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DOD

OPTN/SRTR 2018 Annual Data Report: Deceased Organ Donation

Abstract

SRTR uses data collected by OPTN to calculate metrics such as donation rate, organ yield, and rate of organs recovered for transplant but not transplanted. In 2018, there were 10,721 deceased donors, and this number has been increasing since 2010. The number of deceased donor transplants increased to 29,676 in 2018 from 28,582 in 2017, and this number has been increasing since 2012. The recent increase may be due in part to the rising number of deaths of young people due to the opioid epidemic. In 2018, 4994 organs were discarded, slightly more than 4813 in 2017. In 2018, 3755 kidneys, 278 pancreata, 707 livers, 3 intestines, 23 hearts, and 317 lungs were discarded. These numbers suggest an opportunity to increase numbers of transplants by reducing discards.

Introduction

This chapter reports data collected by the Organ Procurement and Transplantation Network (OPTN) to describe metrics such as donation rate, organ yield, and rate of organs recovered for transplant but not transplanted. These metrics are currently produced, and some, such as organ yield, are used for organ procurement organization (OPO) quality assessment. Recently, the federal government ordered the revision of OPO quality metrics “in order to establish more transparent, reliable, and enforceable objective metrics for evaluating an OPO’s performance” (Reference: Trump DJ. Executive Order on Advancing American Kidney Health 2019 [cited 2019 July 10]. Available from: https://www.whitehouse.gov/presidential-actions/executive-order-advancing-american-kidney-health/.) How OPTN data collection will be used to revise these OPO metrics remains to be seen. This order also aims to reduce organ discards.

Definitions of Terms Related to Deceased Organ Donation

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

Donors

In 2018, 1,073,084 death and imminent death referrals were reported to OPTN by OPOs, a decline from 1,085,646 in 2017 and an increase from 1,072,723 in 2016. These referrals included 11,664 individuals who met the definition of eligible death according to OPTN policy, a slight decline from 11,671 in 2017. In 2018, 21,267 imminent neurological and eligible deaths were reported, a slight decline from 22,260 in 2017 and 23,441 in 2016. The decline was anticipated due to changes in the OPTN definition of imminent neurological and eligible deaths (Figure DOD 2), for example, changing the absence of three brain stem reflexes to the absence of spontaneous breathing and two other brain stem reflexes. There were 10,721 deceased donors in 2018, an increase from 10,286 in 2017; this number has been increasing since 2010. The number of deceased donor transplants increased to 29,676 in 2018 from 28,582 in 2017; this number has been increasing since 2012. This is in contrast to the decline or lack of growth in numbers of deceased donor transplants prior to 2012. In 2018, 6843 living donor transplants (difference between overall transplants and deceased donor transplants) were performed, an increase from 6181 in 2017; this number has been increasing since 2016 (Figure DOD 2). Donations after brain death (DBD) increased to 8591 in 2018, from 8403 in 2017; this number has been increasing since 2012. Donations after circulatory death (DCD) increased to 2130 from 1883 in 2018; this number has been increasing since 2007 (Figure DOD 3). The number of organs authorized for recovery from actual deceased donors continued to increase, to 77,012 in 2018 from 73,638 in 2017; this number has been increasing since 2010. The number of organs recovered for transplant and transplanted increased to 30,595 in 2018 from 29,435 in 2017; this number has been increasing since 2012 (Figure DOD 4). Potential reasons for the increases in organs authorized for recovery, donors, and numbers of deceased donor transplants include the rising number of deaths of young people due to the opioid epidemic and increasing use of organs from DBD donors.

Donation Rate

OPTN policy requires that OPOs report all eligible deaths for OPO performance assessment. However, any performance metric based solely on eligible deaths uses only a subset of potential donors, since successful donations can come from donors not meeting the eligible death definition, e.g., DCD or donors aged older than 75 years. Recognizing this limitation, SRTR’s current donation rate is a measure of how often an eligible death becomes a donor. In 2018, the donation rate was 71.0 eligible donors per 100 eligible deaths, an increase from 69.6 in 2017. However, the 2017 changes to OPTN policy 1.2 defining eligible deaths preclude drawing firm conclusions regarding differences in donation rates between 2017 and 2018 versus prior years. Unadjusted donation rates varied by donation service area (DSA), ranging from 56.2 to 90.1 eligible donors per 100 eligible deaths (Figure DOD 5). This range was unchanged from 2017. Risk-adjusted donation rates are presented for each OPO biannually in the OPO reports on the SRTR website.

