OPTN/SRTR 2019 Annual Data Report: Pancreas

Abstract

The overall number of pancreas transplants decreased slightly, from 1027 in 2018 to 1015, in 2019, up from a nadir of 947 in 2015. However, the number of simultaneous pancreas-kidney transplants (SPKs) increased in 2019, with a corresponding drop in pancreas-after-kidney transplants (PAKs) and pancreas transplants alone (PTAs). New waitlist registrations increased to 1772 in 2019, from 1606 in 2018. This was predominately driven by SPK listings, and those with type 2 diabetes. Waiting time for SPK decreased by 2 months, to a median of 12 months in 2019, but PTA recipient mean waiting time remained substantially higher, at 24 months, in 2018. Both short- and long-term outcomes, including patient survival, kidney graft survival, and acute rejection-free graft survival, have shown consistent improvement over the last decade. Pancreas graft survival data with the uniform definition of allograft failure is being collected by the Organ Procurement and Transplant Network (OPTN) and will be included in a future report.

Introduction

The pancreas allocation system (PAS), revised in 2014, has resulted in positive trends in several areas of pancreas transplantation, many of which are becoming increasingly apparent with time. Most notable of these is the steady increase in the total number of transplants, driven largely by simultaneous pancreas-kidney transplants (SPKs), where the PAS had the most impact. Specifically, the PAS provided a way to acquire time on the SPK waiting list for candidates with type 2 diabetes, but with a body mass index (BMI) ceiling. The number of listings and transplants of candidates with type 2 diabetes increased starting in 2016. It will be interesting to see if the trend continues.

Although there have been multiple reports of good outcomes with SPKs in patients with type 2 diabetes, more well-designed studies are needed to establish standards in the area as use increases. Since the PAS was introduced in 2014, trends in total pancreas transplant volumes and outcomes have been favorable.

The new pancreas graft failure definition implemented in February 2018 (see the “Outcomes” section) will be used in the first full year of pancreas graft survival data in the 2020 Annual Data Report. This is notable because the Scientific Registry of Transplant Recipients (SRTR) has not published pancreas graft survival rates for several years because of a lack of a uniform definition of graft failure.

The decreasing trend in numbers of solitary pancreas transplants - pancreas after kidney (PAK) and pancreas transplant alone (PTA) - continues to be of concern. The waiting time for these transplants is longer than for SPK, which discourages centers from considering PAK after a living-donor kidney transplant because SPK is often more expedient. This should be considered in future Organ Procurement and Transplantation Network (OPTN) pancreas committee allocation discussions.

Notable OPTN pancreas committee activities that have resulted in pending policy changes in 2019 include removal of donor service area (DSA) and region in pancreas allocation policy. SRTR was instrumental in developing simulated allocation modeling for the proposal. The new policy replaces DSA and region with a 250-nautical-mile fixed circle and adds proximity points to candidates’ total allocation scores.

The policy of removing DSA in allocation, approved by the OPTN board in December 2019, is scheduled for implementation in December 2020. While the policy change is pending implementation, work is already underway on the next iteration, which will remove the fixed circle and create a continuous distribution model with a points-based system using different attributes, including proximity. Attributes other than waiting time and dialysis time are not well-defined or correlated with outcomes in pancreas transplants, which will complicate this task, but the SRTR will work with the OPTN kidney and pancreas committees to develop and validate attributes and run simulation models.

Waiting List

Additions to the waiting list increased by 10.3%, to 1772 in 2019, up from 1606 in 2018. This was primarily driven by an increase in listings for SPK (1479 in 2019, versus 1291 in 2018), while new listings for PTA continued a downward trend (168 in 2019, versus 212 in 2018) (Figure PA 1). Numbers of candidates prevalent on the waiting list increased for SPK (3141 in 2019, versus 3015 in 2018), while continuing downward trends for PAK (411 in 2019, versus 436 in 2018) and PTA (547 in 2019, versus 587 in 2018) (Figure PA 2).

The proportion of adults on the waiting list increased slightly in candidates aged 55 years or older, with a corresponding decreases in patients younger than 55 (Figure PA 3). The preponderant age range for candidates was 18-54 years, comprising 89.3% of the total list (Figure PA 3). Sex distribution (54.0% men, versus 46.0% women) was unchanged from 2018 (Figure PA 4).

The percentage of white candidates continued to decline in 2019 (56.1%), with increases in all non-white ethnicities and races (Figure PA 5). The proportion of patients with type 2 diabetes continued to increase, reaching 17.0% in 2019, up from 14.2% in 2018 (Figure PA 6). This was expected given the lifting of the BMI cap for candidates with type 2 diabetes to accrue time on the kidney-pancreas waiting list effective July 2019. Consequently, the proportion of patients with a high BMI (30 kg/m² and greater) on the waiting list increased (21.1% in 2019, up from 18.5% in 2018) (Figure PA 8). This trend is likely to continue as the enthusiasm for performing kidney-pancreas transplants in candidates with type 2 diabetes continues to rise. Although some data are available on the benefit of pancreas transplant, more investigation is needed to fully establish evidence-based standards for transplant in candidates with type 2 diabetes.

Most patients were on the waiting list for <90 days (51.2%) (Figure PA 7), presumably because of an increase in new listings in the latter part of 2019, after the BMI cap for candidates with type 2 diabetes lifted. The proportion of patients waiting 1-2 years increased from 11.5% in 2018 to 13.2% in 2019, whereas the >2-year group decreased to 19.9% in 2019, from 23.4% in 2018 (Figure PA 7). Blood type distribution on the waiting list has remained fairly steady, except for a small trending increase in blood type B candidates over the past 2 years to 15.4% in 2019 (Figure PA 9).

