OPTN/SRTR 2018 Annual Data Report: Kidney

Abstract

Despite the ongoing severe mismatch between organ need and supply, data from 2018 revealed some promising trends. For the fourth year in a row, the number of patients waiting for a kidney transplant in the US declined and numbers of both deceased and living donor kidney transplants increased. These encouraging trends are tempered by ongoing challenges, such as a large proportion of listed patients with dialysis time longer than 5 years. The proportion of candidates aged 65 years or older continued to rise, and the proportion undergoing transplant within 5 years of listing continued to vary dramatically nationwide, from 10% to nearly 80% across donation service areas. Increasing trends in the recovery of organs from hepatitis C positive donors and donors with anoxic brain injury warrant ongoing monitoring, as does the ongoing discard of nearly 20% of recovered organs. While the number of living donor transplants increased, racial disparities persisted in the proportion of living versus deceased donors. Strikingly, the total number of kidney transplant recipients alive with a functioning graft is on track to pass 250,000 in the next 1-2 years. The total number of pediatric kidney transplants remained steady at 756 in 2018. Deeply concerning to the pediatric community is the persistently low level of living donor kidney transplants, representing only 36.2% in 2018.

Introduction

Kidney transplant provides significant quality of life and mortality benefits over dialysis for the treatment of end-stage kidney disease, but optimizing access to kidney transplant and graft survival are ongoing challenges. The Annual Data Report is an opportunity to assess the state of kidney transplantation and examine the positive and unfavorable trends that warrant further monitoring and evaluation. Data are provided on adult and pediatric kidney transplant waiting lists, living donation, deceased donation, transplants, and outcomes.

Adults

Waiting List

Waitlist data from 2018 reveal encouraging trends. The number of patients on the kidney transplant waiting list declined for the fourth year in a row since its peak at nearly 100,000 in 2014 (Figure KI 2). The decline was less than in the previous year, but this was largely due to the greater number of patients added to the list, nearly 3000 more than in the previous 2 years (Figure KI 1, Table KI 5). Encouragingly, the decline in numbers of waitlisted candidates appeared to be due to further increases in both deceased and living donor transplants in 2018, rather than to increases in removals for other reasons; numbers of candidates removed from the list due to death or becoming too sick for transplant decreased.

Previous trends in the demographic characteristics of candidates on the waiting list did not change in 2018. The proportion aged 65 years or older continued to increase, comprising almost a quarter of the waiting list (Figure KI 3, Table KI 2). Approximately 60% of candidates were male (Figure KI 4), a proportion that changed little in the past decade. Similarly, while the proportion of Hispanic candidates has increased incrementally over the past decade, corresponding to a slight decrease in the proportion of white candidates, little has changed in the racial distribution (Figure KI 5). The metropolitan versus non-metropolitan candidate distribution also changed little over the past decade (Table KI 2). Diabetes remained the most common cause of kidney failure, with an ongoing upward trend to nearly 40% of listed candidates (Figure KI 6, Table KI 3). While still higher than it was 5 years ago, the proportion of candidates on the waiting list for more than 5 years did not increase for the first time in a decade (Figure KI 7, Table KI 4). Encouragingly, the 10-year trend in increased proportions of patients listed before starting dialysis continued, but those with more than 5 years on dialysis still comprised one-fifth of the waiting list. While the proportion of candidates with 6-10 years of dialysis time decreased slightly, possibly due to the new allocation policy in 2014 giving credit for time on dialysis, the large number of patients with long dialysis exposure prior to transplant remains a concern given deterioration in the benefits of transplant with longer dialysis exposure (Figure KI 8, Table KI 4).

