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Kidney

OPTN/SRTR 2017 Annual Data Report: Kidney

Abstract

Many positive trends in kidney transplantation were notable in 2017. Deceased donor kidney transplant rates and counts continued to rise, the kidney transplant waiting list declined for the third year in a row after decades of growth, and both short- and long-term allograft survival continued to improve year over year. In total, more than 220,000 patients were living in the United States with a functioning allograft. With 3 years of data available since implementation of the new kidney allocation system, better prediction of longer-term results of the allocation policy changes became possible. The data also reveal several areas in need of improvement and attention. Overall, the challenge of providing adequate access to kidney transplant persisted nationally, with additional dramatic regional variation. The proportion of living donor kidney transplants in both adults and children continued to fall, and racial disparities in living donor kidney transplant grew in the past decade.

Introduction

The 2017 Annual Data Report kidney chapter is an opportunity to examine long-term trends in kidney transplantation, as well as short-term changes since implementation of the new kidney allocation system (KAS) in late 2014. Three years of data since KAS implementation allows us to highlight where the kidney transplant community should focus its attention toward ongoing improvement in access, equity, and outcomes in kidney transplantation. The 2017 data show continuing gains in short- and long-term unadjusted allograft survival. The number of adult patients on the waiting list declined for the third year in a row after decades of consistent growth, with a parallel increase in deceased donor kidney transplants. Likewise, the number of deceased donor transplants increased for pediatric candidates, after nearly a decade of stagnation. Pediatric patients continue to experience an overall high rate of deceased donor transplant compared with adults. Short- and long-term outcomes also continued to improve.

However, geographic disparities in access to kidney transplant remained evident, as did racial disparities in living donor kidney transplant and in both living and deceased donor allograft survival. The proportion of adults and children undergoing living donor kidney transplants continued to fall, despite nearly 9000 people either dying or being removed from the waiting list due to deteriorating condition annually. Unlike the adult waiting list, the pediatric waiting list continued to grow, and the deceased donor transplant rate has declined in the past decade, but remains high compared with the rate for adults. Highly sensitized pediatric patients experience nearly the same deceased donor transplant rate as highly sensitized adults, in contrast to other demographic comparisons. As with adults, living donor transplant also declined as a proportion of pediatric kidney transplant.

In summary, the 2017 data show ongoing successes and opportunities to improve as the transplant community continues to work to improve access and outcomes for patients with end-stage kidney disease.

Adult Kidney Transplant

Waiting List

For the third year in a row, after a peak of nearly 100,000 in 2014, the number of patients on the kidney transplant waiting list fell to 92,685 in 2017 (Figure KI 2). Unlike in 2015, when numbers of prevalent inactive candidate decreased but numbers of prevalent active candidates increased, both numbers decreased in 2017. In total, 30,918 adult candidates were added to the list, and 33,891 were removed (Table KI 5). Deceased donor transplants increased from 13,501 in 2016 to 14,077 in 2017 (Table KI 6). The number of new inactive listings continued to trend down since the new KAS, which eliminated the utility of listing as inactive for candidates already on dialysis and undergoing pretransplant workups (Figure KI 1); however, incomplete workup remained the cited reason for inactive listing for nearly two-thirds of new patients on the list (Table KI 1). Unfortunately, death or deteriorating medical condition remained common reasons for removal from the list, accounting for more than a quarter of removals, and reflecting the ongoing organ shortage despite gains in numbers of deceased donor transplants (Table KI 6). Removals for other reasons were also frequent at more than 13.4% of all removals; more specific data on the reasons for removal may be warranted to ensure that clinically relevant trends are not missed.

Determining racial, sex, and geographic disparities in access to the waiting list is difficult given limited data on the proportions of patients in the United States with advanced chronic kidney disease. However, trends in the characteristics are interesting. The proportion of patients aged 65 years or older continued to increase, from 16.2% in 2007 to 23.1% in 2017 (Table KI 2, Figure KI 3). Men continued to outnumber women at 61.1% of the list, a generally stable or slightly increased proportion over more than 10 years. While overall the racial composition changed little, Hispanic patients have comprised a slowly but steadily increasing proportion, more than 20% of the list in 2017 (Figure KI 5, Table KI 2). Proportions of waitlisted candidates with calculated panel-reactive antibodies (cPRA) 98%-100% continued to decline, from 9.4% in 2013 to 8.2% in 2016 and 7.2% in 2017, after increasing annually prior to 2014. This trend likely reflects more transplants for these candidates under the new KAS (Figure KI 8, Table KI 3). Diabetes as a cause of kidney disease continued to increase, to 37.1% of waitlisted candidates (Table KI 3, Figure KI 6). Despite candidates becoming increasingly older with higher prevalence of diabetes and longer dialysis duration, a concerning post-KAS trend was decreasing proportions willing to accept high-kidney-donor-profile-index (KDPI) kidneys, from 49.9% in 2014 to 45.1% in 2017 (Figure KI 10); these proportions had been increasing prior to KAS. The decline was even more dramatic among candidates aged 65 years or older, from 66.9% in 2011 to 59.8% in 2017 (Figure KI 11). The proportion of candidates with at least one prior kidney transplant also declined, from 16.3% on December 31, 2007 to 12.1% in on December 31, 2017 (Table KI 4).

