OPTN/SRTR 2017 Annual Data Report: Liver

Abstract

Data on adult liver transplants performed in the US in 2017 are notable for (1) continued growth in numbers of new waitlist registrants (11,514) and of transplants performed (8,082); (2) continued increase in the transplant rate (51.5 per 100 waitlist-years); (3) a precipitous decrease in waitlist registrations and transplants for hepatitis C-related indications; (4) reciprocal increases in waitlist registrants and recipients with alcoholic liver disease and with clinical profiles consistent with non-alcoholic fatty liver disease; and (5) continued improvement in graft survival despite changing recipient characteristics such as older age and higher rates of obesity. Variability in transplant rates remained by candidate race, presence of hepatocellular carcinoma, urgency status (status 1A versus model for end-stage liver disease (MELD) score >35), and geography. More than half of all children listed for liver transplant in 2017 were aged younger than 5 years in 2017, and the highest rate of pretransplant mortality persisted for children aged younger than 1 year. Children underwent transplant at higher acuity than the past, as evidenced by higher MELD/pediatric end-stage liver disease scores and listings at status 1A and 1B. Higher acuity at transplant is likely due to lack of access to suitable donor organs, which has been compensated for by persistent trends toward use of partial or split liver grafts and ABO-incompatible grafts. Despite higher illness severity scores at transplant, pediatric graft and patient survival posttransplant have improved over time.

Adult Transplant

Waiting List Registration

The number of candidates added to the liver transplant waiting list continued to increase in 2017 to 11,514, compared with 11,340 in 2016 and 10,636 in 2015 (Figure LI 1). In contrast, the number of candidates waiting at the end of the year continued a downward trend from its peak of 15,365 in 2011 to 13,239 in 2017 (Figure LI 2). Regarding actively listed candidates, 186 more were added to the list in 2017 than in 2016 (11,168 versus 10,982); 513 fewer were waiting at the end of 2017 than at the end of 2016 (10,628 versus 11,141). This is in part explained by more transplants performed (8082 in 2017 versus 7841 in 2016, net increase of 241, Figure LI 46).

The age distribution of adults waiting for liver transplant (Figure LI 3) showed that the proportion of older (aged ≥65 years) candidates continued to increase, to 22.9%, almost twice the proportion 10 years before. A reciprocal decrease occurred in the proportion of candidates aged 50-64 years over the past 5 years.

The proportion of candidates listed with a primary diagnosis of hepatitis C virus (HCV) decreased sharply (Figure LI 6), and proportions with alcoholic liver disease and other diagnosis increased. The latter category likely included many candidates with nonalcoholic fatty liver disease. As HCV patients tend to be over-represented among patients listed with hepatocellular carcinoma (HCC) as their primary diagnosis, the trend shown in Figure LI 6 should be interpreted accordingly. In 2017, 9.9% of candidates had a primary diagnosis of HCC.

Regarding medical urgency, candidates for liver transplant most commonly had model for end-stage liver disease (MELD) scores between 15 and 29 at their most severe during the year (45.6%), with approximately 20% of candidates listed with MELD score of ≥30 (Figure LI 7). Although not dramatically, the proportion of liver candidates with high body mass index (BMI) continued to increase (Figure LI 8). Nearly one in six (17%) liver candidates had a BMI above 35 kg/m², conventionally categorized as morbidly obese, although not all excess weight in these patients is adiposity.

Waiting List Outcome

Deceased donor liver transplant rates among active adult waitlist candidates continued to increase, a trend over the past 5 years (Figure LI 9). The overall deceased donor transplant rate was 51.4 per 100 waitlist-years, surpassing 50 for the first time in the past decade. The increase occurred regardless of age group, sex, or geography (e.g., metropolitan versus non-metropolitan areas) (Figure LI 9, Figure LI 11, Figure LI 12). The transplant rate was more than 20% lower for Hispanic and Asian candidates (41.5 and 40.1 per 100 waitlist-years, respectively) than for white (53.6 per 100 waitlist-years) and black (61.4 per 100 waitlist-years) candidates (Figure LI 10). Differences in underlying liver disease and listing MELD scores likely explain some of the differences, but further analysis of this trend may be warranted.

The gap in transplant rates between HCC and non-HCC candidates persisted, although it has been steadily narrowing since 2006 (Figure LI 11). The transplant rate was much higher for HCC than for non-HCC candidates. The gap was larger among women, with a transplant rate 2.1-fold higher for HCC than for non-HCC candidates (97.0 versus 45.4 per 100 waitlist-years). Among men, the transplant rate was 72% higher for HCC than for non-HCC candidates (89.4 versus 52.1 per 100 waitlist-years).

Figure LI 14 shows 3-year outcomes for adults listed for liver transplant in 2014: 55.2% underwent liver transplant (including 2.2% with living donor livers), 13.1% died, and 20.3% were removed from the list without undergoing transplant. These statistics were virtually identical to those reported in the 2016 ADR. Similarly, waiting time for urgency categories remained unchanged (Figure LI 15); waiting time was shortest for patients at status 1A (median 0.16 months, 4.9 days) followed by those with MELD >35 (median 0.23 months, 7.0 days).

Consistent with the trend in transplant rates (Figure LI 9), the proportion of patients undergoing deceased donor liver transplant within a given time period after listing trended upward (Figure LI 16). Geographic differences in deceased donor transplant rates persisted, regardless of geographic unit (donation service area [DSA], Figure LI 17 or state, Figure LI 18). In the DSA with the lowest proportion, 31.9% of candidates listed in 2014 underwent deceased donor liver transplant within 3 years, compared with 85.5% in the DSA with the highest proportion.

Pretransplant mortality rates for adults continued a downward trend in 2017 for all subgroups, including age, race/ethnicity, diagnosis, urgency category, and geography (Figure LI 19, Figure LI 20, Figure LI 21, Figure LI 22, Figure LI 23, Figure LI 24, Figure LI 25). As expected, mortality rates were lower for younger candidates, Asians, and candidates with lower MELD scores. The mortality rate for candidates with MELD >35 was 260.1 per 100 waitlist-years in 2017, higher than 188.0 per 100 waitlist-years in status 1A candidates (Figure LI 22). Mortality in candidates with MELD >35 continued to decrease since the implementation of the regional share 35 policy; however, as suggested in Figure LI 15, waiting time remained longer than for status 1A candidates. Furthermore, Figure LI 27 illustrates that 6-month mortality after waitlist removal was 69.0% among candidates with MELD >35, compared with 30.8% among status 1A candidates. Reducing mortality further remains a challenge for policy makers in their effort to improve the organ distribution and allocation system.

As previously recognized, waitlist mortality rates varied geographically (Figure LI 26), and did not necessarily mirror transplant rates, suggesting that waitlist outcomes were not determined simply by organ availability. Other potential factors may include access to healthcare in general and to high-quality specialty care for liver disease, referral and waitlist registration practices, and pre-transplant patient management.

Donation

There were a total of 7631 deceased donors in 2017, an increase of 220 over 2016. The proportion of donors aged 18-34 years increased noticeably in the past 4 years (Figure LI 29). This trend has been concomitant with dramatic increases in anoxic brain deaths, likely from drug overdose (Figure LI 38).

The organ discard rate (percentage of organs recovered for transplant and not transplanted) was 8.9%, continuing a downward trend since 2012. The trend was most noticeable for donors aged 65 years or older, although, in general, discard rates were higher for older donors (Figure LI 32). Discard rates were lowest for black donors (5.9%) and highest for donors of other/unknown race (11.0%) (Figure LI 34).

The most striking trend in organ utilization is related to HCV-positive donors (Figure LI 35). The liver discard rate was numerically lower for HCV-positive (8.5%) than for HCV-negative (8.9%) donors. This trend is driven by donation after brain death organs, with a discard rate of 7%, the lowest in the past decade (Figure LI 37). This is not surprising because many HCV-positive livers are from younger donors and are otherwise considered high quality, and because HCV therapy is highly successful even in patients receiving immunosuppression following liver transplant. Figure LI 36 depicts a similar trend of fewer discards of US Public Health Service high-risk organs compared with non-high-risk organs.