The distribution of transplant types continues to show an increasing proportion of SPK candidates over the past decade, comprising 76.6% in 2019, with slight decreases PAKs and a relatively stable proportion of PTAs (Figure PA 10). Particularly striking is the continuing decrease in PAK over the past decade or longer, comprising only 10.0% of the list in 2019, down from 20.3% in 2009 (Figure PA 10).

The proportion of candidates for re-transplants on the waiting list reached its lowest level in a decade (5.6% in 2019) (Figure PA 11). The declining number of solitary pancreas transplants, in which re-transplants are more common, may partially explain this phenomenon.

Deceased-donor transplant rates have steadily risen since 2014, reaching 44.7 per 100 waitlist years in 2019 (Figure PA 12). This increase corresponds to the new pancreas allocation policy implemented in 2014. The rise in transplants is more sustained and marked in candidates with type 2 diabetes, in whom the rate was 60.6 per 100 waitlist years in 2019, versus 21.2 in 2008 (Figure PA 13). Transplant rates across blood types showed similar increasing trends since 2014, though rates for patients with AB blood type were more variable due to smaller numbers of AB patients (Figure PA 14).

However, when looking at transplant rates by type, SPK rates have steadily increased over the past 3 years, diverging from solitary pancreas transplants (PAKs and PTAs), in which transplant rates have decreased (Figure PA 15). This is presumably another effect of the revised PAS, in which solitary pancreas candidates may have a longer wait than do SPK candidates. The OPTN pancreas committee will need to consider this when recommending future changes to allocation policy.

Three-year outcomes for patients listed in 2016 showed that 41.1% of PAK candidates, 50.6% of PTA candidates, and 55.7% of SPK candidates underwent deceased-donor transplants (Figure PA 16, Figure PA 17, Figure PA 18). Patients who died or were removed from the list accounted for 35.3% of PAKs, 33.0% of PTAs, and 31.3% of SPKs (Figure PA 16, Figure PA 17, Figure PA 18). Patients still waiting at the end of 3 years accounted for 23.6% of PAKs, 16.4% of PTAs, and 13.0% of SPKs (Figure PA 16, Figure PA 17, Figure PA 18).

Median months to transplant have decreased over the past 5 years for SPK (12.0 months in 2018-2019) and PTA (24.1 months in 2016-2017) (Figure PA 19). Notably, the difference in waits between the two transplant types continues to be considerably longer for PTAs. In fact, the median could not be calculated for 2018-2019 for PTAs because less than 50% had undergone transplant (Figure PA 19). The same observation was noted in PAK for the entire reporting period (<50% transplants) (Figure PA 19). However, with increased additions to the SPK waiting list, waits for SPK might increase.

No consistent pattern appeared in the geographic distribution of percentages of candidates undergoing transplant within 2 years of listing (Figure PA 20, Figure PA 21, Figure PA 22).

Overall, pretransplant mortality rates have remained steady over the past 4 years, at about 5 per 100 waitlist years (Figure PA 23). This rate was predominately driven by SPK candidates (5.6 per 100 waitlist years in 2019), versus 2.7 per 100 for PTA and 0.9 per 100 for PAK (Figure PA 27). Mortality rates did not consistently differ by age, sex, or race (Figure PA 24, Figure PA 25, Figure PA 26). Groups with small numbers, such as age >55 or race classified as “other” or Asian, showed exaggerated variations due to small numbers.

Geographical variation in pre-transplant mortality rates did not follow a pattern, ranging from 0-17.3 per 100 waitlist years in the Donation Service Areas (DSAs) for the OPO serving the candidate’s listing center (Figure PA 28). Interpretation of this is complicated by variation in listing and removal-from-list practices across the country.

In 2019, 8.3% of candidates removed from the waiting list died within 6 months, a proportion that has steadily increased over the past 3 years (Figure PA 29). SPK, as expected, had the highest death rate (12.0%), followed by PTA (5.1%) and PAK (0.0%) (Figure PA 31). Death rates after removal did not vary substantially by age (Figure PA 30).

Donations

The number of deceased pancreas donors increased in 2019 (1363) over 2018 (1307) (Figure PA 32). Over the past 5 years, the trend has been somewhat positive after reaching a nadir of 1250 donors in 2014 (Figure PA 32), at which time the revised PAS was implemented.

The increase in donors in the last 5 years was driven mostly by the 30-49-year age group (Figure PA 33). However, the 18-29 age group was the largest source of donors, accounting for 50% of all donors (Figure PA 34). The proportion of pediatric donors (aged <18 years) remained relatively steady, at about 20%. There were only three donors aged ≥55 in 2019, down from a high of 40 in 2008. Men accounted for about 70% of donors, a steady proportion (Figure PA 35). The proportion of white donors declined slightly but steadily over the past decade, particularly in the past 4 years, while the proportion of Hispanic donors has notably increased, from 12.1% in 2012 to 17.0% in 2019 (Figure PA 36). The highest proportion of donors were in the normal BMI category of 18.5 to 25 kg/m² (53.5% in 2019), and the distribution of donors by BMI has remained relatively consistent over the past decade (Figure PA 37).