Changes in willingness to accept a high kidney donor profile index (KDPI) (>85%) kidney are notable. With the new kidney allocation system (KAS), allocation of lower-KDPI kidneys with longer expected graft survival was prioritized for candidates with longer expected post-transplant survival, and as expected, transplant rates for older patients fell below the rates for younger patients (Figure KI 14). However, willingness to accept high-KDPI kidneys decreased after the new KAS among older patients, to a low of 60% in 2018. In 2018, reported willingness to accept high-KDPI kidneys was stable to slightly increased among older candidates for whom high-KDPI kidneys are likely the most beneficial (Figure KI 12). The coming years will reveal whether this single-year change represents a reversal of the previously concerning trend. Also notable is the year-over-year increase in willingness to accept a hepatitis C virus (HCV)-positive kidney (Figure KI 13). In a new era of effective HCV treatments, HCV-positive donors have the exciting potential to help ease the organ shortage, and a special chapter of the OPTN/SRTR 2018 Annual Data Report is devoted to further examining HCV-positive transplant.

In addition to deceased donor transplant rate changes for older patients, rates changed for several key groups after the new KAS, and these trends continued in 2018. Disparities in deceased donor transplant rates between whites and other races decreased after the new KAS, and this trend continued in 2018, although rates for Asians remained slightly lower compared with rates for other racial groups (Figure KI 15). After a dramatic spike immediately post-KAS in transplant rates among patients with calculated panel-reactive antibody (cPRA) above 98%, rates leveled off and in 2018 remained similar to rates for lower-cPRA candidates with, the exception of candidates with cPRA 80%-98%, for whom rates remain slightly higher (Figure KI 17). The long-term effects of these allocation policy changes on allograft survival will need to be monitored. Despite the KAS provision allowing for allocation of blood type A2 and A2B kidneys to B recipients, transplant rates among blood type B candidates have not increased markedly. In fact, post-KAS transplant rates increased most among blood type AB candidates, a trend that may warrant further study (Figure KI 18). Transplant rates also rose markedly among patients with less than 1 year on the waiting list post-KAS, again possibly due to credit given for time on dialysis, which resulted in many new patients with long dialysis times moving to the top of the waiting list immediately after listing. This trend continued in 2018, although the rate of increase appears to be plateauing (Figure KI 19). Transplant rates by metropolitan vs. non-metropolitan areas remained similar and relatively unchanged (Figure KI 20, Figure KI 21).

Overall, 40% of patients listed for transplant in 2015 were still waiting in 2018, while approximately 40% underwent transplant and 20% died or were removed from the list for other reasons (Figure KI 22). The 6-month mortality rate for candidates removed from the list remained stable, suggesting that standards for removing patients deemed too sick to undergo transplant have not changed substantially (Figure KI 34). For candidates who did not undergo living donor transplant, 30% underwent transplant within 3 years and less than 40% within 5 years. Nationally, median time to deceased donor transplant for a newly listed candidate has not been calculable for a decade, as 2008 was the last listing year in which more than 50% of the waiting list underwent transplant. The proportion of candidates who undergo transplant within 5 years of listing continued to vary dramatically nationwide, from 10% to 80% across donation service areas (DSA) (Figure KI 24, Figure KI 25). Despite this ongoing mismatch between organ need and supply, a small but positive trend is notable in waitlist survival across age groups, although disparities between white candidates and black, Hispanic, and Asian candidates persisted (Figure KI 26, Figure KI 27, Figure KI 28, Figure KI 29, Figure KI 30, Figure KI 31). Not surprisingly given the large variation in transplant rates, waitlist mortality also varied dramatically by DSA, with rates more than five times higher in some DSAs (Figure KI 32). Resolving this persistent geographic disparity in mortality and access to transplant warrants further investigation.

