2.1 Waiting List

In 2023, there were a total of 24,492 adult liver candidates ever waiting in the United States, with a record 13,954 candidates newly added to the waiting list, an 8.5% increase over the previous year (Figure LI 1 and Figure LI 2). By the end of the year, 14,747 were removed from the list—64.5% for deceased donor liver transplant, 3.9% for living donor liver transplant, 6.4% for death, 6.6% for being too sick, 7.5% for improved condition, and 11.1% for other reasons—and 9,745 were left waiting (Table LI 4 and Table LI 5), a 7.5% decrease from the end of 2022. Compared with previous years, a greater proportion of patients were removed for transplant, and a smaller proportion were removed for death or being too sick for transplant.

Overall, adult candidates in 2023 were younger than in previous years: 6.3% were aged 18-34 years, 20.1% aged 35-49 years, 46.7% aged 50-64 years, and 26.9% aged 65 years or older (Figure LI 3). In terms of sex distribution, female candidates made up an increasing proportion of the waiting list, although still there were more male than female candidates being listed (60.6% and 39.4%, respectively) (Figure LI 4). The racial and ethnic composition was relatively unchanged: 67.8% White, 19.0% Hispanic, 6.5% Black, 4.5% Asian, 1.2% Native American, 0.6% Multiracial, and 0.3% unreported (Figure LI 5).

The most common primary diagnosis among adult waitlist candidates was alcohol-associated liver disease, with 34.9% categorized as alcohol-associated cirrhosis and 4.1% as alcohol-associated hepatitis—increases from 22.8% and 0.1% in 2013, respectively (Figure LI 6). In August 2022, the diagnosis for “alcoholic cirrhosis” was updated to “alcohol-associated cirrhosis without acute alcohol-associated hepatitis,” and the diagnosis of “alcoholic hepatitis” was updated to “acute alcohol-associated hepatitis with or without cirrhosis.” Accordingly, the prevalence of waitlisting for alcohol-associated hepatitis increased from 1.7% in 2021, to 2.1% in 2022, to the 4.1% in 2023, likely related to not only practice changes but also the updated nomenclature. In 2023, 20.4% of registrations had metabolic dysfunction–associated steatohepatitis (MASH) as the primary indication for waitlisting, an increase from 9.6% in 2013. Other specified diagnoses were less common, including hepatocellular carcinoma (HCC) (10.3%), cholestatic liver disease (7.2%), hepatitis C (6.2%), and acute liver failure (1.6%).

Most adult liver transplant candidates in 2023 were overweight by body mass index (BMI); there were 1.6% with BMI of <18.5 kg/m², 23.0% with BMI of 18.5-<25 kg/m², 33.8% with BMI of 25-<30 kg/m², 23.7% with BMI of 30-<35 kg/m², and 17.3% with BMI of 35 kg/m² or greater (Figure LI 8). The most common blood type was O (48.4%), followed by type A (38.0%), type B (10.6%), and type AB (3.1%) (Figure LI 9), mirroring the distribution of the general US population. Similar to previous years, 3.2% of candidates had a history of prior transplant (Figure LI 10).

2.2 Waitlist Outcomes

The overall deceased donor liver transplant rate for adults increased to 94.7 transplants per 100 patient-years in 2023, from 36.1 transplants per 100 patient-years in 2013 (Figure LI 11). This increase occurred across all age and racial and ethnic groups (Figure LI 12 and Figure LI 13). Candidates aged 18-34 years and 35-49 years continued to have higher deceased donor transplant rates than older candidates. White and Black candidates had higher deceased donor transplant rates than Asian or Hispanic candidates. The deceased donor liver transplant rate for patients with blood type AB (254.6 transplants per 100 patient-years) was nearly twice more than that for patients with blood type B and three times more than that for patients with blood types A or O (Figure LI 14).

Deceased donor transplant rates for adult candidates with and without HCC exception points have been similar since 2020, after many years of greater transplant access for patients with HCC and a series of policy changes lengthening their waiting time and decreasing their waitlist priority (Figure LI 15).

In July 2023, MELD 3.0 replaced MELD-sodium (MELD-Na) to represent medical urgency in the liver transplant waiting list, which was intended to address, in part, the sex disparity in deceased donor transplant rates. In 2023, with the second half of the year reflecting the policy change, the gap in adult deceased donor liver transplant rates between sexes had already started to narrow, although the rate was still higher for male candidates compared with female candidates (96.9 versus 91.4 transplants per 100 patient-years) (Figure LI 16).