The rate of discard of pancreata recovered for transplant was concerningly high, at 25.4%, in 2019 (Figure PA 38), a departure from the downward trend in discard rates in the past few years. It remains to be seen if this is the beginning of a trend. Relatively short waits for pancreas transplants probably contributed to this phenomenon. The increase in discard rates in 2019 was distributed across all age-groups, except the youngest (<18), in which the rate stayed at 17% (Figure PA 39). The discard rates did not differ substantially by sex (Figure PA 40) or by ethnicity/race (Figure PA 41). Morbidly obese donors (BMI 35-40 kg/m²) had the highest discard rate (70.6%), substantially higher than those with BMI 25-30 kg/m² (27.5%) and BMI 18-25 kg/m² (22.2%); the moderately obese group (BMI 30-35 kg/m²) fell in between, with a 41.3% discard rate (Figure PA 42). The group with BMI >40 kg/m² had no discards, although this group is seldom, if ever, considered for pancreas donation; <1% of all donors were in this group (Figure PA 37).

There was no difference in discard rates based on increased disease transmission risk (Figure PA 43). This is encouraging to see in pancreas transplants because there is still a notable difference in kidney transplants, with greater discard rates among standard-risk donors as compared to the “increased risk” donors (OPTN/SRTR ADR 2018). An OPTN proposal to eliminate the terminology of “increased risk” is out for public comment at the time of this writing, which might mitigate this effect.

The average pancreas donor risk index (PDRI) of all three types of pancreas transplants ranged from 1.06 to 1.09 in 2019 (Figure PA 45). This tight, low range is representative of the generalized trends toward risk aversion in pancreas transplants. When looking at individual components of PDRI, there is a trend in the last 5 years towards increasing use of donors aged >28 (Figure PA 44) and those dying from anoxic brain injury (Figure PA 46).

Anoxia as a cause of death continued its upward trend (up to 38.8% in 2019) and is closing the gap with head trauma, which is decreasing (48.7% in 2019) possibly due to a combination of factors: 1) The continuing opioid crisis and related anoxic brain injuries; and 2) The decrease in motor-vehicle accident-related deaths (Figure PA 46).

Transplants

The overall number of pancreas transplants decreased slightly, from 1027 in 2018 to 1015 in 2019 (Figure PA 47). This remains considerably higher than the nadir of 947 reported in 2015, with a slight decrease attributed to continued decreases in PTAs (124 to 99) and PAKs (68 to 44) from 2018 to 2019 (Figure PA 48). In fact, SPKs continued to increase, from 835 to 872, the highest annual number of SPKs performed in the last decade (Figure PA 48). Over the last decade, the largest number of pancreas transplant have been performed in recipients aged 35-54 years old, 630 transplants (62.1%) were performed in these age groups in 2019 (Figure PA 49).

The increase in SPKs is likely attributable to marked increases in the total number of pancreas transplants performed for recipients with type 2 diabetes. The increase in raw numbers for this indication, from 147 to 205, contrasts with the reduction in number of pancreas transplants performed for type 1 diabetes, which decreased from 792 to 739 in 2019 (Figure PA 52). The increasing number of black, Asian, and Hispanic recipients also seems to mirror increases in pancreas transplants performed for SPK (Figure PA 51).

Strategies for immunosuppression have been remarkably stable over the past 5 years. Ninety percent of pancreas transplant recipients received induction with a T-cell-depleting agent (Figure PA 53). The high use of aggressive induction therapy likely reflects experience with high rejection rates without T-cell-depleting agents. Most pancreas transplant recipients (94.0%) were maintained on tacrolimus as the calcineurin inhibitor (CNI) of choice and mycophenolate mofetil (MMF) as the anti-proliferative agent of choice for long-term therapy (Figure PA 54). About 30% of recipients on tacrolimus/MMF therapy were maintained on a steroid-free regimen (Figure PA 54), a relatively stable proportion over the past 5 years. The proportion of pancreas transplant recipients in the “other” category remained low, at 2.6%, suggesting that TOR inhibitors have not been widely adopted as components of maintenance immunosuppressive regimens (Figure PA 54).

Most pancreas transplants were performed in unsensitized recipients (65.9% for PAK, 71.6% for PTA, and 69.3% for SPK) (Figure PA 55, Figure PA 56, Figure PA 57). As in previous years, human leukocyte antigen (HLA) matching was not prioritized, with most pancreas transplants in all categories having four or more HLA A, B, and DR mismatches (Figure PA 58). These data are also consistent with most pancreas transplant surgeons’/physicians’ prioritization of quality of the donor organ over HLA matching.

In 2019, programs with volumes of 11 to 24 pancreas transplants per year accounted for 41.1% of transplants performed, while those with volumes of 25 or more accounted for 20.1% of transplants performed. Only 3.6% of transplants were performed at low-volume centers (<3 pancreas transplants per year); this proportion has been relatively constant over the past decade (Figure PA 60).

Outcomes

The 2019 report was compromised by previous variations in reporting pancreas graft failure; future reports will reflect the newer definitions. Although patient survival and kidney allograft survival in SPK and PAK patients have been accurately reported, pancreas graft survival was defined by the reporting program, leading to considerable variation. Some programs considered insulin independence the criteria for pancreas allograft success, while others defined it by C-peptide production. The new, uniform definition for pancreas graft failure includes any of the following: 1) A recipient’s transplanted pancreas is removed; 2) A recipient re-registers for a pancreas transplant; 3) A recipient registers for an islet transplant after undergoing pancreas transplant; or 4) A recipients dies.

