Introduction

OPTN/SRTR 2017 Annual Data Report: Introduction

Introduction for the OPTN/SRTR 2017 Annual Data Report

This introduction provides a brief overview of trends in waitlist and transplant activity for solid organs in the United States. Explanations of trends vary substantially by organ type, and details can be found in the respective organ-specific Annual Data Report chapters. The 2017 Annual Data Report covers transplants through December 31, 2017. Its production was delayed due to a period of incomplete death data during 2017; analyses could not begin until data were complete.

Trends in Kidney Transplantation

In 2017, encouraging trends continued regarding supply and demand for kidney transplants, with increases in total, deceased donor, and living donor transplants, and a noteworthy decline in the number of active candidates listed for deceased donor transplant since 2015 (Figure INT 1). Between 2006 and 2014, the number of active candidates grew by 26.8%, an annual rate of 3.0%. However, a 2.1% decline occurred between 2015 and 2016, and a 1.5% decline between 2016 and 2017. These declines in numbers of patients on the deceased donor waiting list were due to more transplants performed and not to fewer patients added. Indeed, between 2016 and 2017, the number of new patients (active and inactive) added to the waiting list grew by 0.5% (Figure INT 3).

The number of kidney transplants, including recipients of all ages and kidneys transplanted with another organ, grew by 3.9% between 2016 and 2017, from 19,858 to 20,638 (Figure INT 5). This increase was due to a 4.2% increase in deceased donor transplants, from 14,229 to 14,826, and a 3.3% increase in living donor transplants, from 5629 to 5812. Reasons for the increase in deceased donor transplants are speculative, but it is likely due in part to deaths from the opioid epidemic causing increased availability of deceased donor organs. However, this would not explain the encouraging increase in living donor transplants. Again, the demand for kidney transplants, as reflected in the numbers of additions to the deceased donor waiting list, has changed little.

Although the increase in kidney transplants is encouraging, many candidates remain on the waiting list, despite the fact that many kidneys recovered for transplant are not transplanted (Figure INT 7). The proportion of kidneys recovered and not transplanted trended gradually upward between 2006 and 2016, and in 2016 a record 20.0% of recovered kidneys were not transplanted. Between 2016 and 2017, this proportion declined by 5.2%, to 18.9%. However, measures likely can still be taken to find candidates suitable for many if not most of the kidneys that are currently not transplanted.

Patient survival after kidney transplant exceeds survival after all other organ transplants except pancreas (Figure INT 8). Among all kidney transplant recipients in 2008-2012, 1-year patient survival was 97.3%; however, 5-year patient survival was 89.7%, indicating room for improvement.

Trends in Pancreas Transplantation

Pancreas transplant is the only type of solid organ transplant that has consistently declined over the past several years. Between 2008 and 2017, numbers of active candidates on the waiting list for simultaneous kidney-pancreas (SPK) transplant declined by 30.5%, from 1235 to 858, and on the waiting list for pancreas without kidney transplant by 49.5%, from 434 to 219 (Figure INT 2). Numbers of additions to the waiting lists also declined over the same time period, by 20.4% from 1472 to 1171 for simultaneous kidney-pancreas, and by 48.6% from 710 to 365 for pancreas transplant alone (Figure INT 4). Between 2016 and 2017 small decreases occurred in the numbers listed for SPK (2.2%) and pancreas transplant alone (12.4%), while the numbers added to the waiting list increased 4.6% for SPK and decreased 2.7% for pancreas transplant alone. Numbers of pancreas transplants declined every year between 2008 and 2014, from 1229 to 954. Since 2014, the number of pancreas transplants has remained relatively stable, and was 1002 in 2017 (Figure INT 6). Numbers of pancreata recovered but not transplanted have declined, reflecting declines in demand (Figure INT 7). Patient survival after pancreas transplant in 2017 was virtually identical to patient survival after kidney transplant (Figure INT 8).

Trends in Liver Transplantation

Liver transplant, the second most common type of solid organ transplant in the US, is another success story. The number of candidates on the waiting list declined by 4.8% between 2016 and 2017 (Figure INT 1), despite a 1.3% increase in the number of additions to the list (Figure INT 3). The number of liver transplants increased by 3.1% between 2016 and 2017, and 8082 in 2017 was a record number; numbers of liver transplants declined between 2006 and 2012 by 5.9% from 6651 to 6256, but increased by 25.2% between 2013 and 2017, from 6455 to 8082 (Figure INT 5). The increase between 2016 and 2017 was due to increases in deceased donor (by 2.9%, from 7496 to 7715) and living donor (by 6.4%, from 345 to 367) transplants. The most living donor liver transplants since 2001 occurred in 2017. Percentages of deceased donor livers recovered but not transplanted have declined steadily, from 11.2% in 2008 to 8.9% in 2017 (Figure INT 7). Patient survival after liver transplant between 2008 and 2012 was 89.3% at 1 year and 76.5% at 5 years (Figure INT 8).