Compared with 2016, there were 23 more living donors in 2017, a 6.8% increase. The demographic characteristics of living donors did not change substantially over time (Figure LI 39, Figure LI 40, Figure LI 41, Figure LI 42).

Transplants

In 2017, 8082 liver transplants were performed in the US (Figure LI 46), higher than in any previous year. This represented a 3% increase over 2016 (7841) and a 24% increase over a decade before (6494 in 2007). Almost all (95%) were deceased donor transplants (7715, Figure LI 46).

Characteristics of adult transplant recipients in 2017 were similar to those of waitlist registrants (Figure LI 47, Figure LI 48, Figure LI 49). Liver recipients were most commonly aged 50-64 years, male, and white. The increase in numbers of transplants occurred in all age groups and both sexes. Between 2016 and 2017, the number of white recipients increased the most (5406 to 5678, a 5.0% increase); the increase was negligible for black recipients (750 to 752, 0.3% increase) and numbers actually decreased for Hispanic (1204 to 1182, 1.8% decrease) and Asian (369 to 342, 7.3% decrease) recipients. These trends likely reflect disease epidemiology and severity, although further analysis is necessary.

Numbers of adult liver transplant recipients with HCV further declined in 2017 (Figure LI 50). Of all adult recipients, 1005 recipients (12.4%) had HCV as their primary diagnosis, while in 2014 HCV accounted for 23.9% (1610). If this trend continues, fewer liver transplants may be performed for HCV than for cholestatic liver disease in 2018, although a proportion of patients whose primary diagnosis is HCC also have HCV.

In 2017, more than a third (35.9%) of adult recipients in 2017 had a BMI consistent with obesity (>30 kg/m²), and 14.0% were morbidly obese (BMI ≥35 kg/m², Figure LI 51). The number of recipients with alcoholic liver disease (1881), cholestatic disease (930) and other/unknown etiology (2628) is also increasing (Figure LI 50).

The majority (65.9%) of recipients did not receive an induction agent, although the proportion has been decreasing gradually (Figure LI 52). The predominant immunosuppressive regimen (Figure LI 53) in adult liver recipients remained the combination of tacrolimus, mycophenolate, and steroids (59.7%), followed by tacrolimus and mycophenolate (21.6%).

Geographic variability in access to liver transplant has been most commonly measured by the median MELD at transplant of the geographic unit. The median MELD ranged from 19 to 36 (Figure LI 54) by recipient DSA. The highest was reported in Los Angeles, California (CAOP), and the lowest in Puerto Rico (PRLL). The DSA with the lowest median MELD at transplant in the contiguous 48 states was in Connecticut (CTOP, median MELD 22.5). The median of all DSA’s median MELD scores remained at 28.0, unchanged from 2016 (Figure LI 55). However, the width of the interquartile ranges of the medians decreased (from 5.0 to 1.8), indicating reduction in geographic variability in recipient MELD scores. MELD exception score has been another focus of policy debate, with large variability in proportions of patients with exception scores (Figure LI 56). The DSA with the lowest proportion (7.9%) of recipients with exception scores was in Indiana (INOP) and the highest (59.3%) in Oregon (ORUO).

Between 2016 and 2017, a small but consistent decrease in cold ischemia time occurred, ordered in the expected direction (higher MELD strata with longer cold time). The median cold ischemia time for all MELD strata was less than 6 hours (Figure LI 57). Figure LI 58 shows the distribution of total numbers of HLA, B, and DR mismatches among liver-kidney recipients. Most commonly, recipients had five mismatches (33.6%), which has not changed in the recent past.

As the total number of transplants grew nationwide, distribution of the additional organs affected transplant program volume, which appears to have grown mostly in medium to large centers (Figure LI 59). Between 2016 and 2017, programs at the seventy-fifth percentile increased from 94 to 102 transplants per year and those at the fiftieth percentile from 52 to 56. Consequently, medium-large programs with an annual volume of 95-149 transplants performed the largest proportion of transplants (42.3%) (Figure LI 60).

Outcomes

Short- and long-term graft outcomes continued to improve in 2017. Graft failure occurred in 7.3% at 6 months and in 9.6% at 1 year among deceased donor liver transplants performed in 2016, in 16.3% at 3 years for transplants performed in 2014, in 24.1% at 5 years for transplants performed in 2012, and in 43.0% at 10 years for transplants performed in 2007 (Figure LI 61). Graft failure occurred in 6.7% of recipients at 6 months and in 9.9% at 1 year posttransplant among living donor transplants performed in 2016, in 20.3% at 3 years for transplants performed in 2014, in 19.4% at 5 years for transplants performed in 2012, and in 40.1% at 10 years for transplants performed in 2007 (Figure LI 62).

Five-year graft survival outcomes varied in the expected direction for recipient age (Figure LI 63), primary diagnosis (Figure LI 64, Figure LI 68, Figure LI 72), BMI (Figure LI 69), urgency category (Figure LI 65, Figure LI 73), and retransplant status (Figure LI 67) for deceased and living donor recipient characteristics. Without adjustment for other variables, graft survival was better for recipients in metropolitan areas and for those traveling to a distant (>250 miles) program (Figure LI 70, Figure LI 71) for deceased donor recipients only, as these advantages were absent for living donor recipients (Figure LI 74, Figure LI 75).

As of June 30, 2017, 83,925 liver transplant recipients were alive with a functioning graft, including 73,317 who underwent liver transplant as adults (Figure LI 76). At the end of the first year, 11.7% of recipients experienced at least one episode of acute rejection, which was more common in younger recipients (Figure LI 77) and in recipients not receiving a T-cell depleting agent (Figure LI 78). Approximately 1% of adult liver recipients developed posttransplant lymphoproliferative disorder over 5 years, and incidence doubled in recipients who lacked antibodies against Epstein-Barr virus (Figure LI 79).

Adult patient survival after deceased and living donor liver transplant (Figure LI 80, Figure LI 81, Figure LI 82, Figure LI 83, Figure LI 84, Figure LI 85, Figure LI 86, Figure LI 87, Figure LI 88, Figure LI 89) mirrored graft survival (Figure LI 63, Figure LI 64, Figure LI 65, Figure LI 66, Figure LI 67, Figure LI 68, Figure LI 69, Figure LI 70, Figure LI 71, Figure LI 72, Figure LI 73, Figure LI 74, Figure LI 75), except that the geographic differences in graft survival in deceased donor recipients were attenuated when patient survival was considered (Figure LI 84, Figure LI 85).

Pediatric Transplant

Summary

As has been true in the past, more than half of all children listed for liver transplant were aged 5 years or younger in 2017, and the highest rate of pretransplant mortality persisted for children aged younger than 1 year. Children are undergoing transplant at higher acuity than the past, as evidenced by higher MELD/PELD scores and listings at status 1A and 1B. Higher acuity at transplant is likely due to lack of access to suitable donor organs, which has been compensated for by persistent trends toward use of partial or split liver grafts and ABO-incompatible grafts. Despite higher illness severity scores at transplant, graft and patient survival posttransplant have improved over time.

Waiting List

In 2017, 696 new active candidates were added to the pediatric liver transplant waiting list (Figure LI 90); very few (21) were added as inactive. The number of prevalent candidates (on the list on December 31 of the given year) was stable, 373 active and 177 inactive (Figure LI 91). Children aged 1-5 years (33.5%) and 11 years or older (31.7%) made up the largest age groups, followed by ages younger than 1 year, 20.4%, and 6-10 years, 14.4% (Figure LI 92). White candidates continued to make up the largest racial/ethnic group on the waiting list in 2017 (50.9%), followed by Hispanic (23.5%), black (15.4%), and Asian candidates (6.8%) (Figure LI 93). Most (66.4%) candidates had been waiting for less than 1 year, 12.1% for 1 to less than 2 years, 9.31% for 2 to less than 4 years, and 12.3% for 4 or more years (Figure LI 95). In 2006, 27.3% of pediatric candidates had been waiting for 4 or more years. This decline in long waiting times coincided with a shift in severity of illness since 2006. Considerably more candidates were listed with MELD/pediatric end-stage liver disease (PELD) scores above 35 (19.8% in 2017 vs. 6.4% in 2006), many of whom received MELD/PELD exception scores. More candidates were at status 1A/1B as their most severe status during the year (26.9% in 2017 vs. 16.7% in 2006), and fewer had MELD/PELD scores below 15 (15.6% in 2017 vs. 24.4% in 2006) or as inactive (11.7% in 2017 vs. 23.5% in 2006) (Figure LI 96).