Deceased Donation

Deceased kidney donation trends were largely unchanged in 2018 with a few notable exceptions (Figure KI 37, Figure KI 38, Figure KI 39). While the distribution of deceased donor kidneys by age, race, and sex has been stable, the total number of kidneys recovered from donors aged 18-64 years rose steadily over the past decade (Figure KI 35). This may be due to a general increase in recovery by organ procurement organizations, but the opioid epidemic may also play a role, as evidenced by the corresponding rise in proportions of kidneys donated after anoxic brain injury (Figure KI 55). The number of HCV-antibody-positive kidneys recovered also increased, albeit only slightly, while the proportion of recovered HCV-positive organs discarded decreased substantially (Figure KI 48), suggesting an increase in demand for these organs in the era of better treatment options (Figure KI 36, Figure KI 40). Nearly 20% of recovered kidneys were not transplanted. Discarded kidneys are more commonly from older donors, donors with diabetes, hypertension, and/or terminal creatinine above 1.5 mg/dL (Figure KI 42, Figure KI 43, Figure KI 44, Figure KI 45). Discarded kidneys were also more likely to have been biopsied (Figure KI 46). Given that the average kidney donor risk index (KDRI) of biopsied kidneys also decreased (Figure KI 54), this trend again raises concern that biopsy findings may not correspond to significantly decreased graft survival and may lead to the discard of potentially beneficial kidneys. Interestingly, kidneys from donors designated as Public Health Service increased risk for transmission of infectious disease were discarded less than standard infectious risk kidneys, although given that these kidneys often have substantially lower KDPI, this may still reflect discard of potentially beneficial kidneys. Nearly 60% of kidneys recovered with KDPI above 85% were not transplanted (Figure KI 51). Given that KDPI is based on the previous years’ recovered kidneys, discard of high-KDRI kidneys could result in a drift in the KDPI score such that a given KDPI corresponds to a lower KDRI; it is reassuring that after several years of decline, the average KDRI of discarded kidneys increased after 2016 (Figure KI 53).

Living Donation

After a steady decline in living donor transplants for more than a decade, their number increased in 2018 for the second year in a row (Figure KI 56). Living donor transplants continued to represent a small proportion of transplants relative to the size of the waiting list, and compared with their peak in 2004; coming years will reveal whether this positive trend continues. The number and proportion of donors aged older than 50 years continued to rise, corresponding to improved procedural safety and increased concern regarding the long-term risk of kidney donation (Figure KI 57). Living kidney donors remained predominantly female and mostly white (Figure KI 58, Figure KI 59). Reported complications and hospitalizations were uncommon, but loss to follow-up at even 1 year was high (Figure KI 61, Figure KI 62).

Transplants

The total number of kidney transplants increased in 2018 for the fourth year in a row, having been relatively stagnant for many years prior (Figure KI 64). The increase occurred across age groups (except ages <18 years), sex, race, and cause of kidney disease (Figure KI 65, Figure KI 66, Figure KI 67, Figure KI 68). Important demographic differences in transplant recipients are worth noting. White recipients continued to represent a disproportionately large share of living donor transplants, 64.7%, despite making up only 45.9% of all transplants. The racial disparity in living donor transplant was most notable among African American recipients, who accounted for 12.5% of living donor transplants despite making up 26.9% of all transplants (Table KI 8). Most living donor recipients had private insurance at the time of transplant, while most deceased donor recipients had Medicare. Rates of deceased versus living transplant were similar by metropolitan/non-metropolitan breakdown and distance from transplant programs (Table KI 8). Not surprisingly, living donor recipients tended to have less dialysis time and lower cPRA (Table KI 9). About 90% of deceased and of living donor transplants were first-time transplants (Table KI 10), and approximately 18% of each were cytomegalovirus donor-positive/recipient-negative (Table KI 11, Table KI 12).

The proportion of low-KDPI transplanted kidneys decreased slightly, a trend that may warrant investigation, and may reflect discards of increased infectious risk (but often low-KDPI) kidneys in the setting of the opioid epidemic (Figure KI 69). T-cell depleting agents remained the most common induction agent, as most patients continued on a tacrolimus and mycophenolate mofetil (MMF)-based regimen. Approximately 30% were on steroid-free regimens, a relatively stable proportion over the past decade. As noted previously, the proportion of deceased donor transplants in recipients with cPRA 98-100 increased notably after the 2014 KAS, and has since leveled off (Figure KI 72). The increased numbers of transplants occurred in larger transplant programs, at or above the median size, performing at least 250 transplants per year (Figure KI 75, Figure KI 76).