Time on the waiting list showed interesting post-KAS trends in addition to concerning long-term trends. Overall, waiting time increased, with a linear increase in the number of candidates waiting for 5 or more years (Figure KI 7). Given the increased risk of allograft loss with higher waiting time, this trend may slow gains in long-term allograft survival. More than 20% of listed candidates had been on dialysis for at least 6 years before their most recent listing (Figure KI 9). Conversely, the proportion of candidates on the list for less than 1 year decreased post-KAS, possibly reflecting credit for time on dialysis prior to listing.

Deceased donor transplant rates, or transplants per 100 waitlist-years, increased for all patients across age, race, and blood type, but a few notable trends post-KAS warrant discussion. The deceased donor transplant rate increased dramatically for candidates with cPRA 98%-100% in the first year post-KAS, but then leveled off as rates increased for all other cPRA groups (Figure KI 15). After an initially large increase in 2015 for candidates aged 18-34 years, increases since then have been similar to increases for all other age groups (Figure KI 12). Rates for candidates listed for less than 1 year increased markedly after 2014, again likely reflecting more transplants for newly listed candidates who had been on dialysis for many years (Figure KI 17). Finally, while transplant rates remained slightly lower for candidates living in metropolitan vs. nonmetropolitan zip codes (Figure KI 18), rates were lower overall for candidates living 150-<250 nautical miles (NM) from their transplant programs, compared with candidates living either closer than 150NM or 250 NM or further away (Figure KI 19).

Median time to transplant for kidney transplant candidates has not been calculable for more than a decade because half the list had not undergone transplant; as of 2017, only 47.0% of candidates who listed in 2007 had undergone transplant (Figure KI 21). Nationally, for candidates listed in 2014, 42.4% were still waiting in 2017; 21.9% underwent deceased donor transplant, 14.9% underwent living donor transplant, 8.1% died, and 12.7% were removed from the list for other reasons (Figure KI 20). The percentage of patients who underwent deceased donor transplant within 5 years varied from 10.2% to 80.3% across donation service areas (DSAs) (Figure KI 22); waitlist mortality rates also varied, ranging from 1.4 to 9.4 per 100 patient-years across DSAs (Figure KI 29). Overall and by age, race, and diagnosis, mortality rates for listed patients generally decreased over the past 10 years (Figure KI 24, Figure KI 25, Figure KI 26, Figure KI 27, Figure KI 28).

Deceased Donation

Data from 2017 show overall continued increases in numbers of deceased donors, particularly those aged 18-34 years (Figure KI 32, Figure KI 33). Anoxia has surpassed head trauma as the most common cause of donor death (Figure KI 48), likely reflecting the opioid crisis. In 2017, 18.9% of kidneys were discarded, i.e., recovered for transplant and not transplanted (Figure KI 37). Discard rates remained higher for older donors (Figure KI 36) and donors with diabetes (Figure KI 37), but were similar for Public Health Service increased and non-increased risk kidneys (Figure KI 42). Implementation of the new KAS raised concerns about increasing discard rates due to increased geographic sharing and longer cold ischemia times. While the rate of discards appeared to be increasing for the 2 years post-KAS for donors aged 65 years or older or with diabetes (Figure KI 36, Figure KI 37), 2017 rates were similar to 2016 rates. However, the discard rate for high-KDPI (>85%) kidneys appeared to trend upward from 2013 to 2015, then remained flat through 2017 (Figure KI 44).

The discard rate for biopsied kidneys remained markedly higher than the rate for non-biopsied kidneys; nearly one-third of biopsied kidneys were discarded over the past decade (Figure KI 40). While the overall kidney donor risk index (KDRI) for biopsied kidneys was higher than for non-biopsied kidneys, it declined for biopsied kidneys over the past 10 years, from 1.67 in 2006 to 1.52 in 2017 (Figure KI 47), with a relatively stable rate of discard, suggesting that kidneys discarded based on biopsy could have benefitted some listed candidates. Of similar concern is an ongoing trend toward decreasing KDRI of discarded kidneys (Figure KI 46), a possible unintended consequence of clinical use of KDPI rather than KDRI; KDPI assigns a percentile score of 0-100 based on the previous years’ recovered donor kidneys, which can result in drift. Specifically, if recovery practice nationwide becomes more conservative due to the previous year’s discards, the KDRI of a kidney with KDPI above 85 will be lower than in the prior year.

Living Donation

The total number of living donor transplants, in adults and children, has remained flat since 2011, and represents a declining proportion of all kidney transplants (Figure KI 57). Unrelated and paired donations increased, but related donations declined (Figure KI 49). Living donors have become progressively older, possibly due to concern about long-term risks for younger donors, and female donors continued to outnumber male donors (Figure KI 50, Figure KI 51). The proportion of black living donors declined from 12.6% in 2006 to 8.8% in 2017 (Figure KI 52). The extent of this decrease due to medical contraindications or psychosocial barriers needs further study. Proportions of post-donation complications including readmission at 6 weeks, 6 months, and 1 year were 5.4%, 7.4%, and 8.9%, respectively. However, complication rates at only 12 months were unknown for 11.3% of donors (Figure KI 55), illustrating the need to better ascertain living donor outcomes.