Pancreas graft failure can also be defined by a recipient’s total insulin use of 0.5 units/kg/day or more for 90 consecutive days. The latter definition may be problematic if the recipient’s starting insulin dose was less than 0.5 units/kg/day. Nonetheless, more uniform definitions will help SRTR provide more accurate data on pancreas allograft outcomes. The impact of the uniform definitions for pancreas allograft survival is only partially reflected in the 2019 report because the new policy was implemented in early 2018. Regardless, the overall rate of early loss steadily decreased to 6.2%, down from 11.7% in 2008-2009 (Figure PA 61).

The data for kidney allograft survival after SPK is based on uniform definitions (eg, return to dialysis), unlike the variability in the reporting of pancreas allograft outcomes. The outcomes for kidney allografts after SPK remain outstanding, with 1-, 5-, and 10-year all-cause kidney failure at 4.0%, 13.4%, and 34.6%, respectively for the most recent cohorts available for these analyses (Figure PA 62). The long-term kidney allograft success rate after SPK is superior to that of PAK deceased-donor kidney transplants (Figure PA 64) and reflects the high quality (low kidney donor profile index) of deceased-donor kidneys from SPK donors. The 10-year death-censored kidney graft failure rates for SPK and living-donor PAK were 21.4% (Figure PA 63) and 18.5% (Figure PA 67), respectively for the most recent cohort available for analylsis (transplants in 2009). These excellent long-term kidney allograft success rates again reflect the high quality of the deceased-donor kidneys used in SPK and living-donor kidneys in PAK. All-cause kidney allograft failure rates following pancreas after deceased-donor kidney transplant (from time of pancreas transplant) were 1.8% at 1 year posttransplant for patients transplanted in 2017-2018, 18.5% at 5 years posttransplant for patients transplanted in 2013-2014, and 44.03% at 10 years posttransplant for patients transplanted in 2009-2019 (Figure PA 64). All-cause kidney allograft failure rates following pancreas after living-donor kidney transplant from the time of pancreas transplant were slightly higher at 1 year (4.4% for transplants from 2017-2018) and 5 years (21.0% for transplants from 2013-2014), but better at 10 years (33.6% for transplants from 2009-2010) (Figure PA 66), consistent with the higher quality of living-donor kidney transplants compared with deceased-donor kidney transplants.

Rejection rates after all categories of pancreas transplants have been consistently low for the past 5 years, with the incidence of acute rejection by 1 year in 2017-2018 transplant recipients at 12.8%, 18%, and 11.2% for PAK, PTA, and SPK, respectively (Figure PA 69). The relatively higher incidence of rejection in PTA has also been consistent over the past several years and may in part reflect the use of protocol biopsies in this category. Although most transplant centers use T-cell-depleting induction therapy for all categories of pancreas transplants, the incidence of rejection by 1 year was still low in recipients receiving interleukin-2 receptor antagonists (13.9%) and T-cell-depleting agents (11.9%) (Figure PA 70).

The highest cumulative incidence of post-transplant lymphoproliferative disorder (PTLD) at 5 years was observed in Epstein-Barr virus-negative PTA recipients (5.6%), compared with EBV-positive PTA recipients (1.4%) (Figure PA 72). The 5-year cumulative incidence of PTLD in EBV-naive PAK and SPK recipients was lower, at 0.9% and 2.5%, respectively (Figure PA 71, Figure PA 73). The higher incidence of PTLD observed in EBV-naive recipients of PTA likely reflects the more aggressive immunosuppression regimens used after PTA.

The number of pancreas transplant recipients alive as of June 30, 2019, was 19,174 (excluding recipients of multivisceral organs), with most aged 18-49 years (Figure PA 68). Patient mortality remained low for all categories of pancreas transplant recipients at 1 year, at 4.8%. 3.1%, and 2.1% for PAK, PTA, and SPK, respectively (Figure PA 74). Long-term mortality rates continued to demonstrate a gradual decrease in all categories of pancreas transplants. Ten-year mortality rates among 2007-2008 transplant recipients were 24.2%, 17.7%, and 24.2% for PAK, PTA, and SPK respectively, and may reflect the cardiovascular comorbidities in this population (Figure PA 76). Five-year survival rates for PAK, PTA, and SPK were 87.8%, 79.5%, and 91.7%, respectively (Figure PA 77). The poorer rates of survival in PTA may reflect the significant comorbidities prompting referral for pancreas transplantation in non-uremic patients. Five-year survival rates for pancreas recipients were 91.1% and 93.1% for type 1 and type 2 diabetes, respectively (Figure PA 78). As more SPKs are performed for type 2 diabetes, it will be important to see if pancreas outcomes (using the new criteria initiated in 2018) will be comparable in both graft outcomes and survival.

