplant for recipients who were EBV negative and 3.1% for those who were positive (Figure LI 140). Among pediatric liver transplants 2012-2014, overall 5-year patient survival was 89.3% with little variation by age at transplant (Figure LI 142, Figure LI 143). By primary diagnosis, 5-year patient survival ranged from 93% for those with acute liver failure and biliary atresia to 81% for those with hepatoblastoma (Figure LI 144). Patient death occurred in 3.7% of recipients at 6 months and in 4.6% at 1 year posttransplant for transplants performed in 2018, in 9.4% at 3 years for transplants performed in 2016, in 9.2% at 5 years for transplants performed in 2014, and in 18.2% at 10 years for transplants performed in 2009 (Figure LI 141).

Figure List

Waiting list

Figure LI 1. New adult candidates added to the liver transplant waiting list
Figure LI 2. All adult candidates on the liver transplant waiting list
Figure LI 3. Distribution of adults waiting for liver transplant by age
Figure LI 4. Distribution of adults waiting for liver transplant by sex
Figure LI 5. Distribution of adults waiting for liver transplant by race
Figure LI 6. Distribution of adults waiting for liver transplant by diagnosis
Figure LI 7. Distribution of adults waiting for liver transplant by first active lab MELD in the year
Figure LI 8. Distribution of adults waiting for liver transplant by BMI
Figure LI 9. Distribution of adults waiting for liver transplant by blood type
Figure LI 10. Distribution of adults waiting for liver transplant by prior transplant status
Figure LI 11. Adults willing to accept liver from HCV+ donor
Figure LI 12. Overall deceased donor liver transplant rates among adult waitlist candidates
Figure LI 13. Deceased donor liver transplant rates among adult waitlist candidates by age
Figure LI 14. Deceased donor liver transplant rates among adult waitlist candidates by race
Figure LI 15. Deceased donor liver transplant rates among adult waitlist candidates by blood type
Figure LI 16. Deceased donor liver transplant rates among adult waitlist candidates by HCC exception status
Figure LI 17. Deceased donor liver transplant rates among adult waitlist candidates by sex
Figure LI 18. Deceased donor liver transplant rates among adult waitlist candidates by metropolitan vs. non-metropolitan residence
Figure LI 19. Three-year outcomes for adults waiting for liver transplant, new listings in 2016
Figure LI 20. Median months to liver transplant for waitlisted adults
Figure LI 21. Percentage of adults who underwent deceased donor liver transplant within a given time period of listing
Figure LI 22. Percentage of adults who underwent deceased donor liver transplant within 3 years of listing, 2016, by DSA
Figure LI 23. Percentage of adults who underwent deceased donor liver transplant within 3 years of listing, 2016, by state
Figure LI 24. Overall pretransplant mortality rates among adults waitlisted for liver transplant
Figure LI 25. Pretransplant mortality rates among adults waitlisted for liver transplant by age
Figure LI 26. Pretransplant mortality rates among adults waitlisted for liver transplant by race
Figure LI 27. Pretransplant mortality rates among adults waitlisted for liver transplant by sex
Figure LI 28. Pretransplant mortality rates among adults waitlisted for liver transplant by diagnosis
Figure LI 29. Pretransplant mortality rates among adults waitlisted for liver transplant by metropolitan vs. non-metropolitan residence
Figure LI 30. Pretransplant mortality rates among adults waitlisted for liver transplant by first active labe MELD in the year
Figure LI 31. Pretransplant mortality rates among adults waitlisted for liver by HCC exception status
Figure LI 32. Pretransplant mortality rates among adults waitlisted for liver transplant, by active/inactive status
Figure LI 33. Pretransplant mortality rates among adults waitlisted for liver transplant in 2019 by DSA
Figure LI 34. Deaths within six months after removal among adult liver waitlist candidates, overall
Figure LI 35. Deaths within six months after removal among adult liver waitlist candidates, by first active labe MELD in the year
Figure LI 36. Deaths within six months after removal among adult liver waitlist candidates, by age

Deceased donation

Figure LI 37. Overall deceased liver donor count
Figure LI 38. Deceased liver donor count by age
Figure LI 39. Deceased liver donor count by HCV status
Figure LI 40. Distribution of deceased liver donors by age
Figure LI 41. Distribution of deceased liver donors by sex
Figure LI 42. Distribution of deceased liver donors by race
Figure LI 43. Distribution of deceased liver donors by donor HCV status
Figure LI 44. Percent of pediatric donor livers allocated to adult recipients, by DSA of donor hospital, 2015-2019
Figure LI 45. Overall rates of livers recovered for transplant and not transplanted
Figure LI 46. Rates of livers recovered for transplant and not transplanted by donor age
Figure LI 47. Rates of livers recovered for transplant and not transplanted by donor sex
Figure LI 48. Rates of livers recovered for transplant and not transplanted by donor race
Figure LI 49. Rates of livers recovered for transplant and not transplanted by donor cause of death
Figure LI 50. Rates of livers recovered for transplant and not transplanted by donor HCV status
Figure LI 51. Rates of livers recovered for transplant and not transplanted, by donor risk of disease transmission
Figure LI 52. Rates of livers recovered for transplant and not transplanted by DCD status
Figure LI 53. Cause of death among deceased liver donors