For pediatric liver waitlist candidates from 2007 to 2017, sex, race, diagnosis, and geography changed little (Table LI 13, Table LI 14). The proportion of candidates aged 1-5 years increased slightly, and the proportion aged 11-17 years decreased. Medical urgency has changed over time, with an increase in the proportions listed as status 1A and 1B. The proportion of candidates on the waiting list with exception status has increased notably, at 30.0% in 2017 compared with 8.8% a decade earlier (Table LI 14). Waiting time shifted such that 52.9% of candidates waited less than 1 year in 2017, compared with 37.6% in 2007 (Table LI 15). Proportions of candidates listed for multi-organ transplants including liver have increased over time. Liver-kidney transplant candidates accounted for only 1.6% of pediatric liver transplant candidates in 2007 and for 3.5% in 2017. The proportion of liver-pancreas-intestine transplant candidates increased from 8.5% in 2007 to 13.6% in 2017 (Table LI 15). Among candidates removed from the waiting list in 2017, 72.1% underwent deceased donor transplant, 10.1% underwent living donor transplant, 5.0% died, 7.9% were removed from the list because their condition improved, and 1.3% were considered too sick to undergo transplant (Table LI 17). Just over 73% of candidates newly listed in 2014 underwent deceased donor transplant within 3 years, 8.2% underwent living donor transplant, 4.8% died, 8.2% were removed from the list, and 5.4% were still waiting (Figure LI 97). In 2017, the rate of deceased donor transplant among active pediatric candidates continued to increase, reaching 96.1 per 100 active waitlist-years compared with 61.2 in 2007 (Figure LI 98). Rates were highest for candidates aged younger than 1 year, 213.8 per 100 active waitlist-years. The lowest rates were for candidates aged 11 years or older (62.5 per 100 active waitlist-years). Regarding medical urgency status, as expected, transplant rates were highest for status 1A (531.4 per 100 active waitlist-years) and status 1B candidates (422.9 per 100 active waitlist-years) (Figure LI 100). Among candidates listed with MELD/PELD scores, rates ranged from 173.2 for those with MELD/PELD 30-34 to 73.3 for those with MELD/PELD below 15 (Figure LI 99). Pretransplant mortality decreased for all age groups, to 4.6 deaths per 100 waitlist-years in 2016-2017 (Figure LI 103). The pretransplant mortality rate was highest for candidates aged younger than 1 year, at 19.6 deaths per 100 waitlist-years in 2016-2017, compared with 2.6 in the 6-10 and 11-17 year age groups.

Transplant

The number of pediatric liver transplants peaked at 613 in 2008 and was 599 in 2017 (Figure LI 107). The number of pediatric living donor liver transplants remained steady at 72 in 2017, with most (53%) from donors closely related to the recipients (Figure LI 108). Recipients aged younger than 6 years underwent the highest proportion of transplant from living donors, 14.9% (Figure LI 109). In 2017, 21 programs were performing pediatric-only liver transplants, compared with 90 performing adult-only transplants and 29 performing transplants in both adults and children (Figure LI 110). In 2017, 5.3% of transplants in candidates aged 0-10 years, 7.7% in those aged younger than 15 years, and 9.3% in those aged younger than 18 years were performed at programs with volumes of five or fewer pediatric transplants in that year (Figure LI 111). In 2017, 18.0% of liver transplants in pediatric recipients were split liver transplants, compared with 14.4% a decade ago (Figure LI 112). Among adults, the proportion of split liver transplants has remained stable at approximately 1%. Among pediatric transplant recipients 2015-2017, the percentage with exception points by donation service area ranged from 9.1% to 100% in 6 DSAs, with a mean of 68.7% (Figure LI 114). In 2017, median cold ischemia time was similar by allocation MELD/PELD at approximately 6 hours (Figure LI 115). Over the past decade, recipient age, sex, and racial distributions have changed little, although fewer recipients were aged younger than 1 year (23.3% in 2015-2017 compared with 30.0% in 2005-2007) and more were aged 1-5 years (41.3% and 36.2%, respectively, Table LI 18). Cholestatic biliary atresia remained the leading cause of liver failure (32.5%) (Table LI 19). Most pediatric liver transplant recipients were not hospitalized before transplant (62.3%) and fewer were in the intensive care unit, 18.6% in 2015-2017 vs. 26.7% in 2005-2007. Regarding medical urgency status, over the past decade, proportions of recipients undergoing transplant at status 1A decreased markedly, and proportions at status 1B increased. The proportion of patients undergoing transplant with a MELD/PELD 30 or higher increased from 26.8% to 37.6% over the past 10 years. MELD/PELD exception use increased from 24.8% in 2005-2007 to 41.9% in 2015-2017. Types of liver transplant procedures in pediatric recipients changed little over the past decade; 62.8% of patients received a whole liver in 2015-2017, 21.2% received a partial liver (i.e., less than a whole liver was transplanted, possibly from a living donor, and the remainder of the liver was discarded), and 16.0% received a split liver (i.e., two recipients, usually an adult and a child, received one deceased donor liver) (Table LI 20). ABO-incompatible liver transplants occurred in 5.1% of recipients in 2015-2017, increased from 2.3% in the earlier era. In 2015-2017, 8.0% of pediatric liver transplant recipients had undergone previous transplant, a decrease from 10.2% a decade earlier.

Immunosuppression and Outcomes

In 2017, 56.6% of pediatric liver transplant recipients received no induction therapy, 27.6% received interleukin-2 receptor antagonists, and 16.7% received a T-cell depleting agent (Figure LI 116). The most commonly used initial immunosuppression regimens were tacrolimus and steroids (50.6%) and tacrolimus, mycophenolate mofetil, and steroids (25.0%) (Figure LI 117).

Graft survival continued to improve over the past decade among pediatric recipients of deceased donor and living donor livers. Graft failure occurred in 9.4% at 6 months and in 11.0% at 1 year among deceased donor liver transplants performed in 2016, in 13.0% at 3 years for transplants performed in 2014, in 16.0% at 5 years for transplants performed in 2012, and in 26.6% at 10 years for transplants performed in 2007 (Figure LI 119). Graft failure occurred in 3.4% of recipients at 6 months and in 5.5% at 1 year posttransplant among living donor transplants performed in 2015-2016, in 8.4% at 3 years for transplants performed in 2013-2014, in 8.9% at 5 years for transplants performed in 2011-2012, and in 16.7% at 10 years for transplants performed in 2007-2008 (Figure LI 120). By age, 5-year graft survival was 78.4% for recipients aged younger than 1 year, 79.8% for ages 1-5 years, 88.7% for ages 6-10 years, and 81.9% for ages 11-17 years (Figure LI 121). Five-year graft survival was 84.1% for recipients who underwent transplant with a MELD/PELD of 15 or lower, compared with approximately 78% for recipients who underwent transplant as status 1A/1B (Figure LI 123). Five-year graft survival was 82.6% for recipients of a first liver transplant, compared with 68.0% for retransplant recipients (Figure LI 124). In 2015-2016, incidence of acute rejection by 1 year post transplant was 24.7% overall, varying from 26.2% in recipients aged 11-17 years to 21.3% in those aged 6-10 years (Figure LI 126). Regarding use of induction agents and acute rejection, rates ranged from 21.6% among recipients who received interleukin-2 receptor antagonists to 28.4% among those who received T-cell depleting agents (Figure LI 125). Incidence of posttransplant lymphoproliferative disorder was 4.5% at 5 years posttransplant for recipients who were negative for Epstein-Barr virus and 2.9% for those who were positive (Figure LI 127). Among pediatric liver transplants 2008-2012, overall 5-year patient survival was 87.5%, varying from 85.9% for recipients aged 1-5 years to 93.0% for those aged 6-10 years (Figure LI 128). By primary diagnosis, metabolic disease and cholestatic biliary atresia were associated with superior patient survival (Figure LI 129). Of deceased donor transplant recipients in 2011-2016, 6.1% died within 1 year of transplant with cardio/cerebrovascular complications as the leading cause of death (Figure LI 130). Of deceased donor transplant recipients in 2010-2012, 10.6% died within 5 years of transplant (Figure LI 131). The leading causes of death were graft failure (1.6%) and cardio/cerebrovascular complications (1.4%) (Figure LI 131).