Figure List

Waiting list

Figure PA 1. New adult candidates added to the pancreas transplant waiting list
Figure PA 2. All adult candidates on the pancreas transplant waiting list
Figure PA 3. Distribution of adults waiting for pancreas transplant by age
Figure PA 4. Distribution of adults waiting for pancreas transplant by sex
Figure PA 5. Distribution of adults waiting for pancreas transplant by race
Figure PA 6. Distribution of adults waiting for pancreas transplant by diagnosis
Figure PA 7. Distribution of adults waiting for pancreas transplant by waiting time
Figure PA 8. Distribution of adults waiting for pancreas transplant by BMI
Figure PA 9. Distribution of adults waiting for pancreas transplant by blood type
Figure PA 10. Distribution of adults waiting for pancreas transplant by intended transplant type
Figure PA 11. Distribution of adults waiting for pancreas transplant by prior transplant status
Figure PA 12. Overall deceased donor pancreas transplant rates among adult waitlist candidates
Figure PA 13. Deceased donor pancreas transplant rates among adult waitlist candidates by diagnosis
Figure PA 14. Deceased donor pancreas transplant rates among adult waitlist candidates by blood type
Figure PA 15. Deceased donor pancreas transplant rates among adult waitlist candidates by intended transplant type
Figure PA 16. Three-year outcomes for adults waiting for pancreas after kidney transplant, new listings in 2016
Figure PA 17. Three-year outcomes for adults waiting for pancreas transplant alone, new listings in 2016
Figure PA 18. Three-year outcomes for adults waiting for simultaneous kidney-pancreas transplant, new listings in 2016
Figure PA 19. Median months to pancreas transplant for waitlisted adults
Figure PA 20. Percentage of adults listed in 2017 who underwent pancreas after kidney transplant within 2 years, by DSA
Figure PA 21. Percentage of adults listed in 2017 who underwent pancreas transplant alone within 2 years, by DSA
Figure PA 22. Percentage of adults listed in 2017 who underwent simultaneous kidney-pancreas transplant within 2 years, by DSA
Figure PA 23. Overall pretransplant mortality rates among adults waitlisted for pancreas transplant
Figure PA 24. Pretransplant mortality rates among adults waitlisted for pancreas transplant by age
Figure PA 25. Pretransplant mortality rates among adults waitlisted for pancreas transplant by race
Figure PA 26. Pretransplant mortality rates among adults waitlisted for pancreas transplant by sex
Figure PA 27. Pretransplant mortality rates among adults waitlisted for pancreas transplant by intended transplant type
Figure PA 28. Pretransplant mortality rates among adults waitlisted for pancreas transplant in 2019 by DSA
Figure PA 29. Deaths within six months after removal among adult pancreas waitlist candidates, overall
Figure PA 30. Deaths within six months after removal among adult pancreas waitlist candidates, by age
Figure PA 31. Deaths within six months after removal among adult pancreas waitlist candidates, by intended transplant type

Deceased donation

Figure PA 32. Overall deceased pancreas donor count
Figure PA 33. Deceased pancreas donor count by age
Figure PA 34. Distribution of deceased pancreas donors by age
Figure PA 35. Distribution of deceased pancreas donors by sex
Figure PA 36. Distribution of deceased pancreas donors by race
Figure PA 37. Distribution of deceased pancreas donors by donor BMI
Figure PA 38. Overall rates of pancreata recovered for transplant and not transplanted
Figure PA 39. Rates of pancreata recovered for transplant and not transplanted by donor age
Figure PA 40. Rates of pancreata recovered for transplant and not transplanted by donor sex
Figure PA 41. Rates of pancreata recovered for transplant and not transplanted by donor race
Figure PA 42. Rates of pancreata recovered for transplant and not transplanted by donor BMI
Figure PA 43. Rates of pancreata recovered for transplant and not transplanted, by donor risk of disease transmission
Figure PA 44. Donor-specific components of the pancreas donor risk index
Figure PA 45. Average pancreas donor risk index
Figure PA 46. Cause of death among deceased pancreas donors

Transplant

Figure PA 47. Overall pancreas transplants
Figure PA 48. Total pancreas transplants by pancreas transplant type
Figure PA 49. Total pancreas transplants by age
Figure PA 50. Total pancreas transplants by sex
Figure PA 51. Total pancreas transplants by race
Figure PA 52. Total pancreas transplants by diagnosis
Figure PA 53. Induction agent use in adult pancreas transplant recipients
Figure PA 54. Immunosuppression regimen use in adult pancreas transplant recipients
Figure PA 55. C/PRA in adult recipients of pancreas after kidney transplant.
Figure PA 56. C/PRA in adult recipients of pancreas transplant alone.
Figure PA 57. C/PRA in adult recipients of simultaneous kidney-pancreas transplant
Figure PA 58. Total HLA A, B, and DR mismatches among adult pancreas transplant recipients, 2015-2019
Figure PA 59. Annual adult pancreas transplant center volumes by percentile
Figure PA 60. Distribution of adult pancreas transplants by annual center volume

Outcomes

Figure PA 61. Graft failure within the first 90 days posttransplant among adult pancreas transplant recipients
Figure PA 62. Kidney graft failure among adult SPK transplant recipients
Figure PA 63. Death censored kidney graft failure among adult SPK transplant recipients
Figure PA 64. Kidney graft failure among adult PAK transplant recipients with a deceased donor kidney (from time of pancreas transplant)
Figure PA 65. Death-censored kidney graft failure among adult PAK transplant recipients with a deceased donor kidney (from time of pancreas transplant)
Figure PA 66. Kidney graft failure among adult PAK transplant recipients with a living donor kidney (from time of pancreas transplant)
Figure PA 67. Death-censored kidney graft failure among adult PAK transplant recipients with a living donor kidney (from time of pancreas transplant)
Figure PA 68. Recipients alive after pancreas transplant on June 30 of the year, by age at transplant
Figure PA 69. Incidence of acute rejection by 1 year posttransplant among adult pancreas transplant recipients by transplant type, 2017-2018
Figure PA 70. Incidence of acute rejection by 1 year posttransplant among adult pancreas transplant recipients by induction agent, 2017-2018
Figure PA 71. Incidence of PTLD among adult recipients of pancreas after kidney transplant by recipient EBV status at transplant, 2007-2017
Figure PA 72. Incidence of PTLD among adult recipients of pancreas transplant alone by recipient EBV status at transplant, 2007-2017
Figure PA 73. Incidence of PTLD among adult recipients of simultaneous kidney-pancreas transplant by recipient EBV status at transplant, 2007-2017
Figure PA 74. Patient death at one year among adult pancreas transplant recipients
Figure PA 75. Patient death at five years among adult pancreas transplant recipients
Figure PA 76. Patient death at ten years among adult pancreas transplant recipients
Figure PA 77. Patient survival among adult deceased donor pancreas transplant recipients, 2012-2014, by transplant type
Figure PA 78. Patient survival among adult deceased donor pancreas transplant recipients, 2012-2014, by diagnosis
Figure PA 79. Patient survival among adult deceased donor pancreas transplant recipients, 2012-2014, by metropolitan vs. non-metropolitan recipient residence