Living donation

Figure LI 54. Rehospitalization among living liver donors, 2014-2018
Figure LI 55. Number of living liver transplants by donor relation
Figure LI 56. Living liver donors by age
Figure LI 57. Living liver donors by sex
Figure LI 58. Living liver donors by race
Figure LI 59. Living donor liver transplant graft type
Figure LI 60. BMI among living liver donors

Transplant

Figure LI 61. Overall liver transplants
Figure LI 62. Total liver transplants by donor type
Figure LI 63. Total liver transplants by age
Figure LI 64. Total liver transplants by sex
Figure LI 65. Total liver transplants by race
Figure LI 66. Total liver transplants by diagnosis
Figure LI 67. Total kidney-liver transplants by adult vs. pediatric age groups
Figure LI 68. Induction agent use in adult liver transplant recipients
Figure LI 69. Immunosuppression regimen use in adult liver transplant recipients
Figure LI 70. Median MELD scores for adult deceased donor liver transplant recipients by DSA, 2019
Figure LI 71. Variation in DSA-level median MELD at transplant among adult liver recipients
Figure LI 72. Percent of adult liver transplant recipients using exceptions in 2019, by DSA
Figure LI 73. Total HLA A, B, and DR mismatches among adult deceased donor liver-kidney transplant recipients, 2015-2019
Figure LI 74. Annual adult liver transplant center volumes by percentile
Figure LI 75. Distribution of adult liver transplants by annual center volume

Outcomes

Figure LI 76. Graft failure among adult deceased donor liver transplant recipients
Figure LI 77. Graft failure among adult living donor liver transplant recipients
Figure LI 78. Patient death among adult liver transplant recipients
Figure LI 79. Graft survival among adult deceased donor liver transplant recipients, 2012-2014, by age
Figure LI 80. Graft survival among adult deceased donor liver transplant recipients, 2012-2014, by diagnosis
Figure LI 81. Graft survival among adult deceased donor liver transplant recipients, 2012-2014, by medical urgency
Figure LI 82. Graft survival among adult deceased donor liver transplant recipients, 2012-2014, by DCD status
Figure LI 83. Graft survival among adult deceased donor liver transplant recipients, 2012-2014, by HCC status
Figure LI 84. Graft survival among adult deceased donor liver transplant recipients, 2012-2014, by BMI
Figure LI 85. Graft survival among adult deceased donor liver transplant recipients, 2012-2014, by metropolitan vs. non-metropolitan recipient residence
Figure LI 86. Graft survival among adult living donor liver transplant recipients, 2012-2014, by age
Figure LI 87. Graft survival among adult living donor liver transplant recipients, 2012-2014, by race
Figure LI 88. Graft survival among adult living donor liver transplant recipients, 2012-2014, by diagnosis
Figure LI 89. Graft survival among adult living donor liver transplant recipients, 2012-2014, by medical urgency
Figure LI 90. Graft survival among adult living donor liver transplant recipients, 2012-2014, by metropolitan vs. non-metropolitan recipient residence
Figure LI 91. Recipients alive with a functioning liver graft on June 30 of the year, by age at transplant
Figure LI 92. Incidence of acute rejection by 1 year posttransplant among adult liver transplant recipients by age, 2017-2018
Figure LI 93. Incidence of acute rejection by 1 year posttransplant among adult liver transplant recipients by induction agent, 2017-2018
Figure LI 94. Incidence of PTLD among adult liver transplant recipients by recipient EBV status at transplant, 2013-2017
Figure LI 95. Patient survival among adult deceased donor liver transplant recipients, 2012-2014, by age
Figure LI 96. Patient survival among adult deceased donor liver transplant recipients, 2012-2014, by diagnosis
Figure LI 97. Patient survival among adult deceased donor liver transplant recipients, 2012-2014, by medical urgency
Figure LI 98. Patient survival among adult deceased donor liver transplant recipients, 2012-2014, by metropolitan vs. non-metropolitan recipient residence
Figure LI 99. Patient survival among adult living donor liver transplant recipients, 2012-2014, by age
Figure LI 100. Patient survival among adult living donor liver transplant recipients, 2012-2014, by diagnosis
Figure LI 101. Patient survival among adult living donor liver transplant recipients, 2012-2014, by race
Figure LI 102. Patient survival among adult living donor liver transplant recipients, 2012-2014, by MELD score
Figure LI 103. Patient survival among adult living donor liver transplant recipients, 2012-2014, by metropolitan vs. non-metropolitan recipient residence