Outcomes

Overall, short- and long-term all-cause and death-censored graft failure after deceased donor transplant continued to decline, although 3-year graft failure increased slightly after 2015 after many years of decline (Figure KI 77, Figure KI 78). This small change corresponds to the new KAS, and given concerns about increased long-term graft failure with increased cold ischemia time and high-cPRA transplants, this trend should be closely monitored. Short- and long-term living donor graft failure continued to decline (Figure KI 80, Figure KI 81). Graft survival remained lowest among patients with diabetes or hypertension as a cause of kidney disease compared with other diagnoses (Figure KI 83), or with higher KDPI; 5-year graft survival was approximately 65% among deceased donor kidneys with KDPI above 85% (Figure KI 84). Five-year unadjusted graft survival did not differ by donation after circulatory death status (Figure KI 85). Unadjusted graft survival was lower for kidneys that were biopsied at the time of transplant (Figure KI 86); as noted previously, the utility of biopsy in procurement is a question that warrants further study. Unadjusted graft survival was not worse in non-metropolitan compared with metropolitan zip codes, and actually improved with greater distance from transplant programs (Figure KI 87, Figure KI 88).

Graft survival also continued to improve after living donor transplant, with 5-year graft survival nearly 90% in 2018 (Figure KI 89). Five-year unadjusted living donor graft survival was best among Asians and worst among African Americans (Figure KI 90) and recipients with diabetes (Figure KI 91). Estimated glomerular filtration rate at 12 months improved slightly over the past decade, and was 45-90 mL/min/1.73m² for nearly 70% of deceased donor recipients (Figure KI 94). The total number of kidney transplant recipients alive with a functioning graft is on track to pass 250,000 in the next 1-2 years, and trends in patient survival closely mirror those in graft survival (Figure KI 103, Figure KI 104, Figure KI 105, Figure KI 106, Figure KI 107, Figure KI 108, Figure KI 109, Figure KI 110, Figure KI 111, Figure KI 112, Figure KI 113).

Pediatric Kidney Transplant

Waiting List

In 2018, 966 pediatric candidates were added to the kidney transplant waiting list, with 336 (34.8%) as active status (Figure KI 114). 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 1585 on December 31, 2018, with 510 (32%) as active status (Figure KI 115). The most common reason for inactive status among newly listed pediatric candidates in 2018 was incomplete work-up (51.4%), followed by living donor candidate status (15.6%), and too well to need transplant (14.2%) (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 (63.4% to 56.6%) (Table KI 14). Proportions of candidates with congenital anomalies of the kidney and urinary tract (CAKUT) as primary cause of disease increased from 25.9% in 2008 to 36.7% in 2018, and proportions with glomerulonephritis and focal segmental glomerulosclerosis (FSGS) decreased (Table KI 15). By cause of end-stage renal disease (ESRD) and age, CAKUT was most common among candidates aged younger than 6 years, while FSGS and glomerulonephritis were more common among older children (Figure KI 122). For most candidates waiting as of December 31, 2018 (69.8%), cPRA was less than 1% (Table KI 15). The proportion of pediatric candidates waiting for re-transplant decreased from 26.8% in 2008 to 14.4% in 2018. Multi-organ listing remained uncommon; only 1.7% of pediatric candidates were awaiting multi-organ transplant at the end of 2018 (Table KI 16).

Of the 996 pediatric candidates removed from the waiting list in 2018, 596 (59.8%) received a deceased donor kidney, 301 (30.2%) received a living donor kidney, 25 (2.5%) died, 10 (1.0%) were removed from the list because their condition improved, and nine (0.9%) were considered too sick to undergo transplant (Table KI 17, Table KI 18). Among patients newly listed in 2015, 54.5% underwent deceased donor transplant within 3 years, 27.0% underwent living donor transplant, 15.0% were still waiting, 2.1% were removed from the list for other reasons, and 1.5% died (Figure KI 123). The rate of deceased donor transplant among pediatric waitlisted candidates decreased over the past decade and was 37.9 transplants per 100 waitlist-years in 2018, compared with a peak of 52.0 transplants in 2009 (Figure KI 124). Post-KAS, transplant rates changed based on recipient age (Figure KI 124). In 2018, transplant rates were highest for candidates aged 11-17 years (48.1 per 100 waitlist-years), followed by candidates aged 6-10 years (42.9) and candidates aged younger than 6 years (38.7). As expected, transplant rates remained higher than pre-KAS rates for highly sensitized (=98%) candidates, reflecting KAS priority; the transplant rate increased from 6.6 transplants per 100 waitlist-years in 2014 to 15.1 in 2018 (Figure KI 125). Transplant rates for pediatric candidates with cPRA 80%-97% initially declined to 17.1 post-KAS in 2015, but increased to 21.9 in 2018 (Figure KI 125), 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 remained low: 1.3 per 100 waitlist-years in 2018, but varying by age; rates were 2.1 for ages younger than 6 years, 0.4 for 6-10 years, and 0.6 for 11-17 years (Figure KI 128).