Trends in Intestine Transplantation

The number of intestine transplants remained small in 2017, with 109 performed, the lowest number since 106 in 2012 (Figure INT 6). Patient survival after intestine transplant between 2008 and 2012 was 75.2% at 1 year and 55.5% at 5 years (Figure INT 8).

Trends in Heart Transplantation

Numbers of candidates on the heart transplant waiting list grew considerably until 2014, but has been relatively stable since (Figure INT 2). Between 2016 and 2017, the waiting list declined by 4.2%. Numbers of transplants (Figure INT 6) have increased markedly, more than keeping pace with additions to the waiting list (Figure INT 4); transplants increased by 49.5% from 2190 in 2008 to 3273 in 2017. Patient survival after heart transplants performed between 2008 and 2012 was 90.0% at 1 year and 78.6% at 5 years (Figure INT 8).

Trends in Lung Transplantation

Increases in numbers of lung transplants matched the pace of increases in numbers of heart transplants, and both exceeded the pace of increases in numbers of transplants of other organs. Between 2008 and 2017, the number of lung transplants increased by 64.7%, from 1505 to 2478 (Figure INT 6), and between 2016 and 2017 by 5.7%. The number of active candidates on the lung transplant waiting list at year-end grew by 2.5% over the past decade (Figure INT 2), while the number of active and inactive new additions increased by 48.0% over the same period (Figure INT 4). The proportion of lungs recovered for transplant but not transplanted increased between 2016 and 2017, but remained relatively low, 6.8% in 2017 (Figure INT 7).

Summary

Remarkable increases in solid organ transplants occurred in the US over the past 5 years, including increases in kidney, liver, heart, and lung transplants. Numbers of pancreas and intestinal transplants remained relatively low, but generally met the demand of declining numbers on the respective waiting lists. The increases in transplants are mostly due to increases in deceased donor transplants, although an increase in living donor kidney transplants is also encouraging. The number of deceased donor kidneys recovered for transplant but not transplanted remains a challenge.

Figure List

Intro

Figure INT 1. Candidates active on the kidney or liver waiting list on December 31 of the year
Figure INT 2. Candidates active on the waiting list for organs other than isolated kidney or liver on December 31 of the year
Figure INT 3. New candidates added to the kidney or liver waiting list during the year
Figure INT 4. New candidates added to the waiting list during the year for organs other than isolated kidney or liver
Figure INT 5. Total counts of kidney or liver transplants
Figure INT 6. Total counts of transplants for organs other than isolated kidney or liver
Figure INT 7. Rates of organs recovered for transplant and not transplanted
Figure INT 8. Patient survival among all transplant recipients, 2008-2012, by organ

A line plot for candidates active on the kidney or liver waiting list on december 31 of the year; the kidney category increases by 23.1% from 48.5 candidates (in thousands) at 2006 to 59.7 candidates (in thousands) at 2017; and the liver category decreases by 11.7% from 12.5 candidates (in thousands) at 2006 to 11 candidates (in thousands) at 2017. — **Figure INT 1. Candidates active on the kidney or liver waiting list on December 31 of the year**
Candidates concurrently listed at multiple centers are counted once. Those with concurrent listings and active at any program are considered active. Active status is assessed on December 31 of the year.

A line plot for candidates active on the waiting list for organs other than isolated kidney or liver on december 31 of the year; the kidney to pancreas category decreases by 40.6% from 1.4 candidates (in thousands) at 2006 to 0.9 candidates (in thousands) at 2017; the pancreas (pta+pak) category decreases by 59.1% from 0.5 candidates (in thousands) at 2006 to 0.2 candidates (in thousands) at 2017; the intestine category is 0.2 candidates (in thousands) at 2006 and remains relatively constant with a value of 0.2 candidates (in thousands) at 2017; the heart category increases by 119.1% from 1.4 candidates (in thousands) at 2006 to 3 candidates (in thousands) at 2017; and the lung category is 1.1 candidates (in thousands) at 2006 and remains relatively constant with a value of 1.1 candidates (in thousands) at 2017. — **Figure INT 2. Candidates active on the waiting list for organs other than isolated kidney or liver on December 31 of the year**
Candidates concurrently listed at multiple centers are counted once. Those with concurrent listings and active at any program are considered active. PAK, pancreas after kidney; PTA, pancreas transplant alone. Active status is assessed on December 31 of the year.

A line plot for new candidates added to the kidney or liver waiting list during the year; the kidney category increases by 11.1% from 28.2 candidates (in thousands) at 2006 to 31.3 candidates (in thousands) at 2017; and the liver category increases by 19.1% from 10.3 candidates (in thousands) at 2006 to 12.2 candidates (in thousands) at 2017. — **Figure INT 3. New candidates added to the kidney or liver waiting list during the year**
A new candidate is one who first joined the list during the given year, without having been listed in a previous year. Previously listed candidates who underwent transplant and subsequently relisted are considered new. Candidates concurrently listed at multiple centers are counted once. Active and inactive patients are included; active status for kidney candidates is determined on day 7 after first listing.