Kidney Transplants

The total number of kidney transplants rose notably in 2016 and 2017. This gain was almost entirely attributable to an increase in deceased donor transplants, as living donor transplants were essentially flat (Figure KI 57). The increase in transplants occurred across most levels of age, sex, race/ethnicity, and diagnosis groups (Figure KI 58, Figure KI 59, Figure KI 60, Figure KI 61). Although deceased-donor transplants among black and Hispanic patients increased notably post-KAS and approached rates for white patients, the rate of increase from 2016 to 2017 was less than the rate of increase for white recipients (Figure KI 13). Encouragingly, numbers of transplant recipients among minority candidates remained higher than pre-KAS (Figure KI 60). Similarly, while transplant rates in patients aged 65 years or older decreased immediately post-KAS, rates have since increased along with those for other age groups (Figure KI 12). However, disparity in access to living donation persists; only 12.5% of living donor kidney transplants in 2017 were performed in black recipients (Table KI 8), while 32.6% of candidates in 2017 were black (Table KI 2). In contrast, 65.9% of transplant recipients were white, though they made up only 36.2% of the waiting list.

Similar to 2016, 43.2% of deceased donor recipients had been on dialysis for at least 5 years, compared with 12.4% of living donor recipients, in 2017. Conversely, the proportion of deceased donor recipients on the waiting list for more than 5 years was 15.3%, decreased from 19.2% in 2016, likely continuing to reflect credit for time on dialysis under the new KAS (Table KI 9, Table KI 10). Consistent with the higher rate of discards for kidneys with KDPI above 85%, the proportion of transplants using high-KDPI kidneys declined from 11.0% in 2006 to 7.8% in 2017 (Figure KI 62). Given that the KDRI for a kidney with KDPI above 85% declined over the same period, this trend again suggests that kidneys that could benefit some candidates may be unnecessarily discarded. Immediately post-KAS, the proportion of deceased donor transplants among candidates with cPRA 98%-100% increased dramatically to 14.6% from 4.8% (Figure 65). This proportion decreased and then leveled off, but remained higher than pre-KAS prevalence at 10.6% (Figure KI 65).

Transplants were performed across a broad range of transplant program sizes, but 2017 saw a jump in the proportion of transplants performed at large volume (≥250/year) programs, from 16.9% in 2016 to 21.0% in 2017 (Figure KI 69). A steady increase in the use of T-cell depleting agents was again noted in 2017, with nearly 75% of recipients receiving immunosuppression induction with T-cell depleting agents (Figure KI 63). Similarly, tacrolimus remained the basis of most regimens, accounting for all but 7% of regimens (Figure KI 64). Approximately 30% of recipients remained on steroid-free regimens (Figure KI 64).

Outcomes

By mid-2017, more than 220,000 recipients were alive with a functioning graft, an increase from nearly 140,000 in 2006 (Figure KI 88). The longstanding improvement in unadjusted short- and long-term deceased donor graft survival continued in 2017; 6-month all-cause and death-censored graft failure for deceased donor recipients in 2016 was nearly half what it was 10 years ago. All-cause graft failure declined from 7.1% in 2006 to 4.3% in 2016, with a similar decline in 6-month death-censored graft failure from 4.1% to 2.4% over the same period. Long-term failure rates improved; 10-year all-cause graft failure for deceased donor recipients in 2007 declined to 49.7% from 57.6% in 2000, and 10-year death-censored graft failure declined from 31.5% to 25.1% (Figure KI 70, Figure KI 71). Graft failure remained significantly lower after living donor kidney transplants, with similarly positive trends: 6-month and 10-year all-cause graft failure only 1.4% and 34.1%. Censoring for death, more than 80% of living donor kidneys transplanted in 2007 were still functioning in 2017 (Figure KI 74).

Deceased donor transplant allograft failure was higher for patients with diabetes or hypertension as cause of kidney failure than for those with cystic disease or glomerulonephritis (Figure KI 76). However, graft survival did not differ for donation-after-circulatory-death versus donation-after-brain-death kidneys (Figure KI 78), or for metropolitan versus non-metropolitan residents (Figure KI 80). Allograft survival was modestly better for deceased donor recipients living 250 NM or farther from the transplant program (Figure KI 81). Not surprisingly, 5-year graft survival differed by KDPI. However, while graft survival for KDPI above 85% was notably lower than for lower KDPI groups at 63.5%, survival for lower KDPI groups differed only modestly (83.1%, 80.9%, 77.0% for KDPI ≤20%, 21%-34%, 35%-85% respectively) (Figure KI 77). Observed 5-year graft survival was lower for biopsied than for non-biopsied kidneys (74.2% versus 80.6%), suggesting more frequent biopsies of kidneys that are medically likely to be of lower quality (Figure KI 79). While still better than deceased donor graft survival, 5-year living donor graft survival was lower for black recipients than for any other racial/ethnic group, at 83.2% compared with 90.2% for Asian and 87-88% for white and Hispanic recipients (Figure KI 83).

Posttransplant diabetes continued to decline, especially among recipients with the highest body mass index (BMI); 1-year incidence in recipients with BMI 35 kg/m2 or higher was essentially the same as for recipients with BMI 25-34 kg/m2 (Figure KI 91, Figure KI 92). This trend is particularly encouraging given increased use of tacrolimus in lieu of cyclosporine for immunosuppression. Incidence of posttransplant lymphoproliferative disorder (PTLD) remained low overall at 0.6% at 5 years. However, 5-year incidence was higher for recipients who were Epstein-Barr virus (EBV) negative, albeit still low at 1.7% (Figure KI 93).