Figure List

Waiting list

Figure LI 1. New adult candidates added to the liver transplant waiting list
Figure LI 2. Adults listed for liver transplant on December 31 each year
Figure LI 3. Distribution of adults waiting for liver transplant by age
Figure LI 4. Distribution of adults waiting for liver transplant by sex
Figure LI 5. Distribution of adults waiting for liver transplant by race
Figure LI 6. Distribution of adults waiting for liver transplant by diagnosis
Figure LI 7. Distribution of adults waiting for liver transplant by medical urgency
Figure LI 8. Distribution of adults waiting for liver transplant by BMI
Figure LI 9. Deceased donor liver transplant rates among adult waitlist candidates by age
Figure LI 10. Deceased donor liver transplant rates among adult waitlist candidates by race
Figure LI 11. Deceased donor liver transplant rates among adult waitlist candidates by sex and HCC exception status
Figure LI 12. Deceased donor liver transplant rates among waitlist candidates by metropolitan vs. non-metropolitan residence
Figure LI 13. Deceased donor liver transplant rates among waitlist candidates by distance from listing center
Figure LI 14. Three-year outcomes for adults waiting for liver transplant, new listings in 2014
Figure LI 15. Median months to liver transplant for waitlisted adults
Figure LI 16. Percentage of adults who underwent deceased donor liver transplant within a given time period of listing
Figure LI 17. Percentage of adults who underwent deceased donor liver transplant within 3 years of listing in 2014 by DSA
Figure LI 18. Percentage of adults who underwent deceased donor liver transplant within 3 years of listing in 2014 by state
Figure LI 19. Pretransplant mortality rates among adults waitlisted for liver transplant by age
Figure LI 20. Pretransplant mortality rates among adults waitlisted for liver transplant by race
Figure LI 21. Pretransplant mortality rates among adults waitlisted for liver transplant by diagnosis
Figure LI 22. Pretransplant mortality rates among adults waitlisted for liver transplant by high medical urgency
Figure LI 23. Pretransplant mortality rates among adults waitlisted for liver transplant by medical urgency
Figure LI 24. Pretransplant mortality rates among adults waitlisted for liver by metropolitan vs. non-metropolitan residence
Figure LI 25. Pretransplant mortality rates among adults waitlisted for liver, by distance from listing center
Figure LI 26. Pretransplant mortality rates among adults waitlisted for liver transplant in 2016-2017, by DSA
Figure LI 27. Deaths within six months after removal among adult liver waitlist candidates, by MELD at removal

Deceased donation

Figure LI 28. Deceased liver donor count by age
Figure LI 29. Distribution of deceased liver donors by age
Figure LI 30. Distribution of deceased liver donors by race
Figure LI 31. Percent of pediatric liver donors allocated to adult recipients
Figure LI 32. Rates of livers recovered for transplant and not transplanted by donor age
Figure LI 33. Rates of livers recovered for transplant and not transplanted by donor sex
Figure LI 34. Rates of livers recovered for transplant and not transplanted by donor race
Figure LI 35. Rates of livers recovered for transplant and not transplanted by donor HCV status
Figure LI 36. Rates of livers recovered for transplant and not transplanted, by donor risk of disease transmission
Figure LI 37. Rates of livers recovered for transplant and not transplanted by DCD status
Figure LI 38. Cause of death among deceased liver donors

Living donation

Figure LI 39. Liver transplants from living donors by donor relation
Figure LI 40. Living liver donors by age
Figure LI 41. Living liver donors by sex
Figure LI 42. Living liver donors by race
Figure LI 43. Living donor liver transplant graft type
Figure LI 44. Rehospitalization in the first 6 weeks, 6 months, and 1 year among living liver donors, 2012-2016
Figure LI 45. BMI among living liver donors

Transplant

Figure LI 46. Total liver transplants
Figure LI 47. Total liver transplants by age
Figure LI 48. Total liver transplants by sex
Figure LI 49. Total liver transplants by race
Figure LI 50. Total liver transplants by diagnosis
Figure LI 51. Total liver transplants by body mass index (BMI)
Figure LI 52. Induction agent use in adult liver transplant recipients
Figure LI 53. Immunosuppression regimen use in adult liver transplant recipients
Figure LI 54. Median MELD scores for adult deceased donor liver transplant recipients by DSA, 2017
Figure LI 55. Variation in DSA-level median MELD at transplant among adult liver recipients
Figure LI 56. Percent of adult liver transplant recipients using exceptions, by DSA
Figure LI 57. Donor liver cold ischemia among adult liver recipients by allocation MELD
Figure LI 58. Total HLA A, B, and DR mismatches among adult deceased donor liver-kidney transplant recipients, 2013-2017
Figure LI 59. Annual adult liver transplant center volumes, by percentile
Figure LI 60. Distribution of adult liver transplants by annual center volume

Outcomes

Figure LI 61. Graft failure among adult deceased donor liver transplant recipients
Figure LI 62. Graft failure among adult living donor liver transplant recipients
Figure LI 63. Graft survival among adult deceased donor liver transplant recipients, 2012, by age
Figure LI 64. Graft survival among adult deceased donor liver transplant recipients, 2012, by diagnosis
Figure LI 65. Graft survival among adult deceased donor liver transplant recipients, 2012, by medical urgency
Figure LI 66. Graft survival among adult deceased donor liver transplant recipients, 2012, by DCD status
Figure LI 67. Graft survival among adult deceased donor liver transplant recipients, 2012, by retransplant status
Figure LI 68. Graft survival among adult deceased donor liver transplant recipients, 2012, by HCC status
Figure LI 69. Graft survival among adult deceased donor liver transplant recipients, 2012, by BMI
Figure LI 70. Graft survival among adult deceased donor liver transplant recipients, 2012, by metropolitan vs. non-metropolitan recipient residence
Figure LI 71. Graft survival among adult deceased donor liver transplant recipients, 2012, by recipients' distance from transplant center
Figure LI 72. Graft survival among adult living donor liver transplant recipients, 2009-2012, by diagnosis
Figure LI 73. Graft survival among adult living donor liver transplant recipients, 2009-2012, by medical urgency
Figure LI 74. Graft survival among adult living donor liver transplant recipients, 2009-2012, by metropolitan vs. non-metropolitan recipient residence
Figure LI 75. Graft survival among adult living donor liver transplant recipients, 2009-2012, by recipients' distance from transplant center
Figure LI 76. Recipients alive with a functioning liver graft on June 30 of the year, by age at transplant
Figure LI 77. Incidence of acute rejection by 1 year posttransplant among adult liver transplant recipients by age, 2015-2016
Figure LI 78. Incidence of acute rejection by 1 year posttransplant among adult liver transplant recipients by induction status, 2015-2016
Figure LI 79. Incidence of PTLD among adult liver transplant recipients by recipient EBV status at transplant, 2011-2015
Figure LI 80. Patient survival among adult deceased donor liver transplant recipients, 2010-2012, by age
Figure LI 81. Patient survival among adult deceased donor liver transplant recipients, 2010-2012, by diagnosis
Figure LI 82. Patient survival among adult deceased donor liver transplant recipients, 2010-2012, by retransplant
Figure LI 83. Patient survival among adult deceased donor liver transplant recipients, 2010-2012, by medical urgency
Figure LI 84. Patient survival among adult deceased donor liver transplant recipients, 2010-2012, by metropolitan vs. non-metropolitan recipient residence
Figure LI 85. Patient survival among adult deceased donor liver transplant recipients, 2010-2012, by recipients' distance from transplant center
Figure LI 86. Patient survival among adult living donor liver transplant recipients, 2009-2012, by diagnosis
Figure LI 87. Patient survival among adult living donor liver transplant recipients, 2009-2012, by medical urgency
Figure LI 88. Patient survival among adult living donor liver transplant recipients, 2009-2012, by metropolitan vs. non-metropolitan recipient residence
Figure LI 89. Patient survival among adult living donor liver transplant recipients, 2009-2012, by recipients' distance from transplant center