A line plot for new candidates added to the waiting list during the year for organs other than isolated kidney or liver; the kidney to pancreas category decreases by 24.6% from 1.6 candidates (in thousands) at 2006 to 1.2 candidates (in thousands) at 2017; the pancreas (pta+pak) category decreases by 56.3% from 0.8 candidates (in thousands) at 2006 to 0.4 candidates (in thousands) at 2017; the intestine category decreases by 48.5% from 0.3 candidates (in thousands) at 2006 to 0.2 candidates (in thousands) at 2017; the heart category increases by 45.8% from 3 candidates (in thousands) at 2006 to 4.4 candidates (in thousands) at 2017; and the lung category increases by 66.1% from 1.8 candidates (in thousands) at 2006 to 2.9 candidates (in thousands) at 2017. — **Figure INT 4. New candidates added to the waiting list during the year for organs other than isolated kidney or liver**
A new candidate is one who first joined the list during the given year, without having been listed in a previous year. Previously listed candidates who underwent transplant and subsequently relisted are considered new. Candidates concurrently listed at multiple centers are counted once. Active and inactive patients are included. PAK, pancreas after kidney; PTA, pancreas transplant alone.

A line plot for total counts of kidney or liver transplants; the kidney category increases by 14.5% from 18 transplants (in thousands) at 2006 to 20.6 transplants (in thousands) at 2017; and the liver category increases by 21.5% from 6.7 transplants (in thousands) at 2006 to 8.1 transplants (in thousands) at 2017. — **Figure INT 5. Total counts of kidney or liver transplants**
Kidney: patients undergoing kidney or SPK transplant. Retransplants and multi-organ transplants are included. SPK, simultaneous pancreas-kidney.

A line plot for total counts of transplants for organs other than isolated kidney or liver; the pancreas category decreases by 27.9% from 1.4 transplants (in thousands) at 2006 to 1 transplants (in thousands) at 2017; the intestine category decreases by 37.7% from 0.2 transplants (in thousands) at 2006 to 0.1 transplants (in thousands) at 2017; the heart category increases by 47.2% from 2.2 transplants (in thousands) at 2006 to 3.3 transplants (in thousands) at 2017; and the lung category increases by 72.6% from 1.4 transplants (in thousands) at 2006 to 2.5 transplants (in thousands) at 2017. — **Figure INT 6. Total counts of transplants for organs other than isolated kidney or liver**
Pancreas: patients undergoing pancreas or SPK transplant. Heart: patients undergoing heart or heart-lung transplant. Lung: patients undergoing lung or heart-lung transplant. Retransplants and multi-organ transplants are included. SPK, simultaneous pancreas-kidney.

A line plot for rates of organs recovered for transplant and not transplanted; the kidney category increases by 14.5% from 16.5 percent at 2006 to 18.9 percent at 2017; the pancreas category decreases by 21.0% from 30 percent at 2006 to 23.7 percent at 2017; the liver category decreases by 12.3% from 10.1 percent at 2006 to 8.9 percent at 2017; the intestine category decreases by 49.5% from 7.1 percent at 2006 to 3.6 percent at 2017; the heart category decreases by 15.8% from 1.2 percent at 2006 to 1 percent at 2017; and the lung category increases by 47.1% from 4.7 percent at 2006 to 6.8 percent at 2017. — **Figure INT 7. Rates of organs recovered for transplant and not transplanted**
Percentage of organs not transplanted out of all organs recovered for transplant. Kidneys recovered en-bloc are counted once, and kidneys recovered separately are counted twice.

A line plot for patient survival among all transplant recipients, 2008-2012, by organ; the kidney category decreases by 10.3% from 100 percent at 0 Months post-transplant to 89.7 percent at 60 Months post-transplant; the pancreas category decreases by 10.1% from 100 percent at 0 Months post-transplant to 89.9 percent at 60 Months post-transplant; the liver category decreases by 23.5% from 100 percent at 0 Months post-transplant to 76.5 percent at 60 Months post-transplant; the intestine category decreases by 44.5% from 100 percent at 0 Months post-transplant to 55.5 percent at 60 Months post-transplant; the heart category decreases by 21.4% from 100 percent at 0 Months post-transplant to 78.6 percent at 60 Months post-transplant; and the lung category decreases by 44.0% from 100 percent at 0 Months post-transplant to 56 percent at 60 Months post-transplant. — **Figure INT 8. Patient survival among all transplant recipients, 2008-2012, by organ**
Patient survival estimated using unadjusted Kaplan-Meier methods. For recipients of more than one transplant during the period, only the first is considered. Similar overall survival rates for kidney and pancreas recipient may obscure one organ's line on the graph.