Pediatric transplant

Figure LI 104. New pediatric candidates added to the liver transplant waiting list
Figure LI 105. All pediatric candidates on the liver transplant waiting list
Figure LI 106. Distribution of pediatric candidates waiting for liver transplant by age
Figure LI 107. Distribution of pediatric candidates waiting for liver transplant by race
Figure LI 108. Distribution of pediatric candidates waiting for liver transplant by sex
Figure LI 109. Three-year outcomes for newly listed pediatric candidates waiting for liver transplant, 2016
Figure LI 110. Overall deceased donor liver transplant rates among pediatric waitlist candidates
Figure LI 111. Deceased donor liver transplant rates among pediatric waitlist candidates by age
Figure LI 112. Deceased donor liver transplant rates among pediatric waitlist candidates by race
Figure LI 113. Deceased donor liver transplant rates among pediatric waitlist candidates by MELD/PELD
Figure LI 114. Deceased donor liver transplant rates among pediatric waitlist candidates by Status 1A or 1B
Figure LI 115. Deceased donor liver transplant rates among pediatric waitlist candidates by metropolitan vs. non-metropolitan residence
Figure LI 116. Overall pretransplant mortality rates among pediatric candidates waitlisted for liver
Figure LI 117. Pretransplant mortality rates among pediatric candidates waitlisted for liver transplant by age
Figure LI 118. Pretransplant mortality rates among pediatric candidates waitlisted for liver transplant by race
Figure LI 119. Pretransplant mortality rates among pediatric candidates waitlisted for liver transplant by metropolitan vs. non-metropolitan residence
Figure LI 120. Overall pediatric liver transplants
Figure LI 121. Pediatric liver transplants by donor type
Figure LI 122. Pediatric liver transplants by recipient age
Figure LI 123. Pediatric liver transplants from living donors by relation
Figure LI 124. Percent of pediatric liver transplants from living donors by recipient age
Figure LI 125. Number of centers performing pediatric and adult liver transplants by center's age mix
Figure LI 126. Pediatric liver recipients at programs that perform 5 or fewer pediatric transplants annually
Figure LI 127. Split or partial liver transplants in children
Figure LI 128. Percent of pediatric and adult liver transplant recipients allocated by exception
Figure LI 129. Percent of pediatric liver transplant recipients using exceptions, 2017-2019, by DSA
Figure LI 130. Induction agent use in pediatric liver transplant recipients
Figure LI 131. Immunosuppression regimen use in pediatric liver transplant recipients
Figure LI 132. Total HLA A, B, and DR mismatches among pediatric deceased donor liver-kidney transplant recipients, 2015-2019
Figure LI 133. Graft failure among pediatric deceased donor liver transplant recipients
Figure LI 134. Graft failure among pediatric living donor liver transplant recipients
Figure LI 135. Graft survival among pediatric deceased donor liver transplant recipients, 2012-2014, by age
Figure LI 136. Graft survival among pediatric deceased donor liver transplant recipients, 2012-2014, by diagnosis
Figure LI 137. Graft survival among pediatric deceased donor liver transplant recipients, 2012-2014, by MELD/PELD score
Figure LI 138. Graft survival among pediatric liver transplant recipients, 2012-2014, by donor type
Figure LI 139. Incidence of acute rejection by 1 year posttransplant among pediatric liver transplant recipients by age, 2017-2018
Figure LI 140. Incidence of PTLD among pediatric liver transplant recipients by recipient EBV status at transplant, 2007-2017
Figure LI 141. Patient death among pediatric liver transplant recipients
Figure LI 142. Overall patient survival among pediatric deceased donor liver transplant recipients, 2012-2014
Figure LI 143. Patient survival among pediatric deceased donor liver transplant recipients, 2012-2014, by recipient age
Figure LI 144. Patient survival among pediatric deceased donor liver transplant recipients, 2012-2014, by diagnosis
Figure LI 145. Patient survival among pediatric deceased donor liver transplant recipients, 2012-2014, by donor type

Table List

Waiting list

Table LI 1. Demographic characteristics of adults on the liver transplant waiting list on December 31, 2009 and December 31, 2019
Table LI 2. Clinical characteristics of adults on the liver transplant waiting list on December 31, 2009 and December 31, 2019
Table LI 3. Listing characteristics of adults on the liver transplant waiting list on December 31, 2009 and December 31, 2019
Table LI 4. Liver transplant waitlist activity among adults
Table LI 5. Removal reason among adult liver transplant candidates

Living donation

Table LI 6. Complications among living liver donors, 2015-2019
Table LI 7. Living liver donor deaths in the first year after donoation, 2015-2019, by number of days after donation

Transplant

Table LI 8. Demographic characteristics of adult liver transplant recipients, 2009 and 2019
Table LI 9. Clinical characteristics of adult liver transplant recipients, 2009 and 2019
Table LI 10. Transplant characteristics of adult liver transplant recipients, 2009 and 2019
Table LI 11. Adult deceased donor liver donor-recipient serology matching, 2017-2019
Table LI 12. Adult living donor liver donor-recipient serology matching, 2017-2019

Pediatric transplant

Table LI 13. Demographic characteristics of pediatric candidates on the liver transplant waiting list on December 31, 2009 and December 31, 2019
Table LI 14. Clinical characteristics of pediatric candidates on the liver transplant waiting list on December 31, 2009 and December 31, 2019
Table LI 15. Listing characteristics of pediatric candidates on the liver transplant waiting list on December 31, 2009 and December 31, 2019
Table LI 16. Liver transplant waitlist activity among pediatric candidates
Table LI 17. Removal reason among pediatric liver transplant candidates
Table LI 18. Demographic characteristics of pediatric liver transplant recipients, 2007-2009 and 2017-2019
Table LI 19. Clinical characteristics of pediatric liver transplant recipients, 2007-2009 and 2017-2019
Table LI 20. Transplant characteristics of pediatric liver transplant recipients, 2007-2009 and 2017-2019
Table LI 21. Pediatric liver donor-recipient serology matching, 2017-2019
Table LI 22. Pediatric liver donor-recipient serology matching for living donors, 2017-2019