Patient survival closely mirrored graft survival. Five-year recipient survival was lowest for patients with diabetes (85.5% and 88.0% for deceased and living donor recipients, respectively, Figure KI 95 and Figure KI 101), aged older than 65 years (76.4% and 83.6%, respectively, Figure KI 94 and Figure KI 100), and for those who received a high-KDPI (80.1%, Figure KI 96) or biopsied kidney (85.9%, Figure KI 97). Patient survival after either living or deceased donor transplant did not differ significantly by metropolitan versus non-metropolitan residence or distance to the transplant program.

Pediatric Kidney Transplant

Waiting List

In 2017, the highest number of pediatric candidates were added to the kidney transplant waiting list: 1014, with 367 (36%) added as active status (Figure KI 105). The number of prevalent pediatric candidates (listed at age <18 years and on the list on December 31 of the given year) has been steadily increasing and reached 1,575 on December 31, 2017, with 508 (32%) as active status (Figure KI 106). The most common reason for inactive status among newly listed candidates in 2017 was incomplete work-up (51.9%), followed by living donor candidate status (14.8%), and too well to need transplant (14.7%) (Table KI 13). Over the past decade, the age of pediatric candidates on the waiting list shifted, with an increase in those aged 1-5 and 6-10 years and a decrease in those aged 11-17 years (64.8% to 54.7%) (Table KI 14). Proportions of candidates with congenital anomalies of the kidney and urinary tract (CAKUT) as primary cause of disease increased from 25.7% in 2007 to 37.6% in 2017, and proportions with glomerulonephritis and focal segmental glomerulosclerosis (FSGS) decreased (Table KI 15). For most candidates waiting as of December 31, 2017 (67.5%), cPRA was less than 1% (Table KI 15). The proportion of pediatric candidates waiting for retransplant decreased from 26.8% in 2007 to 13.9% in 2017. Multi-organ listing remained uncommon; only 2.1% of pediatric candidates were awaiting multi-organ transplant at the end of 2017 (Table KI 16). The leading cause of ESRD changed with age; CAKUT was most common in children aged younger than 6 years, and FSGS and glomerulonephritis were more common in older children (Figure KI 113).

Of the 971 pediatric candidates removed from the waiting list in 2017, 617 (63.5%) received a deceased donor kidney, 255 (26.3%) received a living donor kidney, 17 (1.8%) died, 15 (1.5%) were considered too sick to undergo transplant, and 6 (0.6%) were removed from the list because their condition improved (Table KI 17, Table KI 18). Among patients newly listed in 2014, 56.3% underwent deceased donor transplant within 3 years, 23.3% underwent living donor transplant, 15.4% were still waiting, 3.9% were removed from the list for other reasons, and 1.2% died (Figure KI 114). The rate of deceased donor transplant among pediatric waitlisted candidates decreased over the past decade and plateaued at 40 transplants per 100 active waitlist-years for the past several years, compared with a peak of 63 in 2006 (Figure KI 115). Considering changes post-KAS implementation, transplant rates varied by age; rates increased for ages younger than 6 and 11-17 years and decreased for ages 6-10 years. In 2017, transplant rates were highest for candidates aged 11-17 years (55.6 per 100 active waitlist-years), followed by ages younger than 6 years (43.9), the age group that previously had the lowest transplant rate among all pediatric candidates. As expected, transplant rates remained higher than pre-KAS rates for highly sensitized (≥98%) patients, reflecting KAS’ priority for these candidates; the transplant rate increased from 6.6 transplants per 100 waitlist-years in 2014 to 14.8 in 2017 (Figure KI 116). Transplant rates for pediatric candidates with cPRA 80%-97% initially declined to 17.1 post-KAS, but increased to 25.4 in 2017 (Figure KI 116), similar to rates in the adult population. In contrast to mortality among candidates waiting for other organs, pretransplant mortality among pediatric candidates waiting for kidney transplant was low: 2.0 per 100 waitlist-years in 2016-2017, but varying by age; the rate was 2.0 for ages younger than 6 and 6-10 years, and 0.9 for ages 11-17 years (Figure KI 119).

Transplant

The total number of pediatric kidney transplants remained steady at just under 750 in 2017 (Figure KI 122). A slow decline continued in the proportion of living donor kidney transplants in pediatric recipients; only 31.5% of pediatric transplants were from living donors in 2017. The number of related living donors decreased dramatically over the past decade (Figure KI 123), and the number of unrelated directed transplants performed in pediatric candidates remained low (54 in 2017) (Figure KI 123). Children aged younger than 6 years made up the largest group of living donor kidney recipients (41.3%) (Figure KI 124).

In 2017, 33 programs were performing only pediatric kidney transplants, compared with 132 performing only adult transplants and 58 performing transplants in both adults and children (Figure KI 125). In 2017, only 5.9% of transplants in candidates aged younger than 10 years were performed at programs with volumes of five or fewer pediatric transplants in that year (Figure KI 126). Most pediatric recipients who underwent transplant between 2015 and 2017 were aged 11-17 years, 61.2% among deceased donor recipients and 51.9% among living donor recipients (Table KI 19). A higher proportion of living donor transplants were performed in recipients aged 1-5 years; this group accounted for 30.5% of pediatric living donor transplants and 19.3% of pediatric deceased donor transplants (Table KI 19).The racial distribution differed for deceased and living donor transplant recipients; a higher proportion of living donor than deceased donor recipients were white (68.1% vs. 40.0%). Private insurance was more common among living donor recipients and Medicare/Medicaid among deceased donor recipients. Most deceased donor recipients (93.6%) underwent transplant with a kidney from a donor with KDPI less than 35% (Table KI 21).