As expected, donation rates varied by organ. In 2018, the highest rate was 64.9 eligible donors per 100 eligible deaths, for 7573 kidneys from 11,664 eligible deaths. This represents a slight increase from 2017, when the kidney donation rate was 63.1 eligible donors per 100 eligible deaths. The number of eligible kidney donors increased from 7368 in 2017. In 2018, the next highest donation rate after kidneys was 64.1 for livers, from 7471 liver eligible donors. The pattern was similar for livers, with a slight increase in the donation rate and an increase in the number of eligible liver donors in 2018 compared with 2017. In 2017, the donation rate was 63.6 eligible donors per 100 eligible deaths for liver, from 7420 liver eligible donors. However, the 2017 changes in OPTN policy 1.2 defining eligible deaths preclude drawing firm conclusions regarding differences in organ-specific donation rates between 2017 and 2018 versus prior years (Figure DOD 6).

In 2018, the lowest donation rate was 10.7 eligible donors per 100 eligible deaths for pancreata, from 1253 eligible pancreas donors. Compared with 2017, the donation rate for pancreas donors remained the same, and the number of donors increased from 1249 eligible pancreas donors (Figure DOD 6). In 2018, the donation rate for heart was 29.4 eligible donors per 100 eligible deaths from 3427 eligible heart donors, and the donation rate for lung was 20.2 from 2359 eligible lung donors. Compared with 2017, the heart donation rate increased from 28.1 eligible donors per 100 eligible deaths from 3279 eligible heart donors, and the donation rate for lung increased from 19.8 from 2310 eligible lung donors (Figure DOD 6).

Organs Recovered per Donor

In 2018, 3.53 organs were recovered per donor, slightly lower than 3.54 in 2017 and 2016 and slightly higher than 3.51 in 2015 and 3.50 in 2014 (Figure DOD 7). The ORPD for all organs combined has been relatively stable compared with 2014 (Figure DOD 7, Figure DOD 8). Given that each donor can potentially donate two kidneys, the ORPD was highest for kidneys, followed by livers (Figure DOD 7, Figure DOD 8). ORPDs have remained stable for kidneys and slightly decreased for livers over the past decade. ORPDs have increased for hearts and lungs over the past decade, remained unchanged for intestines, and declined for pancreata (Figure DOD 8). In 2018, the ORPD varied substantially by DSA, ranging from 2.88 to 4.12, a slightly decreased range from 2.74 to 4.15 in 2017 and from 2.90 to 4.19 in 2016 (Figure DOD 9). The ORPD is an unadjusted number, and thus represents a mix of donor types, including young, old, DBD, and DCD, which explains some of the differences observed. The ORPD for kidneys varied across DSAs from 1.64 to 2.0; for pancreata, from 0.01 to 0.28; for livers, from 0.45 to 0.93; for intestines, from 0 to 0.07; for hearts, from 0 to 0.49; and for lungs, from 0.19 to 0.72 (Figure DOD 9).

Organs Transplanted per Donor and Organ Yield

The number of OTPD was 3.06 in 2018, slightly decreased from 3.07 in 2017, the same as in 2016, and slightly increased from 3.03 in 2015 and 2014 (Figure DOD 10). Given that each donor can potentially donate two kidneys, the OTPD was highest for kidneys, followed by livers (Figure DOD 10, Figure DOD 11). OTPD increased for lungs over the past decade, but declined for pancreata (Figure DOD 11). Numbers of deceased donor organs transplanted in 2018 were as follows: 15,877 kidneys, 1029 pancreata, 7766 livers, 106 intestines, 3443 hearts, and 4542 lungs. In a 2018 unadjusted analysis, not accounting for the mix of DBD and DCD donor types, OTPD varied substantially by DSA, ranging from 2.26 to 3.56 (Figure DOD 12). In 2018, the OTPD for kidneys varied by DSA from 1.28 to 1.72; for pancreata, from 0 to 0.24; for livers, from 0.45 to 0.90; for intestines, from 0 to 0.07; for hearts, from 0 to 0.49; and for lungs, from 0.10 to 0.63.