Table List

Waiting list

Table PA 1. Demographic characteristics of adults on the pancreas transplant waiting list on December 31, 2019
Table PA 2. Clinical characteristics of adults on the pancreas transplant waiting list on December 31, 2019
Table PA 3. Listing characteristics of adults on the pancreas transplant waiting list on December 31, 2019
Table PA 4. Transplant waitlist activity among adults waiting for a pancreas after kidney transplant
Table PA 5. Transplant waitlist activity among adults waiting for a pancreas transplant alone
Table PA 6. Transplant waitlist activity among adults waiting for a simultaneous kidney pancreas transplant
Table PA 7. Removal reason among adults waiting for pancreas after kidney transplant
Table PA 8. Removal reason among adults waiting for pancreas transplant alone
Table PA 9. Removal reason among adults waiting for simultaneous kidney-pancreas transplant

Transplant

Table PA 10. Demographic characteristics of adult pancreas transplant recipients, 2019
Table PA 11. Clinical characteristics of adult pancreas transplant recipients, 2019
Table PA 12. Transplant characteristics of adult pancreas transplant recipients, 2019
Table PA 13. Adult pancreas donor-recipient serology matching, 2017-2019

Table PA 1. Demographic characteristics of adults on the pancreas transplant waiting list on December 31, 2019
Candidates waiting for transplant on December 31, 2019, regardless of first listing date. Distance is computed from candidate's home zip code to the transplant center. PAK, pancreas after kidney; PTA, pancreas transplant alone; SPK, simultaneous kidney pancreas transplant.

Characteristic	PAK, N	PAK, Pct	PTA, N	PTA, Pct	SPK, N	SPK, Pct
Age: 18-34 years	28	9.3%	71	21.3%	371	21.3%
Age: 35-49 years	174	57.8%	172	51.7%	905	52.1%
Age: 50-60 years	84	27.9%	66	19.8%	404	23.2%
Age: > 60 years	15	5.0%	24	7.2%	58	3.3%
Sex: Female	139	46.2%	188	56.5%	803	46.2%
Sex: Male	162	53.8%	145	43.5%	935	53.8%
Race/ethnicity: White	184	61.1%	265	79.6%	887	51.0%
Race/ethnicity: Black	60	19.9%	31	9.3%	475	27.3%
Race/ethnicity: Hispanic	48	15.9%	26	7.8%	272	15.7%
Race/ethnicity: Asian	8	2.7%	8	2.4%	73	4.2%
Race/ethnicity: Other/unknown	1	0.3%	3	0.9%	31	1.8%
Geography: Metropolitan	250	83.1%	266	79.9%	1435	82.6%
Geography: Non-metro	51	16.9%	67	20.1%	303	17.4%
Distance: < 50 miles	198	65.8%	161	48.3%	1035	59.6%
Distance: 50-<100 miles	54	17.9%	58	17.4%	341	19.6%
Distance: 100-<150 miles	22	7.3%	34	10.2%	152	8.7%
Distance: 150-<250 miles	14	4.7%	23	6.9%	120	6.9%
Distance: ≥ 250 miles	12	4.0%	53	15.9%	86	4.9%
Distance: Unknown	1	0.3%	4	1.2%	4	0.2%
BMI: < 18.5 kg/m2	4	1.3%	14	4.2%	20	1.2%
BMI: 18.5-< 25 kg/m2	116	38.5%	146	43.8%	621	35.7%
BMI: 25-< 28 kg/m2	73	24.3%	74	22.2%	426	24.5%
BMI: 28-< 30 kg/m2	35	11.6%	33	9.9%	277	15.9%
BMI: 30-< 35 kg/m2	59	19.6%	54	16.2%	326	18.8%
BMI: ≥ 35 kg/m2	12	4.0%	12	3.6%	67	3.9%
BMI: Unknown	2	0.7%	0	0.0%	1	0.1%
All candidates	301	100.0%	333	100.0%	1738	100.0%

Table PA 2. Clinical characteristics of adults on the pancreas transplant waiting list on December 31, 2019
Candidates waiting for transplant on December 31, 2019, regardless of first listing date. PAK, pancreas after kidney; PTA, pancreas transplant alone; SPK, simultaneous kidney pancreas transplant.