Among adult candidates newly listed in 2018-2020, only 7.0% remained on the waiting list after 3 years, 58.3% received a deceased donor liver transplant, 3.3% received a living donor liver transplant, 8.6% died, and 22.8% were removed from the list for other reasons (Figure LI 17). Of candidates listed in 2022, 41.7% underwent deceased donor liver transplant within 3 months; 48.4%, within 6 months; and 58.2%, within 1 year—all increases compared with previous years (Figure LI 18). The 1-year probability of deceased donor liver transplant increased to 58.2% from 40.6% 10 years prior.

The pretransplant mortality rate among adult waitlist candidates has decreased from 16.9 to 12.9 deaths per 100 patient-years over the past decade and has been overall stable in the past several years (Figure LI 19). In 2023, female candidates still had higher pretransplant mortality rates compared with male candidates (13.9 versus 12.2 deaths per 100 patient-years); MELD 3.0 was in effect for only the latter half of the year, and height- or body size–based disparities may still have contributed (Figure LI 22). By etiology, higher pretransplant mortality rates were observed among those with alcohol-associated hepatitis (29.4 deaths per 100 patient-years), acute liver failure (21.5 deaths per 100 patient-years), and MASH (16.5 deaths per 100 patient-years) (Figure LI 23). Despite the noted allocation policy changes that have lengthened waiting time and lowered waitlist priority for patients with HCC exception points, pretransplant mortality rates remained lower for patients with an HCC exception compared to those without (11.2 versus 13.1 deaths per 100 patient-years) (Figure LI 25). Pretransplant mortality rates still varied widely across the 51 active donation service areas, with a median of 13.1 deaths per 100 patient-years (interquartile range, 10.2-17.2) and ranging from 3.9 to 39.7 deaths per 100 patient-years (Figure LI 26).

Among adults removed from the liver transplant waiting list for reasons other than transplant or death, 14.3% died within 6 months after removal (Figure LI 27). The risk of death within 6 months after removal was higher among those with MELD scores greater than 25 and patients aged 65 years or older (Figure LI 28 and Figure LI 29).

2.3 Transplants

In 2023, there were 10,125 adult liver transplant recipients, another all-time high, representing a 71% increase in the past decade (Figure LI 33). Both deceased and living donation increased, with 9,545 deceased donor and 580 living donor liver transplants performed (Figure LI 34).

Alcohol-associated liver disease continued to be the most common indication for adult liver transplant, with 41.1% of recipients having a primary diagnosis of alcohol-associated liver disease (34.6% alcohol-associated cirrhosis and 6.5% alcohol-associated hepatitis), followed by MASH at 20.3%. Other specified etiologies included HCC (10.4%), hepatitis C virus (HCV) (4.2%), cholestatic liver disease (7.4%), and acute liver failure (2.0%) (Figure LI 38 and Table LI 7). Only 14.6% of patients underwent transplant with HCC MELD exception points, a decrease from 26.4% in 2013. By urgency status, 2.1% underwent transplant as status 1A, 9.7% with an allocation MELD score of 40 or greater, 10.8% with a MELD of 35-39, 26.8% with a MELD of 25-34, 30.9% with a MELD of 15-24, and 19.5% with a MELD of 14 or lower. Compared with 2013, there were more recipients in the lowest urgency category (MELD 14 or lower) and fewer in the higher urgency categories (MELD 25 or higher). Waiting times were also shorter: 63.8% of transplant recipients waited less than 90 days, 10.8% waited 3-<6 months, 13.6% waited 6-<12 months, 7.2% waited 1-<2 years, and 4.5% waited 2 years or longer (Table LI 8).

The proportion of female adult liver transplant recipients has increased: 38.8% in 2023 compared with 34.1% in 2013 (Figure LI 36). In 2023, 69.8% of liver transplant recipients were White, 17.5% Hispanic, 6.6% Black, 4.1% Asian, 0.6% Multiracial, and 0.4% unreported (Figure LI 37). With the decline in hepatitis C and the rise in alcohol-associated liver disease and MASH, the age composition of the waiting list has also shifted, with a higher proportion of recipients aged 35-49 years (23.3% in 2023 versus 16.5% in 2013) and 65 years or older (22.4% versus 16.3%), and fewer aged 50-64 years (46.8% versus 61.6%) (Table LI 6). There were more recipients in the highest BMI categories: BMI of 35 kg/m² or greater, 15.5% in 2023 versus 13.0% in 2013; BMI of 30-<35 kg/m², 22.4% in 2023 versus 21.5% in 2013. Only 3.4% of recipients had a history of previous transplant in 2023, compared with 5.0% in 2013 (Figure LI 40 and Table LI 8).