Table LI 1. Demographic characteristics of adults on the liver transplant waiting list on December 31, 2009 and December 31, 2019
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	2009, N	2009, Percent	2019, N	2019, Percent
Age: 18-34 years	670	4.3%	615	4.9%
Age: 35-49 years	2785	17.9%	1912	15.2%
Age: 50-64 years	10,032	64.3%	6403	51.0%
Age: ≥ 65 years	2104	13.5%	3625	28.9%
Sex: Female	6094	39.1%	4923	39.2%
Sex: Male	9497	60.9%	7632	60.8%
Race/ethnicity: White	11,010	70.6%	8525	67.9%
Race/ethnicity: Black	1088	7.0%	886	7.1%
Race/ethnicity: Hispanic	2565	16.5%	2270	18.1%
Race/ethnicity: Asian	767	4.9%	683	5.4%
Race/ethnicity: Other/unknown	161	1.0%	191	1.5%
Geography: Metropolitan	13,238	84.9%	10,712	85.3%
Geography: Non-metro	2353	15.1%	1843	14.7%
Distance: < 50 miles	8856	56.8%	7462	59.4%
Distance: 50-<100 miles	2730	17.5%	2260	18.0%
Distance: 100-<150 miles	1397	9.0%	1070	8.5%
Distance: 150-<250 miles	1261	8.1%	956	7.6%
Distance: ≥ 250 miles	1239	7.9%	761	6.1%
Distance: Unknown	108	0.7%	46	0.4%
All candidates	15,591	100.0%	12,555	100.0%

Table LI 2. Clinical characteristics of adults on the liver transplant waiting list on December 31, 2009 and December 31, 2019
Candidates waiting for transplant on December 31 of the given year, regardless of first listing date. HCC, hepatocellular carcinoma; HCV, hepatitis C virus.

Characteristic	2009, N	2009, Percent	2019, N	2019, Percent
Diagnosis: Acute liver failure	405	2.6%	160	1.3%
Diagnosis: HCV	4871	31.2%	1789	14.2%
Diagnosis: Alcoholic liver disease	3478	22.3%	3861	30.8%
Diagnosis: Cholestatic disease	1519	9.7%	1062	8.5%
Diagnosis: HCC	559	3.6%	1288	10.3%
Diagnosis: Other/unknown	4759	30.5%	4395	35.0%
Blood type: A	5848	37.5%	4878	38.9%
Blood type: B	1830	11.7%	1272	10.1%
Blood type: AB	363	2.3%	258	2.1%
Blood type: O	7550	48.4%	6147	49.0%
Medical urgency: Status 1A	5	0.0%	3	0.0%
Medical urgency: MELD ≥ 35	44	0.3%	49	0.4%
Medical urgency: MELD 30-34	69	0.4%	248	2.0%
Medical urgency: MELD 15-29	4002	25.7%	4072	32.4%
Medical urgency: MELD < 15	8472	54.3%	5467	43.5%
Medical urgency: Inactive	2999	19.2%	2716	21.6%
Exception status: None	14,435	92.6%	10,457	83.3%
Exception status: HCC	847	5.4%	1735	13.8%
Exception status: Other	309	2.0%	363	2.9%
All candidates	15,591	100.0%	12,555	100.0%

Table LI 3. Listing characteristics of adults on the liver transplant waiting list on December 31, 2009 and December 31, 2019
Candidates waiting for transplant on December 31 of the given year, regardless of first listing date.

Characteristic	2009, N	2009, Percent	2019, N	2019, Percent
Transplant history: First	15,119	97.0%	12,243	97.5%
Transplant history: Retransplant	472	3.0%	312	2.5%
Wait time: < 1 year	5351	34.3%	6001	47.8%
Wait time: 1-< 2 years	2815	18.1%	2329	18.6%
Wait time: 2-< 3 years	1919	12.3%	1327	10.6%
Wait time: 3-< 4 years	1349	8.7%	737	5.9%
Wait time: 4-< 5 years	981	6.3%	561	4.5%
Wait time: ≥ 5 years	3176	20.4%	1600	12.7%
Tx type: Liver alone	15,079	96.7%	11,488	91.5%
Tx type: Liver-kidney	457	2.9%	975	7.8%
Tx type: Liver-pancreas-intestine	23	0.1%	29	0.2%
Tx type: Liver-heart	15	0.1%	36	0.3%
Tx type: Other	17	0.1%	27	0.2%
All candidates	15,591	100.0%	12,555	100.0%

Table LI 4. Liver 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	2017	2018	2019
Patients at start of year	14,093	13,591	13,093
Patients added during year	12,196	12,418	12,767
Patients removed during year	12,674	12,892	13,298
Patients at end of year	13,615	13,117	12,562

Table LI 5. Removal reason among adult liver 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	2017	2018	2019
Deceased donor transplant	7137	7295	7850
Living donor transplant	294	338	442
Transplant outside US	10	2	1
Patient died	1370	1280	1291
Patient refused transplant	121	138	115
Improved, transplant not needed	879	974	890
Too sick for transplant	1210	1254	1114
Other	1653	1611	1595

Table LI 6. Complications among living liver donors, 2015-2019
Complications reported on the OPTN Living Donor Registration Form. Clavien Grade 1, bilious Jackson Pratt drainage more than 10 days; Clavien Grade 2, interventional procedure (endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, percutaneous drainage, etc.); Clavien Grade 3, surgical intervention. Clavien grades refer to biliary complications. Domino liver donors excluded.