Characteristic	PAK, N	PAK, Pct	PTA, N	PTA, Pct	SPK, N	SPK, Pct
Diagnosis: Diabetes type 1	246	81.7%	260	78.1%	1299	74.7%
Diagnosis: Diabetes type 2	46	15.3%	16	4.8%	323	18.6%
Diagnosis: Other	9	3.0%	57	17.1%	116	6.7%
Blood type: A	108	35.9%	137	41.1%	535	30.8%
Blood type: B	32	10.6%	34	10.2%	314	18.1%
Blood type: AB	15	5.0%	7	2.1%	50	2.9%
Blood type: O	146	48.5%	155	46.5%	839	48.3%
CPRA: < 1%	164	54.5%	212	63.7%	1057	60.8%
CPRA: 1-< 20%	21	7.0%	16	4.8%	134	7.7%
CPRA: 20-< 80%	52	17.3%	39	11.7%	286	16.5%
CPRA: 80-< 98%	29	9.6%	28	8.4%	108	6.2%
CPRA: 98-100%	31	10.3%	37	11.1%	153	8.8%
CPRA: Unknown	4	1.3%	1	0.3%	0	0.0%
All candidates	301	100.0%	333	100.0%	1738	100.0%

Table PA 3. Listing characteristics of adults on the pancreas transplant waiting list on December 31, 2019
Candidates waiting for transplant on December 31, 2019, regardless of first listing date. PAK, pancreas after kidney; PTA, pancreas transplant alone; SPK, simultaneous kidney pancreas transplant.

Characteristic	PAK, N	PAK, Pct	PTA, N	PTA, Pct	SPK, N	SPK, Pct
Transplant history: First	213	70.8%	289	86.8%	1667	95.9%
Transplant history: Retransplant	88	29.2%	44	13.2%	71	4.1%
Wait time: < 1 year	109	36.2%	111	33.3%	916	52.7%
Wait time: 1-< 2 years	46	15.3%	79	23.7%	342	19.7%
Wait time: 2-< 3 years	42	14.0%	47	14.1%	203	11.7%
Wait time: 3-< 4 years	29	9.6%	24	7.2%	104	6.0%
Wait time: 4-< 5 years	13	4.3%	20	6.0%	66	3.8%
Wait time: ≥ 5 years	62	20.6%	52	15.6%	107	6.2%
All candidates	301	100.0%	333	100.0%	1738	100.0%

Table PA 4. Transplant waitlist activity among adults waiting for a pancreas after kidney transplant
Candidates listed at more than one center are counted one 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	369	333	286
Patients added during year	122	103	125
Patients removed during year	158	150	110
Patients at end of year	333	286	301

Table PA 5. Transplant waitlist activity among adults waiting for a pancreas transplant alone
Candidates listed at more than one center are counted one 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	377	375	378
Patients added during year	222	212	168
Patients removed during year	224	209	213
Patients at end of year	375	378	333

Table PA 6. Transplant waitlist activity among adults waiting for a simultaneous kidney pancreas transplant
Candidates listed at more than one center are counted one 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	1795	1722	1657
Patients added during year	1253	1292	1479
Patients removed during year	1325	1355	1394
Patients at end of year	1723	1659	1742

Table PA 7. Removal reason among adults waiting for pancreas after kidney transplant
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	64	48	33
Living donor kidney transplant	0	0	0
Patient died	5	5	3
Patient refused transplant	16	9	9
Improved, transplant not needed	0	1	1
Too sick for transplant	15	15	15
Changed to kidney-pancreas list	0	5	2
Other	58	67	47

Table PA 8. Removal reason among adults waiting for pancreas transplant alone
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	116	110	90
Living donor kidney transplant	0	0	0
Patient died	12	4	9
Patient refused transplant	9	4	8
Improved, transplant not needed	6	5	7
Too sick for transplant	13	13	21
Changed to kidney-pancreas list	10	8	5
Other	58	65	73

Table PA 9. Removal reason among adults waiting for simultaneous kidney-pancreas transplant
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	820	859	908
Living donor kidney transplant	64	70	60
Patient died	87	106	82
Patient refused transplant	10	9	6
Improved, transplant not needed	11	7	9
Too sick for transplant	91	76	88
Changed to kidney-pancreas list	0	0	0
Other	242	228	241

Table PA 10. Demographic characteristics of adult pancreas transplant recipients, 2019
Pancreas transplant recipients, including retransplants. Distance is computed from recipient's home zip code to the transplant center. PAK, pancreas after kidney; PTA, pancreas transplant alone; SPK, simultaneous kidney pancreas transplant.

