DOD

OPTN/SRTR 2017 Annual Data Report: Deceased Organ Donation

Abstract

SRTR uses data collected by OPTN to calculate metrics such as donation rate, organ yield, and rate of organs recovered for transplant but not transplanted. In 2017, 1,085,646 death and imminent death referrals were made to organ procurement organizations, of which 22,265 met the definition of eligible (11,673) or imminent neurological (10,592) deaths per OPTN policy. There were 10,286 deceased donors, and this number has been increasing since 2010. The number of organs authorized for recovery has also continued to increase since 2010. The recent increase may be in part due to the rising number of deaths of young individuals due to the opioid epidemic. In 2017, 4813 organs were discarded, including 3542 kidneys, 309 pancreata, 742 livers, 4 intestines, 33 hearts, and 272 lungs. These numbers suggest a need to reduce the number of organs discarded.

Introduction

This chapter reports data collected by the Organ Procurement and Transplantation Network (OPTN) to describe metrics such as donation rate, organ yield, and rate of organs recovered for transplant but not transplanted.

Definitions of Terms Related to Deceased Organ Donation

Referrals: All deaths and imminent deaths that were reported to the organ procurement organization (OPO).
Eligible death: As per OPTN policy 1.2 in place prior to 2017, death of a person aged 70 years or younger who is legally declared brain dead according to hospital policy and does not exhibit any of the following indications: tuberculosis, human immunodeficiency virus (HIV) infection with specified conditions, Creutzfeldt-Jacob Disease, herpetic septicemia, rabies, reactive hepatitis B surface antigen, any retrovirus infection, active malignant neoplasms (except primary central nervous system tumors and skin cancers), Hodgkin disease, multiple myeloma, leukemia, miscellaneous carcinomas, aplastic anemia, agranulocytosis, fungal and viral encephalitis, gangrene of bowel, extreme immaturity, or positive serological or viral culture findings for HIV. On January 1, 2017, a new eligible death definition was enacted. As per this new definition, eligible death is death of a person aged 75 years old or younger who is legally declared brain dead according to state or local law, has a body weight of 5 kg or more, has a body mass index of 50 kg/m² or lower and has at least one kidney, liver, heart, or lung that is deemed to meet the eligible data definitions as per the new OPTN policy 1.2.
Donor: A person from whom at least one organ was recovered for the purpose of transplant, regardless of whether the organ was transplanted.
Eligible donor: A donor whose death met the definition of eligible death.
Organs authorized for recovery: Consent requested and given for recovery of specific organs from a donor. Recovery of organs for transplant must be specifically authorized by the individual(s) authorizing the donation, whether that is the donor or a surrogate donation decision maker, consistent with applicable state law.
Donation rate: Number of eligible donors per 100 eligible deaths.
Organs recovered per donor (ORPD): Total number of organs recovered divided by the number of donors, not limited to eligible deaths.
Organs transplanted per donor (OTPD): Total number of organs transplanted divided by the number of donors, not limited to eligible deaths. For example, the OTPD for kidneys is the total number of kidneys transplanted divided by the total number of all donors.
Organ yield metric: Ratio of observed to expected numbers of organs transplanted; expected numbers based on national experience with similar donors.
Discards or organs recovered for transplant but not transplanted: This is calculated by dividing the number of organs recovered for the purpose of transplant but not transplanted by the number of organs recovered for the purpose of transplant.
DBD: Donations after brain death
DCD: Donations after circulatory death

Donors

In 2017, 1,085,646 death and imminent death referrals were reported to OPTN by OPOs, an increase from 1,072,717 in 2016. These referrals included 11,673 individuals who met the definition of eligible deaths as defined by OPTN policy, an increase from 8947 in 2012. There were 22,265 imminent neurological and eligible deaths in 2017, a slight decline from 23,443 in 2016, which was anticipated due to changes in the OPTN definition of imminent neurological and eligible deaths.(Figure DOD 2) One of the changes to the definition of imminent neurological death was the change from the absence of three brain stem reflexes to the absence of spontaneous breathing and two other brain stem reflexes. There were 10,286 deceased donors, increased from 9971 in 2016, and this number has been increasing since 2010. The number of deceased donor transplants increased to 28,582 in 2017 from 27,622 in 2016 and 24,980 in 2015. This is in contrast to the decline or lack of growth in numbers of deceased donor transplants in previous years. In 2017, 6182 living donor transplants (difference between total transplants and deceased donor transplants) were performed, an increase from 5976 in 2016. This is a change from 2016, when there was a slight decreased from 5989 in 2015 (Figure DOD 2). Donations after brain death (DBD) increased to 8403 in 2017, from 8287 in 2016. Donations after circulatory death (DCD) increased to 1883 from 1684 in 2016. This represents a continuing steady increase in DBD and DCD donations since 2010 (Figure DOD 3). The number of organs authorized for recovery from deceased donors continued to increase to 73,660 in 2017, from 71,550 in 2016 and 55,348 since 2010. The number of organs recovered for transplant and transplanted increased to 29,435 from 28,454 in 2016 and 23,045 since 2012 (Figure DOD 4). Potential reasons for the growth in organs authorized for recovery, donors, and numbers of deceased donor transplants include the rising number of deaths of young individuals due to the opioid epidemic and increasing use of organs from DBD donors.