Level	N	Pct
Biliary complication: Yes	55	2.8%
Biliary complication: No	1890	97.1%
Biliary complication: Unknown	1	0.1%
Clavien Grade: 1	20	1.0%
Clavien Grade: 2	29	1.5%
Clavien Grade: 3	8	0.4%
Vascular complication, requiring intervention: Yes	16	0.8%
Vascular complication, requiring intervention: No	1929	99.1%
Vascular complication, requiring intervention: Unknown	1	0.1%
Other complication, requiring intervention: Yes	121	6.2%
Other complication, requiring intervention: No	1824	93.7%
Other complication, requiring intervention: Unknown	1	0.1%
Re-operation: Yes	39	2.0%
Re-operation: No	1905	97.9%
Re-operation: Unknown	2	0.1%

Table LI 7. Living liver donor deaths in the first year after donoation, 2015-2019, by number of days after donation
Living liver 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	0	0
Accident/homicide	0	0	0
Medical	1	0	0
Cancer	0	0	0
Unknown	0	0	0
TOTAL	1	0	0

Table LI 8. Demographic characteristics of adult liver transplant recipients, 2009 and 2019
Liver transplant recipients, including retransplants. Distance is computed from recipient's home zip code to the transplant center.

Characteristic	2009, N	2009, Percent	2019, N	2019, Percent
Age: 18-34 years	352	6.1%	572	6.9%
Age: 35-49 years	1092	19.0%	1579	18.9%
Age: 50-64 years	3606	62.7%	4274	51.2%
Age: ≥ 65 years	698	12.1%	1920	23.0%
Sex: Female	1862	32.4%	3031	36.3%
Sex: Male	3886	67.6%	5314	63.7%
Race/ethnicity: White	4113	71.6%	5904	70.7%
Race/ethnicity: Black	575	10.0%	610	7.3%
Race/ethnicity: Hispanic	722	12.6%	1335	16.0%
Race/ethnicity: Asian	282	4.9%	356	4.3%
Race/ethnicity: Other/unknown	56	1.0%	140	1.7%
BMI: < 18.5 kg/m2	149	2.6%	145	1.7%
BMI: 18.5-< 25 kg/m2	1627	28.3%	2213	26.5%
BMI: 25-< 28 kg/m2	1261	21.9%	1728	20.7%
BMI: 28-< 30 kg/m2	767	13.3%	1099	13.2%
BMI: 30-< 35 kg/m2	1198	20.8%	1865	22.3%
BMI: ≥ 35 kg/m2	737	12.8%	1286	15.4%
BMI: Unknown	9	0.2%	9	0.1%
Insurance: Private	3413	59.4%	4240	50.8%
Insurance: Medicare	1290	22.4%	2505	30.0%
Insurance: Medicaid	794	13.8%	1281	15.4%
Insurance: Unknown	251	4.4%	319	3.8%
Geography: Metropolitan	4836	84.1%	6973	83.6%
Geography: Non-metro	912	15.9%	1372	16.4%
Distance: < 50 miles	3273	56.9%	4778	57.3%
Distance: 50-<100 miles	913	15.9%	1500	18.0%
Distance: 100-<150 miles	554	9.6%	755	9.0%
Distance: 150-<250 miles	499	8.7%	642	7.7%
Distance: ≥ 250 miles	452	7.9%	617	7.4%
Distance: Unknown	57	1.0%	53	0.6%
All recipients	5748	100.0%	8345	100.0%

Table LI 9. Clinical characteristics of adult liver transplant recipients, 2009 and 2019
Liver transplant recipients, including retransplants. HCC, hepatocellular carcinoma; HCV, hepatitis C virus.

Characteristic	2009, N	2009, Percent	2019, N	2019, Percent
Diagnosis: Acute liver failure	251	4.4%	254	3.0%
Diagnosis: HCV	1529	26.6%	647	7.8%
Diagnosis: Alcoholic liver disease	948	16.5%	2584	31.0%
Diagnosis: Cholestatic disease	460	8.0%	670	8.0%
Diagnosis: HCC	1050	18.3%	1239	14.8%
Diagnosis: Other/unknown	1510	26.3%	2951	35.4%
Blood type: A	2112	36.7%	3071	36.8%
Blood type: B	769	13.4%	1125	13.5%
Blood type: AB	264	4.6%	403	4.8%
Blood type: O	2603	45.3%	3746	44.9%
Medical condition: Hospitalized in ICU	712	12.4%	1146	13.7%
Medical condition: Hospitalized, not ICU	1032	18.0%	1596	19.1%
Medical condition: Not hospitalized	4004	69.7%	5599	67.1%
Medical condition: Hospitalization unknown	0	0.0%	4	0.0%
Medical urgency: Status 1A	260	4.5%	211	2.5%
Medical urgency: MELD ≥ 35	797	13.9%	1702	20.4%
Medical urgency: MELD 30-34	646	11.2%	1538	18.4%
Medical urgency: MELD 15-29	3864	67.2%	4421	53.0%
Medical urgency: MELD < 15	180	3.1%	468	5.6%
Medical urgency: Unknown	1	0.0%	5	0.1%
HCC exception	1386	24.1%	1474	17.7%
Other MELD exception	550	9.6%	858	10.3%
Diabetes	1474	25.6%	2507	30.0%
All recipients	5748	100.0%	8345	100.0%