Transplant

The total number of pediatric kidney transplants remained steady at 756 in 2018 (Figure KI 131). Deeply concerning to the pediatric community is the persistently low level of living donor kidney transplants, representing only 36.2% in 2018. The number of related living donors decreased dramatically over the past decade (Figure KI 132), but the number of unrelated directed transplants performed in pediatric candidates reached its highest at 66 in 2018 (Figure KI 132). Children aged younger than 6 years made up the largest group of living donor kidney recipients (49.1%) (Figure KI 133).

In 2018, 36 programs were performing only pediatric kidney transplants, compared with 150 performing only adult or late teenage (ages 15-17 years) transplants and 53 performing transplants in both adults and children (Figure KI 134). In 2018, 16.4% of transplants in candidates aged younger than 18 years were performed at programs with volume of five or fewer pediatric transplants in that year (Figure KI 135). Most pediatric recipients who underwent transplant between 2016 and 2018 were aged 11-17 years, 61.4% among deceased donor recipients and 51.5% 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 29.9% of pediatric living donor transplants and 19.2% of pediatric deceased donor transplants (Table KI 19).The racial distribution differed for deceased and living donor transplant recipients; a higher proportion of living than deceased donor recipients were white (69.4% vs. 37.4%). Private insurance was more common among living donor recipients (55.3% vs. 26.5%) and Medicare/Medicaid among deceased donor recipients. Most deceased donor recipients (95.2%) 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 39.0% of deceased donor transplants and in 28.9% of living donor transplants (Table KI 22, Table KI 23). The combination of a donor who was positive for Epstein-Barr virus (EBV) and a recipient who was negative occurred in 37.4% of deceased donor transplants and in 51.5% of living donor transplants.

Immunosuppressive Medication Use

Use of T-cell depleting agents continued to increase, reaching 63.6% in 2018. IL-2-RA therapy remained stable at 35.1% (Figure KI 136). In 2018, the most common initial immunosuppression regimens were tacrolimus, MMF, and steroids in 57.8% of recipients, followed by tacrolimus and MMF in 37.5% (Figure KI 137). T-cell depleting agents were more common with increasing cPRA and IL-2-RA use with decreasing cPRA (Figure KI 138).

Outcomes

All-cause graft failure after kidney-alone deceased donor transplant in pediatric recipients was 1.6% at 6 months and 2.2% at 1 year for transplants in 2016-2017, 8.3% at 3 years for transplants in 2014-2015, 17.4 at 5 years for transplants in 2012-2013, and 39.4% at 10 years for transplants in 2008-2009 (Figure KI 142). Corresponding graft failure after living donor transplant was 0.8% at 6 months and 0.8% at 1 year for transplants in 2016-2017, 5.3% at 3 years for transplants in 2014-2015, 8.8% at 5 years for transplants in 2012-2013, and 29.7% at 10 years for transplants in 2008-2009 (Figure KI 145). For the cohort of recipients who underwent transplant in 2009-2013, graft survival was highest for living donor recipients aged younger than 11 years (93.1% at 5 years) and lowest for deceased donor recipients aged 11-17 years (77.2% at 5 years) (Figure KI 148). In the 2016-2017 cohort, the overall incidence of acute rejection within the first year was 11.4%, with some variation by age: highest for ages younger than 6 years (12.5%) and lowest for ages 6-10 years (7.9%) (Figure KI 149). Short-term renal function, measured by eGFR, improved substantially over the past decade. Proportions of living donor and deceased donor recipients with eGFR 90 mL/min/1.73 m² or higher at 12 months posttransplant were 31.3% (increased from 19.7% in 2008) and 28.5 % (increased from 22.3%), respectively (Figure KI 140,141). Incidence of posttransplant lymphoproliferative disorder among EBV-negative recipients from 2006-2016 was 3.1% at 5 years posttransplant, compared with 0.8% among EBV-positive recipients (Figure KI 151). Overall 5-year patient survival among pediatric kidney transplant recipients in 2009-2013 was very high, at 98.4% (Figure KI 152).