The OTPD from DBD donors was 3.34 in 2018, slightly higher than 3.33 in 2017, 3.29 in 2016, 3.25 in 2015, and 3.22 in 2014. The OTPD from DCD donors was 1.94 in 2018, 1.92 in 2017, 1.93 in 2015 and 2016, and 1.97 in 2014 (Figure DOD 13). In 2018, of the 10,721 donors, 19.9% nationally were DCD. In contrast, in 2017, of the 10,286 donors, 18.3% nationally were DCD. Both 2017 and 2018 represent an increase from 17% DCDs in 2016, 16% in 2015, and 15% in 2014.

In 2018, average numbers of kidneys transplanted per donor were 1.46 DBD (12,524 kidneys) and 1.57 DCD (3353 kidneys). In 2017, corresponding values were 1.46 DBD (12,236 kidneys, higher than 11,890 in 2016 and 10,919 in 2015) and 1.54 DCD (2908 kidneys, higher than 2611 in 2016 and 2332 in 2015) (Figure DOD 14). Although the number of DBD kidneys transplanted per donor remained the same as in 2017, the number of kidneys increased due to the increase in the number of donors. Numbers of DBD and DCD kidneys have continued to increase since 2012.

Apart from kidney donors, OTPD was higher from DBD than from DCD donors (Figure DOD 14, Figure DOD 15, Figure DOD 16, Figure DOD 17, Figure DOD 18, Figure DOD 19). The OTPD for kidneys has been higher from DCD than from DBD donors since 2006 (Figure DOD 14). The number of DCD liver donors continued to increase, from 450 in 2016 and 517 in 2017 to 537 in 2018, but the number of DBD liver donors increased more, from 6961 in 2016 and 7114 in 2017 to 7229 in 2018. Similarly, the number of DCD lungs continued to increase, from 163 in 2016 and 165 in 2017 to 226 in 2018, but the number of DBD lung donors increased more, from 3956 in 2016 and 4194 in 2017 to 4316 in 2018. The number of DCD pancreata declined slightly from 26 in 2017 to 25 in 2018, but the number of DBD pancreas donors increased from 974 in 2017 to 1004 in 2018. Among DBD organs, only the number of DBD intestines continued to decline, from 147 in 2016 to 108 in 2017 and 106 in 2018. In 2018, among kidney donors, OTPD varied by kidney donor profile index (KDPI), and was 1.95, 1.86, 1.57 and 0.64 for KDPI <0.20, 0.21-0.34, 0.35-0.85, and >0.85, respectively (Figure DOD 20). The number of kidneys transplanted increased slightly for each category of KDPI compared with 2017. In 2017, among kidney donors, OTPD was 1.93, 1.87, 1.55, 0.63 for KDPI <0.20, 0.21-0.34, 0.35-0.85, and >0.85, respectively (Figure DOD 20).

The yield metric shown in Figure DOD 21, Figure DOD 22, Figure DOD 23, Figure DOD 24, Figure DOD 25, and Figure DOD 26 compares the number of organs transplanted (observed) in 2017-2018 with the number of organs that would be expected to be transplanted based on the national experience with similar donors (expected). A ratio, expressed as observed/expected organs transplanted, of less than 1 indicates that fewer organs were transplanted than would be expected based on the national models for that organ. A ratio of more than 1 indicates that more organs were transplanted than would be expected. The mean observed/expected ratio for all organs varied from 0.86 to 1.05, and from 0.90 to 1.07 for kidneys, 0.30 to 2.43 for pancreata, 0.77 to 1.14 for livers, 0 to 4.30 for intestines, 0.83 to 1.29 for hearts, and 0.43 to 1.96 for lungs.