Donation Rate

OPTN policy requires that OPOs report all eligible deaths for OPO performance assessment. However, any performance metric based solely on eligible deaths uses only a subset of potential donors, since successful donations can come from donors not meeting the eligible death definition, e.g., DCD or donors aged older than 70 years. Recognizing this limitation, SRTR’s current donation rate is a measure of how often an eligible death becomes a donor. In 2017, the donation rate was 69.6 eligible donors per 100 eligible deaths, a decrease from 72.3 in 2016 and 72.2 in 2015. However, the 2017 changes in OPTN policy 1.2 defining eligible deaths make it difficult to draw firm conclusion on differences in donation rate between 2017 and prior years. Unadjusted donation rates varied by donation service area (DSA), ranging from 55.7 to 88.0 (Figure DOD 5). This range decreased slightly from 2016, when it varied from 52.9 to 93.3. Risk-adjusted donation rates are presented for each OPO biannually in the OPO reports on the SRTR website.

The donation rate varied by organ. In 2017, the highest rate was 63.1 eligible donors per 100 eligible deaths, for 7368 kidneys from 11,673 eligible deaths. This represents a slight decrease from 2016, when the donation rate was 66.7 eligible donors per 100 eligible deaths for kidneys. However, the number of kidney eligible donors increased from 7143 in 2016 due to the increase in the number of eligible deaths. In 2017, the next highest donation rate after kidneys was 63.6 for livers, from 7420 liver eligible donors. The pattern was similar for livers, with a slight decrease in the donation rate in 2017 compared with 2016, but an increase in numbers of liver donors due to increases in numbers of eligible deaths. In 2016, the donation rate was 65.6 for liver, from 7041 liver eligible donors. However, the 2017 changes in OPTN policy 1.2 defining eligible deaths make it difficult to draw firm conclusion on differences in organ specific donation rate for between 2017 and prior years.

In 2017, the lowest donation rate was 10.7 for pancreas, from 1249 pancreas eligible donors. Compared with 2016, the donation rate for pancreas donors decreased from 12.0 and the number of donors decreased from 1283 pancreas eligible donors (Figure DOD 6). In 2017, the donation rate for heart was 28.1 from 3279 heart eligible donors and the donation rate for lung was 19.8 from 2310 lung eligible donors.

Organs Recovered per Donor

In 2017, 3.54 organs were recovered per donor, the same as in 2016 and slightly higher than 3.51 in 2015 and 3.50 in 2014 (Figure DOD 7). The ORPD for all organs combined has been relatively stable compared with 2014 (Figure DOD 7, Figure DOD 8). Given that each donor can potentially donate two kidneys, the ORPD was highest for kidneys, followed by livers (Figure DOD 7, Figure DOD 8). ORPDs have remained stable for kidneys and slightly decreased for livers over the past decade. ORPDs have increased for hearts and lungs over the past decade, remained unchanged for intestine, and declined for pancreata (Figure DOD 8). In 2017, the ORPD varied substantially by DSA, ranging from 2.74 to 4.15, a slightly decreased range from 2.90 to 4.19 in 2016 (Figure DOD 9). The ORPD is an unadjusted number, and thus represents a mix of donor types, including young and old and DBD and DCD which explains some of the differences observed. The ORPD for kidneys varied across DSAs from 1.55 to 1.96; for pancreata, from 0 to 0.25; for livers, from 0.60 to 0.98; for intestines, from 0.0 to 0.04; for hearts, from 0 to 0.49; and for lungs, from 0.05 to 0.66 (Figure DOD 9).

Organs Transplanted per Donor and Organ Yield

The number of OTPD was 3.07 in 2017, slightly increased from 3.06 in 2016, and 3.03 in 2015 and 2014 (Figure DOD 10). Given that each donor can potentially donate two kidneys, the OTPD was highest for kidneys, followed by livers (Figure DOD 10, Figure DOD 11). OTPD increased for lungs over the past decade, but declined for pancreata (Figure DOD 11). The numbers of deceased donor organs transplanted in 2017 were as follows: 15,144 kidneys, 1000 pancreata, 7631 livers, 108 intestines, 3272 hearts, and 4359 lungs. In a 2017 unadjusted analysis, not accounting for the mix of DBD and DCD donor types, OTPD varied substantially by DSA, ranging from 2.31 to 3.76 (Figure DOD 12). In 2017, the OTPD for kidneys varied by DSA from 1.20 to 1.71; for pancreata, from 0 to 0.21; for livers, from 0.58 to 0.95; for intestines, from 0 to 0.04; for hearts, from 0 to 0.48; and for lungs, from 0.05 to 0.66.