Pediatric transplant

Figure LI 90. New pediatric candidates added to the liver transplant waiting list
Figure LI 91. Pediatric candidates listed for liver transplant on December 31 each year
Figure LI 92. Distribution of pediatric candidates waiting for liver transplant by age
Figure LI 93. Distribution of pediatric candidates waiting for liver transplant by race
Figure LI 94. Distribution of pediatric candidates waiting for liver transplant by sex
Figure LI 95. Distribution of pediatric candidates waiting for liver transplant by waiting time
Figure LI 96. Distribution of pediatric candidates waiting for liver transplant by medical urgency
Figure LI 97. Three-year outcomes for newly listed pediatric candidates waiting for liver transplant, 2014
Figure LI 98. Deceased donor liver transplant rates among pediatric waitlist candidates by age
Figure LI 99. Deceased donor liver transplant rates among pediatric waitlist candidates by MELD/PELD at listing
Figure LI 100. Deceased donor liver transplant rates among pediatric waitlist candidates by Status 1A or 1B at listing
Figure LI 101. Deceased donor liver transplant rates among pediatric waitlist candidates by metropolitan vs. non-metropolitan residence
Figure LI 102. Deceased donor liver transplant rates among pediatric waitlist candidates by distance from listing center
Figure LI 103. Pretransplant mortality rates among pediatrics waitlisted for liver transplant by age
Figure LI 104. Pretransplant mortality rates among pediatrics waitlisted for liver transplant by race
Figure LI 105. Pretransplant mortality rates among pediatrics waitlisted for liver transplant by metropolitan vs. non-metropolitan residence
Figure LI 106. Pretransplant mortality rates among pediatrics waitlisted for liver transplant by distance from listing center
Figure LI 107. Pediatric liver transplants by donor type
Figure LI 108. Pediatric liver transplants from living donors by relation
Figure LI 109. Percent of pediatric liver transplants from living donors by recipient age
Figure LI 110. Number of centers performing pediatric and adult liver transplants by center's age mix
Figure LI 111. Pediatric liver recipients at programs that perform 5 or fewer pediatric transplants annually
Figure LI 112. Split liver transplants in children and adults
Figure LI 113. Percent of adult and pediatric liver transplant recipients using exceptions
Figure LI 114. Percent of pediatric liver transplant recipients using exceptions, 2015-2017, by DSA
Figure LI 115. Donor liver cold ischemia among pediatric liver recipients by allocation MELD/PELD
Figure LI 116. Induction agent use in pediatric liver transplant recipients
Figure LI 117. Immunosuppression regimen use in pediatric liver transplant recipients
Figure LI 118. Total HLA A, B, and DR mismatches among pediatric deceased donor liver-kidney transplant recipients, 2013-2017
Figure LI 119. Graft failure among pediatric deceased donor liver transplant recipients
Figure LI 120. Graft failure among pediatric living donor liver transplant recipients
Figure LI 121. Graft survival among pediatric deceased donor liver transplant recipients, 2008-2012, by age
Figure LI 122. Graft survival among pediatric deceased donor liver transplant recipients, 2008-2012, by diagnosis
Figure LI 123. Graft survival among pediatric deceased donor liver transplant recipients, 2008-2012, by medical urgency
Figure LI 124. Graft survival among pediatric deceased donor liver transplant recipients, 2008-2012, by retransplant
Figure LI 125. Incidence of acute rejection by 1 year posttransplant among pediatric liver transplant recipients by induction status, 2015-2016
Figure LI 126. Incidence of acute rejection by 1 year posttransplant among pediatric liver transplant recipients by age, 2015-2016
Figure LI 127. Incidence of PTLD among pediatric liver transplant recipients by recipient EBV status at transplant, 2004-2014
Figure LI 128. Patient survival among pediatric deceased donor liver transplant recipients, 2008-2012, by age
Figure LI 129. Patient survival among pediatric deceased donor liver transplant recipients, 2008-2012, by diagnosis
Figure LI 130. One-year cumulative incidence of death by cause among pediatric liver recipients, 2011-2016
Figure LI 131. Five-year cumulative incidence of death by cause among pediatric liver recipients, 2010-2012

Table List

Waiting list

Table LI 1. Demographic characteristics of adults on the liver transplant waiting list on December 31, 2007 and December 31, 2017
Table LI 2. Clinical characteristics of adults on the liver transplant waiting list on December 31, 2007 and December 31, 2017
Table LI 3. Listing characteristics of adults on the liver transplant waiting list on December 31, 2007 and December 31, 2017
Table LI 4. Liver transplant waitlist activity among adults
Table LI 5. Removal reason among adult liver transplant candidates

Living donation

Table LI 6. Complications among living liver donors, 2013-2017
Table LI 7. Living liver donor deaths, 2013-2017, by number of days after donation

Transplant

Table LI 8. Demographic characteristics of adult liver transplant recipients, 2007 and 2017
Table LI 9. Clinical characteristics of adult liver transplant recipients, 2007 and 2017
Table LI 10. Transplant characteristics of adult liver transplant recipients, 2007 and 2017
Table LI 11. Adult deceased donor liver donor-recipient serology matching, 2013-2017
Table LI 12. Adult living donor liver donor-recipient serology matching, 2013-2017

Pediatric transplant

Table LI 13. Demographic characteristics of pediatric candidates on the liver transplant waiting list on December 31, 2007 and December 31, 2017
Table LI 14. Clinical characteristics of pediatric candidates on the liver transplant waiting list on December 31, 2007 and December 31, 2017
Table LI 15. Listing characteristics of pediatric candidates on the liver transplant waiting list on December 31, 2007 and December 31, 2017
Table LI 16. Liver transplant waitlist activity among pediatric candidates
Table LI 17. Removal reason among pediatric liver transplant candidates
Table LI 18. Demographic characteristics of pediatric liver transplant recipients, 2005-2007 and 2015-2017
Table LI 19. Clinical characteristics of pediatric liver transplant recipients, 2005-2007 and 2015-2017
Table LI 20. Transplant characteristics of pediatric liver transplant recipients, 2005-2007 and 2015-2017

Table LI 1 Demographic characteristics of adults on the liver transplant waiting list on December 31, 2007 and December 31, 2017
Candidates waiting for transplant on December 31, 2007, and December 31, 2017, regardless of first listing date; multiple listings are collapsed.

Characteristic	2007, N	2007, Percent	2017, N	2017, Percent
Age: 18-34 years	605	3.9%	605	4.6%
Age: 35-49 years	3060	19.9%	1968	14.9%
Age: 50-64 years	9726	63.3%	7312	55.2%
Age: ≥ 65 years	1973	12.8%	3354	25.3%
Sex: Female	6120	39.8%	5029	38.0%
Sex: Male	9244	60.2%	8210	62.0%
Race/ethnicity: White	11,095	72.2%	9015	68.1%
Race/ethnicity: Black	997	6.5%	987	7.5%
Race/ethnicity: Hispanic	2384	15.5%	2342	17.7%
Race/ethnicity: Asian	761	5.0%	714	5.4%
Race/ethnicity: Other/unknown	127	0.8%	181	1.4%
Geography: Metropolitan	12,912	84.0%	11,240	84.9%
Geography: Non-metro	2452	16.0%	1999	15.1%
Distance: < 50 miles	8602	56.0%	7933	59.9%
Distance: 50-<100 miles	2698	17.6%	2216	16.7%
Distance: 100-<150 miles	1410	9.2%	1121	8.5%
Distance: 150-<250 miles	1340	8.7%	1039	7.8%
Distance: ≥ 250 miles	1135	7.4%	865	6.5%
Distance: Unknown	179	1.2%	65	0.5%
All candidates	15,364	100.0%	13,239	100.0%

Table LI 2 Clinical characteristics of adults on the liver transplant waiting list on December 31, 2007 and December 31, 2017
Candidates waiting for transplant on December 31, 2007, and December 31, 2017, regardless of first listing date; multiple listings are collapsed. HCC, hepatocellular carcinoma; HCV, hepatitis C virus.