Organs Recovered for Transplant but Not Transplanted

The number of organs recovered for transplant but not transplanted is calculated by subtracting the number of organs transplanted from the number of organs recovered for the purpose of transplant. The percentage of organs not transplanted is then calculated by dividing the number of organs not transplanted by the number of organs recovered for the purpose of transplant. The percentage in 2018 for all organs combined was 13.2 per recovered organ, the same as in 2017 and slightly lower than 13.8 per recovered organ in 2016 (Figure DOD 27). In 2018, 4994 organs were discarded, slightly more than 4813 in 2017, slightly less than 4859 in 2016, and slightly more than 4368 in 2015. In 2018, 3755 kidneys, 278 pancreata, 707 livers, 3 intestines, 23 hearts, and 317 lungs were discarded. The numbers of kidneys, livers, and lungs discarded increased from 3542, 742, and 272, respectively, in 2017. (Figure DOD 27).

Use of DCD Organs and High KDPI Kidneys

Use of DCD organs varied across OPOs (Figure DOD 28). In 2018, the percentage of DCD donor organs among deceased donor transplant recipients varied across DSAs from 0 to 50.9, a broader range than 0 to 37.2 in 2017. In 2018, the percentage of donors with KDPI higher than 0.85 also varied across the DSAs, ranging from 0 to 19.7, a narrower range than 0 to 29.9 in 2017 (Figure DOD 29).

Disposition of Organs

The disposition of organs from actual donors is described in Figure DOD 30, Figure DOD 31, Figure DOD 32, Figure DOD 33, Figure DOD 34, Figure DOD 35, Figure DOD 36, and Figure DOD 37. Donor characteristics in 2018 are compared with characteristics in 2008 in Table DOD 1. The most remarkable difference was the increase in HIV-positive donors to 18 in 2018 from none in 2008. This increase is due to the HIV Organ Policy Equity (HOPE) Act, which modified rules regarding organ donation between HIV-positive individuals and authorized use of these organs as part of clinical research. Other remarkable differences were an increase in anoxia as cause of donor death from 21.7% in 2008 to 43.3% in 2018, and a decrease in stroke from 40.1% in 2008 to 26.7% in 2018. The number of DCD donors increased from 10.6% in 2008 to 19.9% in 2018. The increases in numbers of donors aged 18-34 years from 26.1% to 29.4% and 35-49 years from 26.1% to 27.5%, and the increase in anoxia as cause of death from 21.7% 43.3%, may reflect increased deaths due to the opioid abuse epidemic.

Figure List

Summary

Figure DOD 1. Relationship between deaths, donations, and transplants
Figure DOD 2. Overall counts of eligible deaths, donors, and transplants, 2007-2018
Figure DOD 3. Overall counts of deceased donors, DBD donors, and DCD donors, 2007-2018
Figure DOD 4. Overall counts of authorized, recovered and transplanted organs, 2007-2018

Donation rates

Figure DOD 5. Eligible Donors per 100 eligible deaths by DSA, 2018
Figure DOD 6. Overall and organ-specific eligible donors per 100 eligible deaths, 2018

Organs recovered per donor

Figure DOD 7. Organs recovered per donor, all organs and kidney, 2018
Figure DOD 8. Organs recovered per donor, pancreas, liver, intestine, heart, and lung, 2018
Figure DOD 9. Organs recovered per donor by DSA, 2018

Organs transplanted per donor

Figure DOD 10. Organs transplanted per donor, all organs and kidney, 2007 - 2018
Figure DOD 11. Organs transplanted per donor, pancreas, liver, intestine, heart, and lung, 2007 - 2018
Figure DOD 12. Organs transplanted per donor, by DSA, 2018
Figure DOD 13. Organs transplanted per donor, by DBD and DCD status
Figure DOD 14. Kidneys transplanted per donor, by DBD and DCD status
Figure DOD 15. Pancreata transplanted per donor, by DBD and DCD status
Figure DOD 16. Livers transplanted per donor, by DBD and DCD status
Figure DOD 17. Intestines transplanted per donor, by DBD and DCD status
Figure DOD 18. Hearts transplanted per donor, by DBD and DCD status
Figure DOD 19. Lungs transplanted per donor, by DBD and DCD status
Figure DOD 20. Kidneys transplanted per donor, by KDPI