The OTPD from DBD donors was 3.33 in 2017, slightly higher than 3.29 in 2016, 3.25 in 2015, and 3.22 in 2014. The OTPD from DCD donors was 1.92 in 2017, slightly lower than 1.93 in 2015 and 2016, and 1.97 in 2014 (Figure DOD 13). In 2017, of the 10,286 donors, 18.3% nationally were DCD, an increase from 17% in 2016, 16% in 2015 and 15% in 2014.

In 2017, average numbers of kidneys transplanted per donor were 1.46 for DBD (12,236 kidneys, higher than 11,890 in 2016 and 10,919 in 2015) and 1.54 for DCD (2908 kidneys more than 2611 in 2016 and 2332 in 2015) donors (Figure DOD 14). Although the number of kidneys transplanted per donor for DBD donors decreased compared with 2016, the number of kidneys increased due to the increase in the number of donors. The average number of kidneys transplanted varied by kidney donor profile index (KDPI), and was 1.93, 1.87, 1.55, 0.63 for KDPI <0.20, 0.21-0.34, 0.35-0.85, and >0.85, respectively (Figure DOD 20). The number of kidneys transplanted increased slightly for each category of KDPI. Apart from kidney donors, OTPD was higher from DBD than from DCD donors (Figure DOD 14, Figure DOD 15, Figure DOD 16, Figure DOD 17, Figure DOD 18, Figure DOD 19). The OTPD for kidneys has been higher from DCD than from DBD donors since 2006 (Figure DOD 14). The number of DCD liver donors continued to increase, from 450 in 2016 to 517 in 2017, but the number of DBD liver donors increased more, from 6961 in 2016 to 7114 in 2017. Similarly, the number of DCD lungs continued to increase, from 163 in 2016 to 165 in 2017, but the number of DCD lung donors increased more, from 3956 in 2016 to 4194 in 2017. Among DBD organs, only the number of DBD pancreata and DBD intestines continued to decline. The number of DBD pancreata declined from 992 in 2016 to 974 in 2017,and intestines declined from 147 in 2016 to 108 in 2017.

The yield metric shown in Figure DOD 21, Figure DOD 22, Figure DOD 23, Figure DOD 24, Figure DOD 25, and Figure DOD 26 compares the number of organs transplanted (observed) in 2016-2017 with the number of organs that would be expected to be transplanted based on the national experience with similar donors (expected). A ratio, expressed as observed/expected organs transplanted, of less than 1 indicates that fewer organs were transplanted than would be expected based on the national models for that organ. A ratio of more than 1 indicates that more organs were transplanted than would be expected. The mean observed/expected ratio for all organs varied from 0.93 to 1.10.

Organs Recovered for Transplant but Not Transplanted

The number of organs recovered for transplant but not transplanted is calculated by subtracting the number of organs transplanted from the number of organs recovered for the purpose of transplant. The percentage of organs not transplanted is then calculated by dividing the number of organs not transplanted by the number of organs recovered for the purpose of transplant. The percentage in 2017 for all organs combined was 13.2 per recovered organ, slightly lower than 13.8 per recovered organ in 2016 (Figure DOD 27). In 2017, 4813 organs were discarded, slightly less than 4859 in 2016 and slightly more than 4368 in 2015. In 2017, 3542 kidneys, 309 pancreata, 742 livers, 4 intestines, 33 hearts, and 272 lungs were discarded. (Figure DOD 27). The numbers of kidneys, livers, and hearts discarded increased from 3631, 739, and 31, respectively, in 2016 (Figure DOD 27).

Use of DCD Organs and High KDPI Kidneys

Use of DCD organs also varied (Figure DOD 28). The percentage of DCD donor organs among deceased donor transplant recipients varied across DSAs from 0 to 37.2. The percentage of donors with KDPI higher than 0.85 also varied across the DSAs, ranging from 0 to 29.9 (Figure DOD 29).

Disposition of Organs

The disposition of actual organs is described in Figure DOD 30, Figure DOD 31, Figure DOD 32, Figure DOD 33, Figure DOD 34, Figure DOD 35, Figure DOD 36, and Figure DOD 37. Donor characteristics in 2017 are compared with characteristics in 2006 in Table DOD 1. The most remarkable difference was the increase in HIV-positive donors to 6 in 2017 from none in 2007. This increase is due to the HIV Organ Policy Equity Act (HOPE), which modified rules regarding organ donation between HIV-positive individuals and authorized use of these organs as part of clinical research. Other remarkable differences were an increase in anoxia as cause of donor death from 18.5% in 2007 to 42.2% in 2017, and a decrease in stroke from 40.9% in 2007 to 26.6% in 2017. The number of DCD donors increased from 8.2% in 2007 to 16.1% in 2017. The increase in number of donors aged 18-34 years from 26.4% to 30.8% possibly reflects increased deaths due to the opioid abuse epidemic. Another demographic change noted was a decrease in US citizenship among donors from 98.5% in 2007 to 89.5% in 2017, with a concomitant increase in non-US citizenship from 0% in 2007 to 3.2% in 2017. Likewise, other/unknown citizenship increased from 1.5% in 2007 to 7.2% in 2017.