Table LI 10. Transplant characteristics of adult liver transplant recipients, 2009 and 2019
Liver transplant recipients, including retransplants. DBD, donation after brain death; DCD, donation after circulatory death.

Characteristic	2009, N	2009, Percent	2019, N	2019, Percent
Wait time: < 31 days	2015	35.1%	2914	34.9%
Wait time: 31-60 days	683	11.9%	828	9.9%
Wait time: 61-90 days	424	7.4%	547	6.6%
Wait time: 3-< 6 months	877	15.3%	1019	12.2%
Wait time: 6-< 12 months	753	13.1%	1660	19.9%
Wait time: 1-< 2 years	511	8.9%	873	10.5%
Wait time: 2-< 3 years	197	3.4%	219	2.6%
Wait time: ≥ 3 years	288	5.0%	285	3.4%
Donor type: Deceased	5580	97.1%	7900	94.7%
Donor type: Living	168	2.9%	445	5.3%
Procedure: Whole liver	5519	96.0%	7805	93.5%
Procedure: Partial liver	156	2.7%	444	5.3%
Procedure: Split liver	73	1.3%	96	1.2%
DCD status: DBD	5463	95.0%	7633	91.5%
DCD status: DCD	285	5.0%	712	8.5%
Transplant history: First	5334	92.8%	8044	96.4%
Transplant history: Retransplant	414	7.2%	301	3.6%
Tx type: Liver only	5354	93.1%	7558	90.6%
Tx type: Liver-kidney	347	6.0%	704	8.4%
Tx type: Liver-intestine-pancreas	17	0.3%	17	0.2%
Tx type: Liver-intestine	1	0.0%	0	0.0%
Tx type: Other	29	0.5%	66	0.8%
All recipients	5748	100.0%	8345	100.0%

Table LI 11. Adult deceased donor liver donor-recipient serology matching, 2017-2019
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-	14.5%	0.6%	95.1%	72.7%	74.4%
D-	R+	22.0%	5.7%	3.6%	17.1%	18.5%
D-	R unk	0.3%	1.6%	1.1%	1.2%	1.2%
D+	R-	22.6%	6.1%	0.1%	4.2%	2.5%
D+	R+	39.5%	74.1%	0.0%	4.7%	3.3%
D+	R unk	0.7%	11.9%	0.0%	0.1%	0.1%
D unk	R-	0.1%	0.0%	0.0%	0.0%	0.0%
D unk	R+	0.3%	0.1%	0.0%	0.0%	0.0%
D unk	R unk	0.0%	0.0%	0.0%	0.0%	0.0%

Table LI 12. Adult living donor liver donor-recipient serology matching, 2017-2019
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-	32.5%	1.1%	94.6%	85.7%	83.0%
D-	R+	26.0%	10.2%	2.4%	11.4%	11.8%
D-	R unk	0.2%	2.8%	1.0%	1.0%	0.9%
D+	R-	14.0%	5.6%	0.2%	0.2%	0.0%
D+	R+	25.4%	71.0%	0.0%	0.5%	0.0%
D+	R unk	0.4%	4.3%	0.0%	0.0%	0.0%
D unk	R-	0.9%	0.6%	1.8%	1.1%	4.0%
D unk	R+	0.6%	1.0%	0.0%	0.1%	0.2%
D unk	R unk	0.0%	3.5%	0.0%	0.0%	0.1%

Table LI 13. Demographic characteristics of pediatric candidates on the liver transplant waiting list on December 31, 2009 and December 31, 2019
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	2009, N	2009, Percent	2019, N	2019, Percent
Age: < 1 year	59	10.8%	44	11.3%
Age: 1-5 years	177	32.5%	146	37.3%
Age: 6-10 years	127	23.3%	82	21.0%
Age: 11-17 years	182	33.4%	119	30.4%
Sex: Female	293	53.8%	188	48.1%
Sex: Male	252	46.2%	203	51.9%
Race/ethnicity: White	286	52.5%	173	44.2%
Race/ethnicity: Black	75	13.8%	66	16.9%
Race/ethnicity: Hispanic	146	26.8%	106	27.1%
Race/ethnicity: Asian	27	5.0%	31	7.9%
Race/ethnicity: Other/unknown	11	2.0%	15	3.8%
Geography: Metropolitan	472	86.6%	335	85.7%
Geography: Non-metro	73	13.4%	56	14.3%
Distance: < 50 miles	294	53.9%	182	46.5%
Distance: 50-<100 miles	64	11.7%	69	17.6%
Distance: 100-<150 miles	46	8.4%	40	10.2%
Distance: 150-<250 miles	45	8.3%	44	11.3%
Distance: ≥ 250 miles	81	14.9%	48	12.3%
Distance: Unknown	15	2.8%	8	2.0%
All candidates	545	100.0%	391	100.0%

Table LI 14. Clinical characteristics of pediatric candidates on the liver transplant waiting list on December 31, 2009 and December 31, 2019
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. Pediatric candidates aged 12 to 17 years can be assigned MELD or PELD scores.