Characteristic	2007, N	2007, Percent	2017, N	2017, Percent
Diagnosis: Acute liver failure	501	3.3%	239	1.8%
Diagnosis: HCV	4773	31.1%	2605	19.7%
Diagnosis: Alcoholic liver disease	3530	23.0%	3794	28.7%
Diagnosis: Cholestatic disease	1521	9.9%	1056	8.0%
Diagnosis: HCC	398	2.6%	1161	8.8%
Diagnosis: Other/unknown	4641	30.2%	4384	33.1%
Blood type: A	5773	37.6%	5130	38.7%
Blood type: B	1824	11.9%	1471	11.1%
Blood type: AB	367	2.4%	324	2.4%
Blood type: O	7400	48.2%	6314	47.7%
Medical urgency: Status 1A	3	0.0%	4	0.0%
Medical urgency: Status 1B	32	0.2%	63	0.5%
Medical urgency: MELD ≥ 35	37	0.2%	330	2.5%
Medical urgency: MELD 30-34	3112	20.3%	4261	32.2%
Medical urgency: MELD 15-29	8581	55.9%	5970	45.1%
Medical urgency: MELD < 15	1	0.0%	0	0.0%
Medical urgency: Unknown	3598	23.4%	2611	19.7%
Exception status: None	14,636	95.3%	10,737	81.1%
Exception status: HCC	521	3.4%	1756	13.3%
Exception status: Other	207	1.3%	746	5.6%
All candidates	15,364	100.0%	13,239	100.0%

Table LI 3 Listing characteristics of adults on the liver transplant waiting list on December 31, 2007 and December 31, 2017
Candidates waiting for transplant on December 31, 2007, and December 31, 2017, regardless of first listing date; multiple listings are collapsed.

Characteristic	2007, N	2007, Percent	2017, N	2017, Percent
Transplant history: First	14,743	96.0%	12,908	97.5%
Transplant history: Retransplant	621	4.0%	331	2.5%
Wait time: < 1 year	4669	30.4%	5920	44.7%
Wait time: 1-< 2 years	2529	16.5%	2351	17.8%
Wait time: 2-< 3 years	1744	11.4%	1315	9.9%
Wait time: 3-< 4 years	1450	9.4%	959	7.2%
Wait time: 4-< 5 years	1163	7.6%	665	5.0%
Wait time: ≥ 5 years	3809	24.8%	2029	15.3%
Tx type: Liver alone	14,963	97.4%	12,276	92.7%
Tx type: Liver-kidney	348	2.3%	876	6.6%
Tx type: Liver-pancreas-intestine	20	0.1%	27	0.2%
Tx type: Liver-heart	15	0.1%	37	0.3%
Tx type: Other	18	0.1%	23	0.2%
All candidates	15,364	100.0%	13,239	100.0%

Table LI 4 Liver transplant waitlist activity among adults
Candidates concurrently listed at more than one center are counted once, from the time of earliest listing to the time of latest removal. 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	2015	2016	2017
Patients at start of year	14,622	14,037	13,703
Patients added during year	10,635	11,340	11,514
Patients removed during year	11,205	11,655	11,978
Patients at end of year	14,052	13,722	13,239

Table LI 5 Removal reason among adult liver transplant candidates
Removal reason as reported to the OPTN. Candidates with death dates that precede removal dates are assumed to have died waiting.

Removal reason	2015	2016	2017
Deceased donor transplant	6193	6903	7119
Living donor transplant	278	283	293
Transplant outside US	2	5	10
Patient died	1692	1413	1334
Patient refused transplant	92	121	115
Improved, transplant not needed	776	763	850
Too sick for transplant	1215	1194	1177
Other	957	973	1080

Table LI 6 Complications among living liver donors, 2013-2017
Complications reported on the OPTN Living Donor Registration Form. Clavien Grade 1, bilious Jackson Pratt drainage more than 10 days; Clavien Grade 2, interventional procedure (endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, percutaneous drainage, etc.); Clavien Grade 3, surgical intervention. Clavien grades refer to biliary complications. Domino liver donors excluded.

Level	N	Pct
Biliary complication: Yes	46	3.0%
Biliary complication: No	1502	96.9%
Biliary complication: Unknown	2	0.1%
Clavien Grade: 1	11	0.7%
Clavien Grade: 2	30	1.9%
Clavien Grade: 3	8	0.5%
Vascular complication, requiring intervention: Yes	11	0.7%
Vascular complication, requiring intervention: No	1536	99.1%
Vascular complication, requiring intervention: Unknown	3	0.2%
Other complication, requiring intervention: Yes	111	7.2%
Other complication, requiring intervention: No	1432	92.4%
Other complication, requiring intervention: Unknown	7	0.5%
Re-operation: Yes	37	2.4%
Re-operation: No	1510	97.4%
Re-operation: Unknown	3	0.2%

Table LI 7 Living liver donor deaths, 2013-2017, by number of days after donation
Living liver donors, excluding domino livers. Numbers of deaths reported to OPTN or the Social Security Administration. No deaths occurred within a year of donation among living liver donors, 2011-2015.

Cause	0-30 days	31-90 days	91-365 days
Suicide	0	0	0
Accident/homicide	0	0	0
Medical	1	0	0
Cancer	0	0	0
Unknown	0	0	0
Total	1	0	0

Table LI 8 Demographic characteristics of adult liver transplant recipients, 2007 and 2017
Adult liver transplant recipients, including retransplants.

Characteristic	2007, N	2007, Percent	2017, N	2017, Percent
Age: 18-34 years	385	6.5%	478	6.4%
Age: 35-49 years	1316	22.3%	1308	17.5%
Age: 50-64 years	3540	60.1%	4023	53.8%
Age: ≥ 65 years	648	11.0%	1674	22.4%
Sex: Female	1899	32.2%	2620	35.0%
Sex: Male	3990	67.8%	4863	65.0%
Race/ethnicity: White	4258	72.3%	5382	71.9%
Race/ethnicity: Black	524	8.9%	648	8.7%
Race/ethnicity: Hispanic	774	13.1%	1040	13.9%
Race/ethnicity: Asian	294	5.0%	302	4.0%
Race/ethnicity: Other/unknown	39	0.7%	111	1.5%
BMI: < 18.5 kg/m2	171	2.9%	117	1.6%
BMI: 18.5-< 25 kg/m2	1769	30.0%	1993	26.6%
BMI: 25-< 28 kg/m2	1302	22.1%	1567	20.9%
BMI: 28-< 30 kg/m2	705	12.0%	922	12.3%
BMI: 30-< 35 kg/m2	1212	20.6%	1761	23.5%
BMI: ≥ 35 kg/m2	728	12.4%	1116	14.9%
BMI: Unknown	2	0.0%	7	0.1%
Insurance: Private	3546	60.2%	3773	50.4%
Insurance: Medicare	1312	22.3%	2274	30.4%
Insurance: Medicaid	803	13.6%	1128	15.1%
Insurance: Unknown	228	3.9%	308	4.1%
Geography: Metropolitan	4863	82.6%	6249	83.5%
Geography: Non-metro	1026	17.4%	1234	16.5%
Distance: < 50 miles	3368	57.2%	4327	57.8%
Distance: 50-<100 miles	985	16.7%	1271	17.0%
Distance: 100-<150 miles	524	8.9%	704	9.4%
Distance: 150-<250 miles	462	7.8%	613	8.2%
Distance: ≥ 250 miles	458	7.8%	520	6.9%
Distance: Unknown	92	1.6%	48	0.6%
All recipients	5889	100.0%	7483	100.0%

Table LI 9 Clinical characteristics of adult liver transplant recipients, 2007 and 2017
Adult liver transplant recipients, including retransplants. HCC, hepatocellular carcinoma; HCV, hepatitis C virus.