Yield

Figure DOD 21. Observed-to-expected yield per kidney, 2017-2018
Figure DOD 22. Observed-to-expected yield per pancreas, 2017-2018
Figure DOD 23. Observed-to-expected yield per liver, 2017-2018
Figure DOD 24. Observed-to-expected yield per intestine, 2017-2018
Figure DOD 25. Observed-to-expected yield per heart, 2017-2018
Figure DOD 26. Observed-to-expected yield per lung, 2017-2018

Organ recovered for transplant and not transplanted

Figure DOD 27. Organs recovered for transplant and not transplanted

Organ quality

Figure DOD 28. Variation in percentage of DCD donors from all donors, 2018
Figure DOD 29. Variation in percentage of kidney donors with KDPI greater than 85% among deceased donor kidney transplant recipients, by DSA, 2018

Organ use charts

Figure DOD 30. Organ use chart for reported left kidneys, 2018
Figure DOD 31. Organ use chart for reported right kidneys, 2018
Figure DOD 32. Organ use chart for reported en bloc kidneys, 2018
Figure DOD 33. Organ use chart for pancreas, 2018
Figure DOD 34. Organ use chart for liver, 2018
Figure DOD 35. Organ use chart for intestine, 2018
Figure DOD 36. Organ use chart for heart, 2018
Figure DOD 37. Organ use chart for lung, 2018

Table List

Donor characteristics

Table DOD 1. Characteristics of deceased donors, 2008 and 2018

A venn diagram that illustrates the difficult conceptual definitions and relationships between donor deaths and becoming an organ donor.  Basically, the true potential donor pool is only contained by in-hospital deaths but overlaps and is not contained by referrals to OPO, eligible deaths.

Figure DOD 1. Relationship between deaths, donations, and transplants
Conceptual schematic (Venn diagram) of actual and potential organ donors. A. Only in rare instances do out-of-hospital deaths result in organ donation. B. Most in-hospital deaths are reported to the local organ procurement organization. C. The number of "True" Potential Donors (dashed circle) is yet to be defined. D. Eligible Deaths. E. Actual donors, not all of whom result in transplants. F. Deceased donor transplants. OPO, organ procurement organization.


A line plot for overall counts of eligible deaths, donors, and transplants, 2007-2018; the imminent or eligible deaths category is NA count at 2007 and is count at 2018; the eligible deaths category is NA count at 2007 and is count at 2018; the deceased donors (dd) category increases by 32.6% from 8086 count at 2007 to 10721 count at 2018; the dd meeting eligibility criteria category is NA count at 2007 and is count at 2018; the total transplants category increases by 28.7% from 28369 count at 2007 to 36519 count at 2018; and the dd transplants category increases by 34.6% from 22053 count at 2007 to 29676 count at 2018.

Figure DOD 2. Overall counts of eligible deaths, donors, and transplants, 2007-2018
The number and source of donors with the number of transplants.


A line plot for overall counts of deceased donors, dbd donors, and dcd donors, 2007-2018; the deceased donors category increases by 32.6% from 8086 count at 2007 to 10721 count at 2018; the dbd donors category increases by 17.8% from 7295 count at 2007 to 8591 count at 2018; and the dcd donors category increases by 169.3% from 791 count at 2007 to 2130 count at 2018.

Figure DOD 3. Overall counts of deceased donors, DBD donors, and DCD donors, 2007-2018
The number of deceased donors, DBD donors and DCD donors.


A line plot for overall counts of authorized, recovered and transplanted organs, 2007-2018; the organs authorized category increases by 38.8% from 55487 count of organs at 2007 to 77012 count of organs at 2018; the organs recovered category increases by 34.2% from 29459 count of organs at 2007 to 39538 count of organs at 2018; and the organs transplanted category increases by 33.0% from 23000 count of organs at 2007 to 30595 count of organs at 2018.

Figure DOD 4. Overall counts of authorized, recovered and transplanted organs, 2007-2018
The number of authorized , recovered, and transplanted organs.