The combination of a donor who was positive for cytomegalovirus and a pediatric recipient who was negative occurred in 38.4% of deceased donor transplants and in 30.8% of living donor transplants (Table KI 22, Table KI 23). The combination of a donor who was positive for EBV and a recipient who was negative occurred in 36.2% of deceased donor transplants and in 50.6% of living donor transplants.

Immunosuppressive Medication Use

Use of T-cell depleting agents continued to increase, reaching 65.9% in 2017. IL-2-RA therapy use remained steady at 33.8% (Figure KI 127). In 2017, the most common initial immunosuppression regimens were tacrolimus, MMF, and steroids in 57.6% of recipients, followed by tacrolimus and MMF in 32.9% (Figure KI 128). T-cell depleting agents were more common with increasing cPRA and IL-2-RA use with decreasing cPRA (Figure KI 129).

Outcomes

All-cause graft failure after kidney-alone deceased donor transplant in pediatric recipients was 2.0% at 6 months and 2.3% at 1 year for transplants in 2015-2016, 11.1% at 3 years for transplants in 2013-2014, 16.2% at 5 years for transplants in 2011-2012, and 41.7% at 10 years for transplants in 2007-2008 (Figure KI 132). Corresponding graft failure after living donor transplant was 1.4% at 6 months and 1.8% at 1 year for transplants in 2015-2016, 5.0% at 3 years for transplants in 2013-2014, 10.2% at 5 years for transplants in 2011-2012, and 30.0% at 10 years for transplants in 2007-2008 (Figure KI 135). For the cohort of recipients who underwent transplant in 2008-2012, graft survival was highest for living donor recipients aged younger than 11 years (91.5% at 5 years) and lowest for deceased donor recipients aged 11-17 years (76.5% at 5 years) (Figure KI 138). In the 2015-2016 cohort, the overall incidence of acute rejection was 12.2% with some variation by age: highest for ages younger than 6 (13.5%) and lowest for ages 6-10 years (9.7%) (Figure KI 139). Short-term renal function, measured by eGFR, improved substantially over the past decade. The proportion of recipients with eGFR 90 mL/min/1.73 m2 or higher at 12 months posttransplant increased from 15% in 2006 to 27.7% in 2016 (Figure KI 131). In the 2016 cohort, 72.7% of recipients had CKD stage 1-2 at 1 year posttransplant, with eGFR 60 mL/min/1.73 m2 or higher. Incidence of PTLD among EBV-negative recipients was 3.0% at 5 years posttransplant, compared with 0.7% among EBV-positive recipients (Figure KI 141). Overall 5-year patient survival among pediatric kidney transplant recipients in 2008-2012 was very high at 98.2% (Figure KI 142).

Figure List

Waiting list

Figure KI 1. New adult candidates added to the kidney transplant waiting list
Figure KI 2. Adults listed for kidney transplant on December 31 each year
Figure KI 3. Distribution of adults waiting for kidney transplant by age
Figure KI 4. Distribution of adults waiting for kidney transplant by sex
Figure KI 5. Distribution of adults waiting for kidney transplant by race
Figure KI 6. Distribution of adults waiting for kidney transplant by diagnosis
Figure KI 7. Distribution of adults waiting for kidney transplant by waiting time
Figure KI 8. Distribution of adults waiting for kidney transplant by C/PRA
Figure KI 9. Distribution of adults waiting for kidney transplant by time on dialysis
Figure KI 10. Distribution of adults waiting for kidney transplant by willingness to accept ECD or KDPI > 85% kidney
Figure KI 11. Adults willing to accept a kidney designated ECD or KDPI > 85% by age
Figure KI 12. Deceased donor kidney transplant rates among adult waitlist candidates by age
Figure KI 13. Deceased donor kidney transplant rates among adult waitlist candidates by race
Figure KI 14. Deceased donor kidney transplant rates among adult waitlist candidates by diagnosis
Figure KI 15. Deceased donor kidney transplant rates among adult waitlist candidates by C/PRA
Figure KI 16. Deceased donor kidney transplant rates among adult waitlist candidates by blood type
Figure KI 17. Deceased donor kidney transplant rates among adult waitlist candidates by time on the waitlist
Figure KI 18. Deceased donor kidney transplant rates among waitlist candidates by metropolitan vs. non-metropolitan residence
Figure KI 19. Deceased donor kidney transplant rates among waitlist candidates by distance from listing center
Figure KI 20. Three-year outcomes for adults waiting for kidney transplant, new listings in 2014
Figure KI 21. Percentage of adults who underwent deceased donor kidney transplant within a given time period of listing
Figure KI 22. Percentage of adults who underwent deceased donor kidney transplant within 5 years of listing in 2012 by DSA
Figure KI 23. Percentage of adults who underwent deceased donor kidney transplant within 5 years of listing in 2012 by state
Figure KI 24. Pretransplant mortality rates among adults waitlisted for kidney transplant by age
Figure KI 25. Pretransplant mortality rates among adults waitlisted for kidney transplant by race
Figure KI 26. Pretransplant mortality rates among adults waitlisted for kidney transplant by diagnosis
Figure KI 27. Pretransplant mortality rates among adults waitlisted for kidney by metropolitan vs. non-metropolitan residence
Figure KI 28. Pretransplant mortality rates among adults waitlisted for kidney, by distance from listing center
Figure KI 29. Pretransplant mortality rates among adults waitlisted for kidney transplant in 2017, by DSA
Figure KI 30. Deaths within six months after removal among adult kidney waitlist candidates, by diagnosis group at removal
Figure KI 31. Deaths within six months after removal among adult kidney waitlist candidates, by age at removal