Characteristic	2007, N	2007, Percent	2017, N	2017, Percent
Diagnosis: Acute liver failure	311	5.3%	245	3.3%
Diagnosis: HCV	1468	24.9%	1005	13.4%
Diagnosis: Alcoholic liver disease	1144	19.4%	1881	25.1%
Diagnosis: Cholestatic disease	568	9.6%	671	9.0%
Diagnosis: HCC	820	13.9%	1314	17.6%
Diagnosis: Other/unknown	1578	26.8%	2367	31.6%
Blood type: A	2102	35.7%	2753	36.8%
Blood type: B	735	12.5%	963	12.9%
Blood type: AB	314	5.3%	376	5.0%
Blood type: O	2738	46.5%	3391	45.3%
Medical condition: Hospitalized in ICU	702	11.9%	996	13.3%
Medical condition: Hospitalized, not ICU	997	16.9%	1409	18.8%
Medical condition: Not hospitalized	4190	71.1%	5078	67.9%
Medical urgency: Status 1A	292	5.0%	197	2.6%
Medical urgency: MELD ≥ 35	714	12.1%	1595	21.3%
Medical urgency: MELD 30-34	470	8.0%	1406	18.8%
Medical urgency: MELD 15-29	4083	69.3%	3953	52.8%
Medical urgency: MELD < 15	325	5.5%	332	4.4%
Medical urgency: Unknown	5	0.1%	0	0.0%
HCC exception	1264	21.5%	1656	22.1%
Other MELD exception	448	7.6%	933	12.5%
Diabetes	1437	24.4%	2150	28.7%
All recipients	5889	100.0%	7483	100.0%

Table LI 10 Transplant characteristics of adult liver transplant recipients, 2007 and 2017
Adult liver transplant recipients, including retransplants. DBD, donation after brain death; DCD, donation after circulatory death.

Characteristic	2007, N	2007, Percent	2017, N	2017, Percent
Wait time: < 31 days	2176	37.0%	2441	32.6%
Wait time: 31-60 days	715	12.1%	724	9.7%
Wait time: 61-90 days	455	7.7%	445	5.9%
Wait time: 3-< 6 months	826	14.0%	885	11.8%
Wait time: 6-< 12 months	688	11.7%	1531	20.5%
Wait time: 1-< 2 years	458	7.8%	922	12.3%
Wait time: 2-< 3 years	209	3.5%	231	3.1%
Wait time: ≥ 3 years	358	6.1%	304	4.1%
Wait time: Unknown	4	0.1%	0	0.0%
Donor type: Deceased	5691	96.6%	7188	96.1%
Donor type: Living	198	3.4%	295	3.9%
Procedure: Whole liver	5616	95.4%	7103	94.9%
Procedure: Partial liver	194	3.3%	293	3.9%
Procedure: Split liver	79	1.3%	87	1.2%
DCD status: DBD	5587	94.9%	6969	93.1%
DCD status: DCD	302	5.1%	514	6.9%
Tx type: Liver only	5394	91.6%	6697	89.5%
Tx type: Liver-kidney	431	7.3%	720	9.6%
Tx type: Other	64	1.1%	66	0.9%
Transplant history: First	5444	92.4%	7174	95.9%
Transplant history: Retransplant	445	7.6%	309	4.1%
All recipients	5889	100.0%	7483	100.0%

Table LI 11 Adult deceased donor liver donor-recipient serology matching, 2013-2017
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. If all fields are unknown, incomplete, or pending, the person is categorized as unknown for that serology; otherwise, serology is assumed negative. CMV, cytomegalovirus; EBV, Epstein-Barr virus; HB, hepatitis B; HCV, hepatitis C virus; HIV, human immunodeficiency virus.

Donor	Recipient	CMV	EBV	HB core	HB surf. ant.	HCV	HIV
D-	R-	13.3%	0.5%	75.5%	94.0%	63.6%	96.1%
D-	R+	22.8%	4.1%	16.7%	3.9%	28.2%	0.5%
D-	R unk	0.5%	1.4%	2.8%	2.0%	1.7%	2.7%
D+	R-	20.9%	9.4%	3.5%	0.0%	0.6%	0.0%
D+	R+	41.1%	68.3%	1.5%	0.0%	5.8%	0.0%
D+	R unk	1.0%	16.3%	0.1%	0.0%	0.1%	0.0%
D unk	R-	0.1%	0.0%	0.0%	0.1%	0.0%	0.6%
D unk	R+	0.3%	0.1%	0.0%	0.0%	0.0%	0.0%
D unk	R unk	0.0%	0.0%	0.0%	0.0%	0.0%	0.0%

Table LI 12 Adult living donor liver donor-recipient serology matching, 2013-2017
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. If all fields are unknown, incomplete, or pending, the person is categorized as unknown for that serology; otherwise, serology is assumed negative. CMV, cytomegalovirus; EBV, Epstein-Barr virus; HB, hepatitis B; HCV, hepatitis C virus; HIV, human immunodeficiency virus.

Donor	Recipient	CMV	EBV	HB core	HB surf. ant.	HCV	HIV
D-	R-	27.9%	1.8%	82.3%	89.3%	74.2%	32.1%
D-	R+	25.1%	9.8%	9.6%	2.4%	20.0%	0.1%
D-	R unk	0.5%	3.5%	2.2%	3.0%	2.2%	1.2%
D+	R-	14.7%	6.1%	0.7%	0.2%	0.4%	0.0%
D+	R+	28.2%	61.8%	0.7%	0.1%	0.2%	0.0%
D+	R unk	0.6%	3.9%	0.0%	0.1%	0.0%	0.0%
D unk	R-	1.2%	0.7%	3.5%	4.4%	2.3%	64.8%
D unk	R+	1.6%	1.6%	0.5%	0.1%	0.5%	0.2%
D unk	R unk	0.2%	10.9%	0.5%	0.5%	0.4%	1.7%

Table LI 13 Demographic characteristics of pediatric candidates on the liver transplant waiting list on December 31, 2007 and December 31, 2017
Candidates aged younger than 18 years waiting for transplant on December 31 of given year, regardless of first listing date; multiple listings are collapsed. Age calculated at snapshot. Candidates listed as children who turned 18 before the cohort date are excluded.

Characteristic	2007, N	2007, Percent	2017, N	2017, Percent
Age: < 1 year	68	9.8%	45	9.7%
Age: 1-5 years	241	34.6%	188	40.6%
Age: 6-10 years	151	21.7%	93	20.1%
Age: 11-17 years	237	34.0%	137	29.6%
Sex: Female	363	52.1%	229	49.5%
Sex: Male	334	47.9%	234	50.5%
Race/ethnicity: White	376	53.9%	234	50.5%
Race/ethnicity: Black	119	17.1%	61	13.2%
Race/ethnicity: Hispanic	147	21.1%	114	24.6%
Race/ethnicity: Asian	40	5.7%	37	8.0%
Race/ethnicity: Other/unknown	15	2.2%	17	3.7%
Geography: Metropolitan	574	82.4%	379	81.9%
Geography: Non-metro	123	17.6%	84	18.1%
Distance: < 50 miles	331	47.5%	198	42.8%
Distance: 50-<100 miles	93	13.3%	69	14.9%
Distance: 100-<150 miles	74	10.6%	46	9.9%
Distance: 150-<250 miles	64	9.2%	62	13.4%
Distance: ≥ 250 miles	115	16.5%	78	16.8%
Distance: Unknown	20	2.9%	10	2.2%
All candidates	697	100.0%	463	100.0%

Table LI 14 Clinical characteristics of pediatric candidates on the liver transplant waiting list on December 31, 2007 and December 31, 2017
Candidates aged younger than 18 years waiting for transplant on December 31, 2007, and December 31, 2017, regardless of first listing date; multiple listings are collapsed. Candidates listed as children who turned 18 before the cohort date are excluded. Pediatric candidates aged 12 to 17 years can be assigned MELD or PELD scores.