Most adult liver transplants were covered by private insurance (50.9%), followed by Medicare (26.0%) and Medicaid (19.0%). Based on the rural-urban commuting area designation of their home zip code, 82.8% of recipients lived in metropolitan areas; 56.7% lived less than 50 miles from the transplant center, 17.6% within 50-<100 miles, 9.2% within 100-<150 miles, 7.8% within 150-<250 miles, and 7.9% 250 miles or farther (Table LI 6).

Recipients of livers procured from DCD made up 16.7% of adult liver transplants in 2023, a marked increase from preceding years (11.3% in 2022 and 5.2% in 2013), likely related to the wider availability of machine perfusion technologies (Figure LI 39). Only 91 adults received split deceased donor livers (0.9% of adult transplants in 2023 versus 1.2% in 2013) (Table LI 8).

In 2023, there were 804 adult recipients of SLK transplants, representing 7.9% of total liver transplants, a decrease from 9.6% in 2017 when standardized medical eligibility criteria were introduced (Figure LI 41). By far, patients who received SLK transplant were listed via the chronic kidney disease criteria (89.7%) rather than acute kidney injury (9.5%) or metabolic disease (0.2%) criteria (Figure LI 42).

Regarding immunosuppression, induction therapy was used in 30.3% of adult liver transplants, most often with interleukin-2 receptor antibody alone (24.6%) rather than T-cell–depleting agent alone (5.6%) (Figure LI 46 and Figure LI 47). Most liver transplant recipients were maintained on a combination of tacrolimus, a mycophenolate agent, and steroids (66.6%); the remainder used tacrolimus and mycophenolate (18.7%), tacrolimus and steroids (4.4%), or another regimen (10.3%) (Figure LI 48).

2.4 Outcomes

Graft failure was reported in 6.3% at 6 months and 7.9% at 1 year for adult deceased donor liver transplant recipients in 2022, 15.8% at 3 years for those who received transplant in 2020, 20.7% at 5 years for those who received transplant in 2018, and 36.7% at 10 years for those who received transplant in 2013 (Figure LI 49). Overall patient outcomes followed a similar pattern, with mortality of 5.0% at 6 months, 6.5% at 1 year, 14.0% at 3 years, 19.0% at 5 years, and 34.6% at 10 years (Figure LI 51). Over the past decade, 1-year graft failure and patient mortality have decreased; these values were 7.9% and 6.5%, respectively, for patients who underwent transplant in 2022, compared with 11.6% and 10.0%, respectively, for patients who underwent transplant in 2012.

Among adult recipients of deceased donor liver transplant in 2016-2018, 5-year graft survival was 75.0% among those aged 65 years or older, 79.3% for those aged 50-64 years, 82.2% for those aged 35-49 years, and 80.8% for those aged 18-34 years. Patient survival followed a similar pattern (Figure LI 52 and Figure LI 68). Lower graft and patient survival were observed in Black or Other race compared with White, Hispanic, or Asian recipients (Figure LI 53 and Figure LI 69); in male recipients compared with female recipients (Figure LI 54 and Figure LI 70); in those with HCC and MASH diagnoses compared with other etiologies (Figure LI 55 and Figure LI 71); and in those with MELD scores of 40 or greater compared with other MELD categories (39 or lower) (Figure LI 56 and Figure LI 72). In all of these groups, however, 5-year graft survival still exceeded 74.1% and patient survival exceeded 75.1%. The 5-year graft survival rate for DCD livers was 75.6%, compared with 79.2% for recipients of donation after brain death (DBD) livers (Figure LI 57). Liver transplant recipients with HCC MELD exception had a 5-year graft survival rate of 77.6% compared with 79.3% in those without (Figure LI 58).

Graft outcomes among adult living donor liver transplant recipients were: 5.8% graft failure at 6 months, 6.6% at 1 year, 13.6% at 3 years, 21.2% at 5 years, and 40.8% at 10 years (Figure LI 50). The 5-year graft survival among living donor liver transplant recipients was highest for cholestatic liver disease (85.8%) and MASH (83.9%) compared with other etiologies (Figure LI 63). Older recipients (aged 65 years or older) had worse outcomes, with 5-year patient survival of 76.6%, compared with 82.5%, 88.4%, and 94.2% for ages 50-64 years, 35-49 years, and 18-34 years, respectively (Figure LI 73).