Deceased donation

Figure KI 32. Deceased kidney donor count by age
Figure KI 33. Distribution of deceased kidney donors by age
Figure KI 34. Distribution of deceased kidney donors by race
Figure KI 35. Percent of pediatric kidney donors allocated to adult recipients
Figure KI 36. Rates of kidneys recovered for transplant and not transplanted by donor age
Figure KI 37. Rates of kidneys recovered for transplant and not transplanted by donor diabetes status
Figure KI 38. Rates of kidneys recovered for transplant and not transplanted by donor hypertension status
Figure KI 39. Rates of kidneys recovered for transplant and not transplanted by donor terminal creatinine
Figure KI 40. Rates of kidneys recovered for transplant and not transplanted by donor biopsy status
Figure KI 41. Rates of kidneys recovered for transplant and not transplanted by donor cause of death
Figure KI 42. Rates of kidneys recovered for transplant and not transplanted, by donor risk of disease transmission
Figure KI 43. Rates of kidneys recovered for transplant and not transplanted by DCD status
Figure KI 44. Rates of kidneys recovered for transplant and not transplanted by KDPI
Figure KI 45. Donor-specific components of the kidney donor risk index
Figure KI 46. Average kidney donor risk index
Figure KI 47. Average kidney donor risk index by biopsy status
Figure KI 48. Cause of death among deceased kidney donors

Living donation

Figure KI 49. Kidney transplants from living donors by donor relation
Figure KI 50. Living kidney donors by age
Figure KI 51. Living kidney donors by sex
Figure KI 52. Living kidney donors by race
Figure KI 53. Intended living kidney donor procedure type
Figure KI 54. Rehospitalization in the first 6 weeks, 6 months, and 1 year among living kidney donors, 2012-2016
Figure KI 55. Kidney complications among living kidney donors, 2012-2016
Figure KI 56. BMI among living kidney donors

Transplant

Figure KI 57. Total kidney transplants
Figure KI 58. Total kidney transplants by age
Figure KI 59. Total kidney transplants by sex
Figure KI 60. Total kidney transplants by race
Figure KI 61. Total kidney transplants by diagnosis
Figure KI 62. Kidney transplants by kidney donor profile index (KDPI)
Figure KI 63. Induction agent use in adult kidney transplant recipients
Figure KI 64. Immunosuppression regimen use in adult kidney transplant recipients
Figure KI 65. C/PRA at time of kidney transplant in adult deceased donor recipients
Figure KI 66. C/PRA at time of kidney transplant in adult living donor recipients
Figure KI 67. Total HLA A, B, and DR mismatches among adult kidney transplant recipients, 2013-2017
Figure KI 68. Annual adult kidney transplant center volumes, by percentile
Figure KI 69. Distribution of adult kidney transplants by annual center volume

Outcomes

Figure KI 70. Graft failure among adult deceased donor kidney transplant recipients
Figure KI 71. Death-censored graft failure among adult deceased donor kidney transplant recipients
Figure KI 72. Death with function among adult deceased donor kidney transplant recipients
Figure KI 73. Graft failure among adult living donor kidney transplant recipients
Figure KI 74. Death-censored graft failure among adult living donor kidney transplant recipients
Figure KI 75. Death with function among adult living donor kidney transplant recipients
Figure KI 76. Graft survival among adult deceased donor kidney transplant recipients, 2012, by diagnosis
Figure KI 77. Graft survival among adult deceased donor kidney transplant recipients, 2012, by KDPI
Figure KI 78. Graft survival among adult deceased donor kidney transplant recipients, 2012, by DCD status
Figure KI 79. Graft survival among adult deceased donor kidney transplant recipients, 2012, by biopsy status
Figure KI 80. Graft survival among adult deceased donor kidney transplant recipients, 2012, by metropolitan vs. non-metropolitan recipient residence
Figure KI 81. Graft survival among adult deceased donor kidney transplant recipients, 2012, by recipients' distance from transplant center
Figure KI 82. Graft survival among adult living donor kidney transplant recipients, 2012, by age
Figure KI 83. Graft survival among adult living donor kidney transplant recipients, 2012, by race
Figure KI 84. Graft survival among adult living donor kidney transplant recipients, 2012, by diagnosis
Figure KI 85. Graft survival among adult living donor kidney transplant recipients, 2012, by metropolitan vs. non-metropolitan recipient residence
Figure KI 86. Graft survival among adult living donor kidney transplant recipients, 2012, by recipients' distance from transplant center
Figure KI 87. Distribution of eGFR at 6 months posttransplant among adult kidney transplant recipients
Figure KI 88. Recipients alive with a functioning kidney graft on June 30 of the year, by age at transplant
Figure KI 89. Incidence of acute rejection by 1 year posttransplant among adult kidney transplant recipients by age, 2015-2016
Figure KI 90. Incidence of acute rejection by 1 year posttransplant among adult kidney transplant recipients by induction status, 2015-2016
Figure KI 91. Posttransplant diabetes among adult kidney transplant recipients
Figure KI 92. Posttransplant diabetes within 1 year among adult kidney transplant recipients by BMI at transplant
Figure KI 93. Incidence of PTLD among adult kidney transplant recipients by recipient EBV status at transplant, 2011-2015
Figure KI 94. Patient survival among adult deceased donor kidney transplant recipients, 2012, by age
Figure KI 95. Patient survival among adult deceased donor kidney transplant recipients, 2012, by diagnosis
Figure KI 96. Patient survival among adult deceased donor kidney transplant recipients, 2012, by KDPI
Figure KI 97. Patient survival among adult deceased donor kidney transplant recipients, 2012, by biopsy status
Figure KI 98. Patient survival among adult deceased donor kidney transplant recipients, 2012, by metropolitan vs. non-metropolitan recipient residence
Figure KI 99. Patient survival among adult deceased donor kidney transplant recipients, 2012, by recipients' distance from transplant center
Figure KI 100. Patient survival among adult living donor kidney transplant recipients, 2012, by age
Figure KI 101. Patient survival among adult living donor kidney transplant recipients, 2012, by diagnosis
Figure KI 102. Patient survival among adult living donor kidney transplant recipients, 2012, by race
Figure KI 103. Patient survival among adult living donor kidney transplant recipients, 2012, by metropolitan vs. non-metropolitan recipient residence
Figure KI 104. Patient survival among adult living donor kidney transplant recipients, 2012, by recipients' distance from transplant center