Characteristic	2007, N	2007, Percent	2017, N	2017, Percent
Diagnosis: Acute liver failure	49	7.0%	26	5.6%
Diagnosis: Cholestatic biliary atresia	234	33.6%	159	34.3%
Diagnosis: Other cholestatic	85	12.2%	57	12.3%
Diagnosis: Hepatoblastoma	8	1.1%	8	1.7%
Diagnosis: Metabolic	63	9.0%	57	12.3%
Diagnosis: Other/unknown	258	37.0%	156	33.7%
Blood type: A	219	31.4%	139	30.0%
Blood type: B	90	12.9%	58	12.5%
Blood type: AB	12	1.7%	9	1.9%
Blood type: O	376	53.9%	257	55.5%
Medical urgency: Status 1A	13	1.9%	23	5.0%
Medical urgency: Status 1B	39	5.6%	70	15.1%
Medical urgency: MELD/PELD ≥ 30	34	4.9%	32	6.9%
Medical urgency: MELD/PELD 15-29	91	13.1%	89	19.2%
Medical urgency: MELD/PELD < 15	180	25.8%	115	24.8%
Medical urgency: Inactive	340	48.8%	134	28.9%
Exception status: None	636	91.2%	324	70.0%
Exception status: Granted	61	8.8%	139	30.0%
All candidates	697	100.0%	463	100.0%

Table LI 15 Listing characteristics of pediatric candidates on the liver transplant waiting list on December 31, 2007 and December 31, 2017
Candidates aged younger than 18 years waiting for transplant on December 31, 2007, and December 31, 2017, regardless of first listing date; multiple listings are collapsed. Candidates listed as children who turned 18 before the cohort date are excluded.

Characteristic	2007, N	2007, Percent	2017, N	2017, Percent
Transplant history: First	624	89.5%	417	90.1%
Transplant history: Retransplant	73	10.5%	46	9.9%
Wait time: < 1 year	262	37.6%	245	52.9%
Wait time: 1-< 2 years	90	12.9%	87	18.8%
Wait time: 2-< 3 years	61	8.8%	51	11.0%
Wait time: 3-< 4 years	51	7.3%	22	4.8%
Wait time: 4-< 5 years	35	5.0%	20	4.3%
Wait time: ≥ 5 years	198	28.4%	38	8.2%
Tx type: Liver alone	595	85.4%	379	81.9%
Tx type: Liver-kidney	11	1.6%	16	3.5%
Tx type: Liver-pancreas-intestine	59	8.5%	63	13.6%
Tx type: Liver-heart	1	0.1%	0	0.0%
Tx type: Other	31	4.4%	5	1.1%
All candidates	697	100.0%	463	100.0%

Table LI 16 Liver transplant waitlist activity among pediatric candidates
Candidates concurrently listed at more than one center are counted once, from the time of earliest listing to the time of latest removal. 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	2015	2016	2017
Patients at start of year	576	569	579
Patients added during year	710	740	717
Patients removed during year	715	730	746
Patients at end of year	571	579	550

Table LI 17 Removal reason among pediatric liver transplant candidates
Removal reason as reported to the OPTN. Candidates with death dates that precede removal dates are assumed to have died waiting.

Removal reason	2015	2016	2017
Deceased donor transplant	502	516	538
Living donor transplant	80	60	75
Transplant outside US	0	0	1
Patient died	30	36	37
Patient refused transplant	2	2	2
Improved, transplant not needed	62	59	59
Too sick for transplant	23	18	10
Other	16	39	24

Table LI 18 Demographic characteristics of pediatric liver transplant recipients, 2005-2007 and 2015-2017
Liver transplant recipients, including retransplants. Pediatric candidates aged 12 to 17 years can be assigned MELD or PELD scores.

Characteristic	2005-07, N	2005-07, Percent	2015-17, N	2015-17, Percent
Age: < 1 year	525	30.0%	409	23.3%
Age: 1-5 years	633	36.2%	723	41.3%
Age: 6-10 years	232	13.2%	257	14.7%
Age: 11-17 years	361	20.6%	363	20.7%
Sex: Female	875	50.0%	891	50.9%
Sex: Male	876	50.0%	861	49.1%
Race/ethnicity: White	929	53.1%	880	50.2%
Race/ethnicity: Black	297	17.0%	289	16.5%
Race/ethnicity: Hispanic	383	21.9%	396	22.6%
Race/ethnicity: Asian	105	6.0%	136	7.8%
Race/ethnicity: Other/unknown	37	2.1%	51	2.9%
Insurance: Private	857	48.9%	690	39.4%
Insurance: Medicare	18	1.0%	18	1.0%
Insurance: Medicaid	705	40.3%	845	48.2%
Insurance: Other government	122	7.0%	119	6.8%
Insurance: Unknown	49	2.8%	80	4.6%
Geography: Metropolitan	1446	82.6%	1448	82.6%
Geography: Non-metro	305	17.4%	304	17.4%
Distance: < 50 miles	783	44.7%	843	48.1%
Distance: 50-<100 miles	247	14.1%	233	13.3%
Distance: 100-<150 miles	186	10.6%	163	9.3%
Distance: 150-<250 miles	190	10.9%	188	10.7%
Distance: ≥ 250 miles	298	17.0%	269	15.4%
Distance: Unknown	47	2.7%	56	3.2%
All recipients	1751	100.0%	1752	100.0%

Table LI 19 Clinical characteristics of pediatric liver transplant recipients, 2005-2007 and 2015-2017
Liver transplant recipients, including retransplants. Pediatric candidates aged 12 to 17 years can be assigned MELD or PELD scores.

Characteristic	2005-07, N	2005-07, Percent	2015-17, N	2015-17, Percent
Diagnosis: Acute liver failure	202	11.5%	181	10.3%
Diagnosis: Cholestatic biliary atresia	518	29.6%	570	32.5%
Diagnosis: Other cholestatic	236	13.5%	228	13.0%
Diagnosis: Hepatoblastoma	89	5.1%	135	7.7%
Diagnosis: Metabolic	185	10.6%	262	15.0%
Diagnosis: Other/unknown	521	29.8%	376	21.5%
Blood type: A	601	34.3%	578	33.0%
Blood type: B	208	11.9%	254	14.5%
Blood type: AB	82	4.7%	59	3.4%
Blood type: O	860	49.1%	861	49.1%
Medical condition: Hospitalized in ICU	468	26.7%	326	18.6%
Medical condition: Hospitalized, not ICU	277	15.8%	334	19.1%
Medical condition: Not hospitalized	1006	57.5%	1092	62.3%
Medical urgency: Status 1A	360	20.6%	249	14.2%
Medical urgency: Status 1B	135	7.7%	384	21.9%
Medical urgency: MELD/PELD ≥ 30	469	26.8%	658	37.6%
Medical urgency: MELD/PELD 15-29	509	29.1%	286	16.3%
Medical urgency: MELD/PELD < 15	271	15.5%	170	9.7%
Medical urgency: Unknown	7	0.4%	5	0.3%
Any MELD/PELD exception	434	24.8%	734	41.9%
All recipients	1751	100.0%	1752	100.0%

Table LI 20 Transplant characteristics of pediatric liver transplant recipients, 2005-2007 and 2015-2017
Liver transplant recipients, including retransplants. Pediatric candidates aged 12 to 17 years can be assigned MELD or PELD scores. DBD, donation after brain death; DCD, donation after circulatory death.

Characteristic	2005-07, N	2005-07, Percent	2015-17, N	2015-17, Percent
Wait time: < 31 days	699	39.9%	579	33.0%
Wait time: 31-60 days	265	15.1%	293	16.7%
Wait time: 61-90 days	185	10.6%	173	9.9%
Wait time: 3-< 6 months	272	15.5%	303	17.3%
Wait time: 6-< 12 months	178	10.2%	214	12.2%
Wait time: 1-< 2 years	98	5.6%	132	7.5%
Wait time: 2-< 3 years	16	0.9%	26	1.5%
Wait time: ≥ 3 years	32	1.8%	32	1.8%
Wait time: Unknown	6	0.3%	0	0.0%
ABO: Compatible/identical	1711	97.7%	1663	94.9%
ABO: Incompatible	40	2.3%	89	5.1%
Donor type: Deceased	1559	89.0%	1539	87.8%
Donor type: Living	192	11.0%	213	12.2%
Procedure: Whole liver	1143	65.3%	1101	62.8%
Procedure: Partial liver	369	21.1%	371	21.2%
Procedure: Split liver	239	13.6%	280	16.0%
DCD status: DBD	1735	99.1%	1748	99.8%
DCD status: DCD	16	0.9%	4	0.2%
Tx type: Liver only	1489	85.0%	1593	90.9%
Tx type: Liver-kidney	37	2.1%	48	2.7%
Tx type: Other	225	12.8%	111	6.3%
Transplant history: First	1572	89.8%	1611	92.0%
Transplant history: Retransplant	179	10.2%	141	8.0%
All recipients	1751	100.0%	1752	100.0%