Characteristic	PAK, N	PAK, Pct	PTA, N	PTA, Pct	SPK, N	SPK, Pct	All, N	All, Pct
Age: 18-34 years	4	9.1%	20	24.7%	202	23.2%	226	22.7%
Age: 35-49 years	30	68.2%	34	42.0%	456	52.5%	520	52.3%
Age: 50-60 years	9	20.5%	20	24.7%	184	21.2%	213	21.4%
Age: > 60 years	1	2.3%	7	8.6%	27	3.1%	35	3.5%
Sex: Female	18	40.9%	44	54.3%	326	37.5%	388	39.0%
Sex: Male	26	59.1%	37	45.7%	543	62.5%	606	61.0%
Race/ethnicity: White	27	61.4%	66	81.5%	426	49.0%	519	52.2%
Race/ethnicity: Black	8	18.2%	9	11.1%	254	29.2%	271	27.3%
Race/ethnicity: Hispanic	7	15.9%	6	7.4%	144	16.6%	157	15.8%
Race/ethnicity: Asian	2	4.5%	0	0.0%	41	4.7%	43	4.3%
Race/ethnicity: Other/unknown	0	0.0%	0	0.0%	4	0.5%	4	0.4%
BMI: < 18.5 kg/m2	0	0.0%	3	3.7%	11	1.3%	14	1.4%
BMI: 18.5-< 25 kg/m2	21	47.7%	31	38.3%	353	40.6%	405	40.7%
BMI: 25-< 28 kg/m2	10	22.7%	14	17.3%	248	28.5%	272	27.4%
BMI: 28-< 30 kg/m2	5	11.4%	14	17.3%	132	15.2%	151	15.2%
BMI: 30-< 35 kg/m2	7	15.9%	17	21.0%	107	12.3%	131	13.2%
BMI: ≥ 35 kg/m2	1	2.3%	2	2.5%	18	2.1%	21	2.1%
Insurance: Private	20	45.5%	57	70.4%	373	42.9%	450	45.3%
Insurance: Medicare	20	45.5%	18	22.2%	416	47.9%	454	45.7%
Insurance: Other government	4	9.1%	5	6.2%	75	8.6%	84	8.5%
Insurance: Unknown	0	0.0%	1	1.2%	5	0.6%	6	0.6%
Geography: Metropolitan	39	88.6%	67	82.7%	728	83.8%	834	83.9%
Geography: Non-metro	5	11.4%	14	17.3%	141	16.2%	160	16.1%
Distance: < 50 miles	23	52.3%	30	37.0%	515	59.3%	568	57.1%
Distance: 50-<100 miles	11	25.0%	19	23.5%	168	19.3%	198	19.9%
Distance: 100-<150 miles	2	4.5%	9	11.1%	90	10.4%	101	10.2%
Distance: 150-<250 miles	4	9.1%	9	11.1%	58	6.7%	71	7.1%
Distance: ≥ 250 miles	4	9.1%	12	14.8%	33	3.8%	49	4.9%
Distance: Unknown	0	0.0%	2	2.5%	5	0.6%	7	0.7%
All recipients	44	100.0%	81	100.0%	869	100.0%	994	100.0%

Table PA 11. Clinical characteristics of adult pancreas transplant recipients, 2019
Pancreas transplant recipients, including retransplants. PAK, pancreas after kidney; PTA, pancreas transplant alone; SPK, simultaneous kidney pancreas transplant.

Characteristic	PAK, N	PAK, Pct	PTA, N	PTA, Pct	SPK, N	SPK, Pct	All, N	All, Pct
Diagnosis: Diabetes type 1	39	88.6%	55	67.9%	643	74.0%	737	74.1%
Diagnosis: Diabetes type 2	5	11.4%	5	6.2%	195	22.4%	205	20.6%
Diagnosis: Other	0	0.0%	21	25.9%	31	3.6%	52	5.2%
Blood type: A	24	54.5%	35	43.2%	290	33.4%	349	35.1%
Blood type: B	4	9.1%	10	12.3%	117	13.5%	131	13.2%
Blood type: AB	0	0.0%	0	0.0%	41	4.7%	41	4.1%
Blood type: O	16	36.4%	36	44.4%	421	48.4%	473	47.6%
All recipients	44	100.0%	81	100.0%	869	100.0%	994	100.0%

Table PA 12. Transplant characteristics of adult pancreas transplant recipients, 2019
Pancreas transplant recipients, including retransplants. PAK, pancreas after kidney; PTA, pancreas transplant alone; SPK, simultaneous kidney pancreas transplant.

Characteristic	PAK, N	PAK, Pct	PTA, N	PTA, Pct	SPK, N	SPK, Pct	All, N	All, Pct
Wait time: < 31 days	4	9.1%	11	13.6%	158	18.2%	173	17.4%
Wait time: 31-60 days	3	6.8%	12	14.8%	114	13.1%	129	13.0%
Wait time: 61-90 days	5	11.4%	5	6.2%	68	7.8%	78	7.8%
Wait time: 3-< 6 months	2	4.5%	20	24.7%	150	17.3%	172	17.3%
Wait time: 6-< 12 months	10	22.7%	11	13.6%	144	16.6%	165	16.6%
Wait time: 1-< 2 years	9	20.5%	10	12.3%	133	15.3%	152	15.3%
Wait time: 2-< 3 years	8	18.2%	6	7.4%	53	6.1%	67	6.7%
Wait time: ≥ 3 years	3	6.8%	6	7.4%	49	5.6%	58	5.8%
Transplant history: First	34	77.3%	72	88.9%	864	99.4%	970	97.6%
Transplant history: Retransplant	10	22.7%	9	11.1%	5	0.6%	24	2.4%
Tx type: Kidney-pancreas	0	0.0%	0	0.0%	867	99.8%	867	87.2%
Tx type: Pancreas only	44	100.0%	58	71.6%	0	0.0%	102	10.3%
Tx type: Other	0	0.0%	23	28.4%	2	0.2%	25	2.5%
All recipients	44	100.0%	81	100.0%	869	100.0%	994	100.0%

Table PA 13. Adult pancreas 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-	19.8%	1.8%	97.8%	96.0%	96.4%
D-	R+	21.4%	11.5%	1.3%	2.1%	2.2%
D-	R unk	0.1%	0.9%	0.7%	1.0%	1.0%
D+	R-	26.1%	5.7%	0.1%	0.7%	0.4%
D+	R+	31.9%	78.2%	0.0%	0.1%	0.1%
D+	R unk	0.1%	1.9%	0.0%	0.0%	0.0%
D unk	R-	0.4%	0.0%	0.1%	0.0%	0.0%
D unk	R+	0.2%	0.1%	0.0%	0.0%	0.0%
D unk	R unk	0.0%	0.0%	0.0%	0.0%	0.0%