Characteristic	2009, N	2009, Percent	2019, N	2019, Percent
Diagnosis: Acute liver failure	48	8.8%	20	5.1%
Diagnosis: Cholestatic biliary atresia	182	33.4%	131	33.5%
Diagnosis: Other cholestatic	55	10.1%	49	12.5%
Diagnosis: Hepatoblastoma	8	1.5%	7	1.8%
Diagnosis: Metabolic	56	10.3%	47	12.0%
Diagnosis: Other/unknown	196	36.0%	137	35.0%
Blood type: A	152	27.9%	113	28.9%
Blood type: B	73	13.4%	48	12.3%
Blood type: AB	10	1.8%	5	1.3%
Blood type: O	310	56.9%	225	57.5%
Medical urgency: Status 1A	0	0.0%	3	0.8%
Medical urgency: Status 1B	11	2.0%	23	5.9%
Medical urgency: MELD/PELD ≥ 30	55	10.1%	83	21.2%
Medical urgency: MELD/PELD 15-29	80	14.7%	58	14.8%
Medical urgency: MELD/PELD < 15	150	27.5%	101	25.8%
Medical urgency: Inactive	249	45.7%	123	31.5%
Exception status: None	469	86.1%	283	72.4%
Exception status: Granted	76	13.9%	108	27.6%
All candidates	545	100.0%	391	100.0%

Table LI 15. Listing characteristics of pediatric candidates on the liver transplant waiting list on December 31, 2009 and December 31, 2019
Candidates aged younger than 18 years waiting for transplant on December 31, 2008 in the given year, regardless of first listing date. Candidates listed as children who turned 18 before the cohort date are excluded.

Characteristic	2009, N	2009, Percent	2019, N	2019, Percent
Transplant history: First	488	89.5%	357	91.3%
Transplant history: Retransplant	57	10.5%	34	8.7%
Wait time: < 1 year	246	45.1%	215	55.0%
Wait time: 1-< 2 years	60	11.0%	69	17.6%
Wait time: 2-< 3 years	49	9.0%	35	9.0%
Wait time: 3-< 4 years	36	6.6%	24	6.1%
Wait time: 4-< 5 years	28	5.1%	18	4.6%
Wait time: ≥ 5 years	126	23.1%	30	7.7%
Tx type: Liver alone	472	86.6%	319	81.6%
Tx type: Liver-kidney	7	1.3%	12	3.1%
Tx type: Liver-pancreas-intestine	43	7.9%	52	13.3%
Tx type: Liver-heart	1	0.2%	3	0.8%
Tx type: Other	22	4.0%	5	1.3%
All candidates	545	100.0%	391	100.0%

Table LI 16. Liver 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	2017	2018	2019
Patients at start of year	570	546	517
Patients added during year	751	734	686
Patients removed during year	774	763	741
Patients at end of year	547	517	462

Table LI 17. Removal reason among pediatric liver 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	2017	2018	2019
Deceased donor transplant	536	511	483
Living donor transplant	73	62	82
Transplant outside US	1	0	0
Patient died	38	33	29
Patient refused transplant	1	1	1
Improved, transplant not needed	56	91	87
Too sick for transplant	10	20	15
Other	59	45	44

Table LI 18. Demographic characteristics of pediatric liver transplant recipients, 2007-2009 and 2017-2019
Pediatric liver transplant recipients, including retransplants. Distance is computed from recipient's home zip code to the transplant center.

Characteristic	2007-09, N	2007-09, Percent	2017-19, N	2017-19, Percent
Age: < 1 year	542	30.3%	442	25.8%
Age: 1-5 years	692	38.7%	668	39.0%
Age: 6-10 years	232	13.0%	248	14.5%
Age: 11-17 years	324	18.1%	355	20.7%
Sex: Female	892	49.8%	825	48.2%
Sex: Male	898	50.2%	888	51.8%
Race/ethnicity: White	925	51.7%	861	50.3%
Race/ethnicity: Black	321	17.9%	280	16.3%
Race/ethnicity: Hispanic	387	21.6%	397	23.2%
Race/ethnicity: Asian	118	6.6%	125	7.3%
Race/ethnicity: Other/unknown	39	2.2%	50	2.9%
Insurance: Private	797	44.5%	626	36.5%
Insurance: Medicare	15	0.8%	19	1.1%
Insurance: Medicaid	794	44.4%	850	49.6%
Insurance: Other government	120	6.7%	134	7.8%
Insurance: Unknown	64	3.6%	84	4.9%
Geography: Metropolitan	1439	80.4%	1403	81.9%
Geography: Non-metro	351	19.6%	310	18.1%
Distance: < 50 miles	802	44.8%	826	48.2%
Distance: 50-<100 miles	250	14.0%	245	14.3%
Distance: 100-<150 miles	184	10.3%	179	10.4%
Distance: 150-<250 miles	193	10.8%	174	10.2%
Distance: ≥ 250 miles	310	17.3%	238	13.9%
Distance: Unknown	51	2.8%	51	3.0%
All recipients	1790	100.0%	1713	100.0%

Table LI 19. Clinical characteristics of pediatric liver transplant recipients, 2007-2009 and 2017-2019
Pediatric liver transplant recipients, including retransplants. Pediatric candidates aged 12 to 17 years can be assigned MELD or PELD scores.