Pediatric transplant

Figure KI 105. New pediatric candidates added to the kidney transplant waiting list
Figure KI 106. Pediatric candidates listed for kidney transplant on December 31 each year
Figure KI 107. Distribution of pediatric candidates waiting for kidney transplant by age
Figure KI 108. Distribution of pediatric candidates waiting for kidney transplant by race
Figure KI 109. Distribution of pediatric candidates waiting for kidney transplant by diagnosis
Figure KI 110. Distribution of pediatric candidates waiting for kidney transplant by sex
Figure KI 111. Distribution of pediatric candidates waiting for kidney transplant by waiting time
Figure KI 112. Distribution of pediatric candidates waiting for kidney transplant by C/PRA
Figure KI 113. Primary cause of ESRD in pediatric candidates waiting for kidney transplant by age, 2011-2015
Figure KI 114. Three-year outcomes for newly listed pediatric candidates waiting for kidney transplant, 2014
Figure KI 115. Deceased donor kidney transplant rates among pediatric waitlist candidates by age
Figure KI 116. Deceased donor kidney transplant rates among pediatric waitlist candidates by C/PRA
Figure KI 117. Deceased donor kidney transplant rates among pediatric waitlist candidates by metropolitan vs. non-metropolitan residence
Figure KI 118. Deceased donor kidney transplant rates among pediatric waitlist candidates by distance from listing center
Figure KI 119. Pretransplant mortality rates among pediatrics waitlisted for kidney transplant by age
Figure KI 120. Pretransplant mortality rates among pediatrics waitlisted for kidney transplant by metropolitan vs. non-metropolitan residence
Figure KI 121. Pretransplant mortality rates among pediatrics waitlisted for kidney transplant by distance from listing center
Figure KI 122. Pediatric kidney transplants by donor type
Figure KI 123. Pediatric kidney transplants from living donors by relation
Figure KI 124. Percent of pediatric kidney transplants from living donors by recipient age
Figure KI 125. Number of centers performing pediatric and adult kidney transplants by center's age mix
Figure KI 126. Pediatric kidney recipients at programs that perform 5 or fewer pediatric transplants annually
Figure KI 127. Induction agent use in pediatric kidney transplant recipients
Figure KI 128. Immunosuppression regimen use in pediatric kidney transplant recipients
Figure KI 129. Induction use by C/PRA among pediatric kidney transplant recipients, 2013-2017
Figure KI 130. Total HLA A, B, and DR mismatches among pediatric kidney transplant recipients, 2013-2017
Figure KI 131. Distribution of eGFR at 12 months posttransplant among pediatric kidney-alone transplant recipients
Figure KI 132. Graft failure among pediatric deceased donor kidney-alone transplant recipients
Figure KI 133. Death-censored graft failure among pediatric deceased donor kidney-alone transplant recipients
Figure KI 134. Death with function among pediatric deceased donor kidney-alone transplant recipients
Figure KI 135. Graft failure among pediatric living donor kidney-alone transplant recipients
Figure KI 136. Death-censored graft failure among pediatric living donor kidney-alone transplant recipients
Figure KI 137. Death with function among pediatric living donor kidney-alone transplant recipients
Figure KI 138. Graft survival among pediatric kidney transplant recipients by age and donor type, 2008-2012
Figure KI 139. Incidence of acute rejection by 1 year posttransplant among pediatric kidney transplant recipients by induction status, 2015-2016
Figure KI 140. Incidence of acute rejection by 1 year posttransplant among pediatric kidney transplant recipients by age, 2015-2016
Figure KI 141. Incidence of PTLD among pediatric kidney transplant recipients by recipient EBV status at transplant, 2004-2014
Figure KI 142. Patient survival among pediatric kidney transplant recipients, 2008-2012, by recipient age and donor type

Table List

Waiting list

Table KI 1. Reasons for inactive status among new adult kidney transplant listings, 2017
Table KI 2. Demographic characteristics of adults on the kidney transplant waiting list on December 31, 2007, December 31, 2012 and December 31, 2017
Table KI 3. Clinical characteristics of adults on the kidney transplant waiting list on December 31, 2007, December 31, 2012 and December 31, 2017
Table KI 4. Listing characteristics of adults on the kidney transplant waiting list on December 31, 2007, December 31, 2012 and December 31, 2017
Table KI 5. Kidney transplant waitlist activity among adults
Table KI 6. Removal reason among adult kidney transplant candidates