Among liver recipients who underwent transplant in 2022, the incidence of reported acute rejection by 1-year posttransplant was higher among younger adult patients (20.2% for age 18-34 years) and lower among older patients (7.9% for age 65 years or older) (Figure LI 65). Among adult liver transplant recipients in 2012-2018, the 5-year incidence of reported posttransplant lymphoproliferative disorder was 1.0% in those with positive Epstein-Barr virus (EBV) status at transplant and 2.0% in those with negative EBV status at transplant (Figure LI 67).

In 2023, there were 734 new adult registrations for kidney transplant with a previous history of liver transplant (Figure LI 43). The most common primary diagnosis for kidney transplant waitlisting among liver transplant recipients was hepatorenal syndrome (31.1%), followed by Other/unknown (20.2%), diabetes (17.7%), and calcineurin nephrotoxicity (16.6%) (Figure LI 44). Hepatorenal syndrome as the primary diagnosis for kidney transplant increased notably after implementation of the SLK eligibility criteria, as did safety net listings (i.e., waitlisting 60-<365 days after liver transplant), which accounted for 327 (44.6%) new registrations (Figure LI 43). There were 418 kidney transplants in recipients with a previous history of liver transplant, which increased from 274 since implementation of the safety net policy in 2017 (Figure LI 45).

4.1 Waiting List

In 2023, there were 1,142 pediatric liver candidates listed at any time during the year in the United States, with 438 on the list at the start of the year and 704 candidates newly added (Figure LI 102, Figure LI 103, and Table LI 12). Over the course of the year, 738 patients were removed (63.7% for deceased donor liver transplant, 10.7% for living donor liver transplant, 3.7% for death, 1.8% for being too sick, 13.0% for improved condition, and 7.2% for a reason of Other), leaving 404 candidates still waiting, an 8% decrease from 2022 (Table LI 12 and Table LI 13).

Among pediatric candidates, the largest age category was 1-5 years (35.3%), followed by 12-17 years (21.3%) and younger than 1 year (18.4%) (Figure LI 104). Compared with 10 years ago, there were more liver transplant candidates in the younger age groups and fewer adolescents (12 years or older). In terms of race and ethnicity, most candidates were White (45.9%), followed by Hispanic (24.8%), Black (17.5%), Asian (6.0%), Multiracial (4.1%), Native American (1.1%), and unreported (0.7%) (Figure LI 105).

Among pediatric candidates who had been listed in 2018-2020, 66.9% received deceased donor liver transplant, 9.8% received living donor liver transplant, 3.2% died, 16.0% were removed from the list, and 4.1% were still waiting (Figure LI 107).

Overall deceased donor liver transplant rates for pediatric candidates remained stable in 2023 at 110.9 transplants per 100 patient-years, which had increased slightly after the allocation policy change in 2020 that prioritized pediatric donors for pediatric recipients (Figure LI 108). Deceased donor liver transplant rates were higher for age younger than 1 year compared with other pediatric age categories (Figure LI 109) and for the White, Black, and Other racial and ethnic categories compared with the Hispanic and Asian categories (Figure LI 110).

The overall pretransplant mortality rate for pediatric candidates in 2023 was 6.7 deaths per 100 patient-years, which has increased from a nadir of 4.9 deaths per 100 patients-years in 2020 (Figure LI 111). Despite the higher deceased donor liver transplant rate, the highest pretransplant mortality was still among the age category of younger than 1 year (18.6 deaths per 100 patient-years; Figure LI 112) and among the Black and Other racial and ethnic categories compared with Hispanic, White, and Asian (Figure LI 113).

4.2 Transplants

In 2023, there were 534 pediatric liver transplants, including retransplant and multiorgan recipients, a relatively stable number compared with previous years (Figure LI 114). The proportion of living donation has increased, to 14.6% in 2023 from 7.7% in 2013 (Figure LI 115).

Among all pediatric liver transplant recipients, 24.9% were aged younger than 1 year, 37.6% were aged 1-5 years, 16.9% were aged 6-11 years, and 20.6% were aged 12-17 years (Figure LI 116 and Table LI 14). The most common diagnosis among these liver transplant recipients was biliary atresia (37.5%), followed by Other/unknown etiologies (24.3%), metabolic disease (14.8%), hepatoblastoma (8.1%), acute liver failure (8.1%), and other cholestatic disease (7.3%) (Table LI 15). Similar to adult liver transplant, the proportion of pediatric recipients with a history of prior transplant decreased: 4.5% in 2023 compared with 8.8% in 2013 (Table LI 16).