Characteristic	2007-09, N	2007-09, Percent	2017-19, N	2017-19, Percent
Diagnosis: Acute liver failure	189	10.6%	156	9.1%
Diagnosis: Cholestatic biliary atresia	570	31.8%	573	33.5%
Diagnosis: Other cholestatic	239	13.4%	210	12.3%
Diagnosis: Hepatoblastoma	96	5.4%	122	7.1%
Diagnosis: Metabolic	187	10.4%	296	17.3%
Diagnosis: Other/unknown	509	28.4%	356	20.8%
Blood type: A	629	35.1%	575	33.6%
Blood type: B	245	13.7%	232	13.5%
Blood type: AB	68	3.8%	48	2.8%
Blood type: O	848	47.4%	858	50.1%
Medical condition: Hospitalized in ICU	459	25.6%	298	17.4%
Medical condition: Hospitalized, not ICU	314	17.5%	314	18.3%
Medical condition: Not hospitalized	1017	56.8%	1101	64.3%
Medical urgency: Status 1A	273	15.3%	207	12.1%
Medical urgency: Status 1B	207	11.6%	397	23.2%
Medical urgency: MELD/PELD ≥ 30	521	29.1%	760	44.4%
Medical urgency: MELD/PELD 15-29	532	29.7%	192	11.2%
Medical urgency: MELD/PELD < 15	251	14.0%	152	8.9%
Medical urgency: Unknown	6	0.3%	5	0.3%
Any MELD/PELD exception	492	27.5%	821	47.9%
All recipients	1790	100.0%	1713	100.0%

Table LI 20. Transplant characteristics of pediatric liver transplant recipients, 2007-2009 and 2017-2019
Pediatric liver transplant recipients, including retransplants. DBD, donation after brain death; DCD, donation after circulatory death.

Characteristic	2007-09, N	2007-09, Percent	2017-19, N	2017-19, Percent
Wait time: < 31 days	744	41.6%	529	30.9%
Wait time: 31-60 days	294	16.4%	276	16.1%
Wait time: 61-90 days	180	10.1%	207	12.1%
Wait time: 3-< 6 months	256	14.3%	314	18.3%
Wait time: 6-< 12 months	158	8.8%	211	12.3%
Wait time: 1-< 2 years	110	6.1%	107	6.2%
Wait time: 2-< 3 years	17	0.9%	29	1.7%
Wait time: ≥ 3 years	25	1.4%	40	2.3%
Wait time: Unknown	6	0.3%	0	0.0%
ABO: Compatible/identical	1728	96.5%	1621	94.6%
ABO: Incompatible	62	3.5%	92	5.4%
Donor type: Deceased	1600	89.4%	1500	87.6%
Donor type: Living	190	10.6%	213	12.4%
Procedure: Whole liver	1147	64.1%	1048	61.2%
Procedure: Partial liver	365	20.4%	334	19.5%
Procedure: Split liver	278	15.5%	331	19.3%
DCD status: DBD	1778	99.3%	1708	99.7%
DCD status: DCD	12	0.7%	5	0.3%
Transplant history: First	1616	90.3%	1593	93.0%
Transplant history: Retransplant	174	9.7%	120	7.0%
Tx type: Liver only	1508	84.2%	1568	91.5%
Tx type: Liver-kidney	49	2.7%	59	3.4%
Tx type: Liver-intestine-pancreas	173	9.7%	74	4.3%
Tx type: Liver-intestine	45	2.5%	3	0.2%
Tx type: Other	15	0.8%	9	0.5%
All recipients	1790	100.0%	1713	100.0%

Table LI 21. Pediatric liver donor-recipient serology matching, 2017-2019
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-	32.5%	19.4%
D-	R+	19.1%	10.9%
D-	R unk	0.5%	0.5%
D+	R-	30.6%	37.1%
D+	R+	16.4%	30.4%
D+	R unk	0.5%	1.5%
D unk	R-	0.2%	0.1%
D unk	R+	0.3%	0.1%
D unk	R unk	0.0%	0.0%

Table LI 22. Pediatric liver donor-recipient serology matching for living donors, 2017-2019
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-	34.7%	8.5%
D-	R+	10.3%	3.8%
D-	R unk	0.9%	0.0%
D+	R-	28.6%	58.7%
D+	R+	22.5%	26.3%
D+	R unk	0.9%	0.9%
D unk	R-	1.9%	0.0%
D unk	R+	0.0%	1.4%
D unk	R unk	0.0%	0.5%