Living donation

Table KI 7. Living kidney donor deaths, 2013-2017, by number of days after donation

Transplant

Table KI 8. Demographic characteristics of adult kidney transplant recipients, 2017
Table KI 9. Clinical characteristics of adult kidney transplant recipients, 2017
Table KI 10. Transplant characteristics of adult kidney transplant recipients, 2017
Table KI 11. Adult deceased donor kidney donor-recipient serology matching, 2013-2017
Table KI 12. Adult living donor kidney donor-recipient serology matching, 2013-2017

Pediatric transplant

Table KI 13. Reasons for inactive status among new pediatric kidney transplant listings, 2016
Table KI 14. Demographic characteristics of pediatric candidates on the kidney transplant waiting list on December 31, 2007, December 31, 2012, and December 31, 2017
Table KI 15. Clinical characteristics of pediatric candidates on the kidney transplant waiting list on December 31, 2007, December 31, 2012, and December 31, 2017
Table KI 16. Listing characteristics of pediatric candidates on the kidney transplant waiting list on December 31, 2007, December 31, 2012, and December 31, 2017
Table KI 17. Kidney transplant waitlist activity among pediatric candidates
Table KI 18. Removal reason among pediatric kidney transplant candidates
Table KI 19. Demographic characteristics of pediatric kidney transplant recipients, 2015-2017
Table KI 20. Clinicial characteristics of pediatric kidney transplant recipients, 2015-2017
Table KI 21. Transplant characteristics of pediatric kidney transplant recipients, 2015-2017
Table KI 22. Pediatric deceased donor kidney donor-recipient serology matching, 2013-2017
Table KI 23. Pediatric living donor kidney donor-recipient serology matching, 2013-2017

A line plot for new adult candidates added to the kidney transplant waiting list; the active category increases by 11.6% from 20.9 candidates (in thousands) at 2006 to 23.3 candidates (in thousands) at 2017; the inactive category is 6.5 candidates (in thousands) at 2006 and remains relatively constant with a value of 7 candidates (in thousands) at 2017; and the all category increases by 10.9% from 27.4 candidates (in thousands) at 2006 to 30.3 candidates (in thousands) at 2017.

Figure KI 1. New adult candidates added to the kidney transplant waiting list
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 is determined on day 7 after first listing. Includes kidney and kidney-pancreas listings.


A line plot for adults listed for kidney transplant on december 31 each year; the active category increases by 23.5% from 47.9 candidates (in thousands) at 2006 to 59.2 candidates (in thousands) at 2017; the inactive category increases by 77.2% from 18.9 candidates (in thousands) at 2006 to 33.5 candidates (in thousands) at 2017; and the all category increases by 38.7% from 66.8 candidates (in thousands) at 2006 to 92.7 candidates (in thousands) at 2017.

Figure KI 2. Adults listed for kidney transplant on December 31 each year
Candidates concurrently listed at multiple centers are counted once. Those with concurrent listings and active at any program are considered active. Includes kidney and kidney-pancreas listings.


A line plot for distribution of adults waiting for kidney transplant by age; the 18 to 34 category decreases by 27.0% from 12.7 percent at 2006 to 9.3 percent at 2017; the 35 to 49 category decreases by 19.0% from 31.2 percent at 2006 to 25.3 percent at 2017; the 50 to 64 category is 41.7 percent at 2006 and remains relatively constant with a value of 43.7 percent at 2017; the 65 to 74 category increases by 52.7% from 13 percent at 2006 to 19.8 percent at 2017; and the  greater than or equal to 75 category increases by 32.3% from 1.5 percent at 2006 to 1.9 percent at 2017.

Figure KI 3. Distribution of adults waiting for kidney transplant by age
Candidates waiting for transplant at any time in the given year. Candidates listed concurrently at multiple centers are counted once. Age is determined at the later of listing date or January 1 of the given year. Active and inactive candidates are included.


A line plot for distribution of adults waiting for kidney transplant by sex; the male category is 58.8 percent at 2006 and remains relatively constant with a value of 61.1 percent at 2017; and the female category is 41.2 percent at 2006 and remains relatively constant with a value of 38.9 percent at 2017.

Figure KI 4. Distribution of adults waiting for kidney transplant by sex
Candidates waiting for transplant at any time in the given year. Candidates listed concurrently at multiple centers are counted once. Active and inactive patients are included.


A line plot for distribution of adults waiting for kidney transplant by race; the white category decreases by 10.2% from 42.6 percent at 2006 to 38.3 percent at 2017; the black category is 33 percent at 2006 and remains relatively constant with a value of 31.9 percent at 2017; the hispanic category increases by 21.0% from 16.2 percent at 2006 to 19.6 percent at 2017; the asian category increases by 27.4% from 6.8 percent at 2006 to 8.6 percent at 2017; and the other/unknown category increases by 18.0% from 1.4 percent at 2006 to 1.7 percent at 2017.

Figure KI 5. Distribution of adults waiting for kidney transplant by race
Candidates waiting for transplant at any time in the given year. Candidates listed concurrently at multiple centers are counted once. Active and inactive candidates are included.