In terms of medical urgency, 9.7% of pediatric liver transplant recipients underwent transplant as status 1A; 22.3%, as status 1B; 1.7%, with MELD or PELD score of 40 or greater; 1.1%, with MELD/PELD of 35-39; 6.7%, with MELD/PELD of 25-34; 16.9%, with MELD/PELD of 15-24; and 41.2%, with MELD/PELD of 14 or lower (Table LI 15). In July 2023, criteria for status 1B qualification were updated, along with PELD updating to PELD-creatinine, but this has not yet resulted in any detectable changes in the medical urgency status. Among pediatric liver transplant recipients in 2023, 65.4% had waited fewer than 90 days, 16.7% waited for 3-<6 months, 10.5% waited for 6-<12 months, 5.1% waited for 1-<2 years, and 2.4% waited for 2 or more years (Table LI 16). Overall, waiting times were shorter than in 2013. The proportion of ABO-incompatible pediatric transplants increased: 4.3% in 2023 compared with 3.6% in 2013. No pediatric patients received a liver from a DCD donor in 2023. Most received whole liver (58.4%), followed by partial liver (21.7%) and split liver (19.9%), which represents a modest increase in split liver acceptance since 2021 (Figure LI 117).

The most common insurance among pediatric liver transplant recipients in 2023 was Medicaid (50.7%), followed by private insurance (37.8%). Based on the recipient’s reported zip code, 82.5% lived in metropolitan areas; 45.1% lived less than 50 miles from the transplant center, 16.7% within 50-<100 miles, 12.2% within 100-<150 miles, 11.4% within 150-<250 miles, and 12.9% were 250 miles or farther (Table LI 14).

Induction agent use was reported in 40.4% of pediatric liver transplant recipients in 2023 (Figure LI 118), more commonly interleukin-2 receptor antibody than T-cell depleting agent (Figure LI 119). The most common immunosuppression regimens were combination tacrolimus, mycophenolate, and steroids (39.0%) or combination tacrolimus and steroids (36.9%) (Figure LI 120).

4.3 Outcomes

Short-term graft failure rates among pediatric deceased donor liver transplant recipients increased in 2022 (9.1% at 6 months and 10.7% at 1 year) compared with previous years (Figure LI 121). Longer-term graft failure rates were similar: 10.6% at 3 years for transplants in 2020, 12.2% at 5 years for transplants in 2018, and 23.1% at 10 years for transplants in 2013. Mirroring the graft outcomes, short-term patient mortality worsened (7.6% at 6 months, 8.9% at 1 year, and 9.8% at 3 years) compared with previous years (Figure LI 129). Longer-term outcomes were stable or improved, with a patient mortality rate of 7.6% at 5 years for transplants in 2018 and 13.9% at 10 years for transplants in 2013.

Among pediatric deceased donor liver transplant recipients in 2016-2018, overall 5-year graft survival was 86.3% and patient survival was 90.3% (Figure LI 126, Figure LI 130, and Figure LI 133). Five-year graft survival was highest among those with metabolic disease (95.5%), biliary atresia (90.9%), or other cholestatic disease (87.6%) and was lowest among those with a diagnosis of hepatoblastoma (78.8%) or Other/unknown etiology (75.0%) (Figure LI 124).

Outcomes among pediatric living donor liver transplant recipients were superior to those among deceased donor recipients, with graft failure rates of 5.7% at 6 months, 5.7% at 1 year, 7.6% at 3 years, 9.7% at 5 years, and 17.1% at 10 years (Figure LI 122); overall 5-year patient survival was 94.9% (Figure LI 126 and Figure LI 133).

The incidence of acute rejection by 1-year posttransplant for pediatric liver transplant recipients was 19.3% for those younger than 1 year, 25.9% for ages 1-5 years, 22.9% for ages 6-11 years, and 15.6% for ages 12-17 years (Figure LI 127), rates that are higher than those observed in adult recipients. The overall 5-year incidence of posttransplant lymphoproliferative disorder for pediatric recipients who underwent transplant in 2012-2018 was 4.4%: 5.2% among those with EBV-negative status and 3.1% among those with EBV-positive status at the time of transplant (Figure LI 128).