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 time on dialysis
Figure KI 9. Distribution of adults waiting for kidney transplant by C/PRA
Figure KI 10. Distribution of adults waiting for kidney transplant by willingness to accept ECD or KDPI > 85% kidney
Figure KI 11. Distribution of adults waiting for kidney transplant by prior kidney transplant status
Figure KI 12. Adults willing to accept a kidney designated ECD or KDPI > 85% by age
Figure KI 13. Adults willing to accept kidney from HCV+ donor
Figure KI 14. Deceased donor kidney transplant rates among adult waitlist candidates by age
Figure KI 15. Deceased donor kidney transplant rates among adult waitlist candidates by race
Figure KI 16. Deceased donor kidney transplant rates among adult waitlist candidates by diagnosis
Figure KI 17. Deceased donor kidney transplant rates among adult waitlist candidates by C/PRA
Figure KI 18. Deceased donor kidney transplant rates among adult waitlist candidates by blood type
Figure KI 19. Deceased donor kidney transplant rates among adult waitlist candidates by time on the waitlist
Figure KI 20. Deceased donor kidney transplant rates among adult waitlist candidates by metropolitan vs. non-metropolitan residence
Figure KI 21. Deceased donor kidney transplant rates among adult waitlist candidates by distance from listing center
Figure KI 22. Three-year outcomes for adults waiting for kidney transplant, new listings in 2015
Figure KI 23. Percentage of adults who underwent deceased donor kidney transplant within a given time period of listing
Figure KI 24. Percentage of adults who underwent deceased donor kidney transplant within 5 years of listing in 2013 by DSA
Figure KI 25. Percentage of adults who underwent deceased donor kidney transplant within 5 years of listing in 2013 by state
Figure KI 26. Pretransplant mortality rates among adults waitlisted for kidney transplant by age
Figure KI 27. Pretransplant mortality rates among adults waitlisted for kidney transplant by race
Figure KI 28. Pretransplant mortality rates among adults waitlisted for kidney transplant by diagnosis
Figure KI 29. Pretransplant mortality rates among adults waitlisted for kidney by metropolitan vs. non-metropolitan residence
Figure KI 30. Pretransplant mortality rates among adults waitlisted for kidney, by distance from listing center
Figure KI 31. Pretransplant mortality rates among adults waitlisted for kidney, by active/inactive status
Figure KI 32. Pretransplant mortality rates among adults waitlisted for kidney transplant in 2018, by DSA
Figure KI 33. Deaths within six months after removal among adult kidney waitlist candidates, by diagnosis group at removal
Figure KI 34. Deaths within six months after removal among adult kidney waitlist candidates, by age at removal

Deceased donation

Figure KI 35. Deceased kidney donor count by age
Figure KI 36. Deceased kidney donor count by donor HCV antibody status
Figure KI 37. Distribution of deceased kidney donors by age
Figure KI 38. Distribution of deceased kidney donors by sex
Figure KI 39. Distribution of deceased kidney donors by race
Figure KI 40. Distribution of deceased kidney donors by donor HCV status
Figure KI 41. Percent of pediatric donor kidneys allocated to adult recipients, by DSA of donor hospital, 2014-2018
Figure KI 42. Rates of kidneys recovered for transplant and not transplanted by donor age
Figure KI 43. Rates of kidneys recovered for transplant and not transplanted by donor diabetes status
Figure KI 44. Rates of kidneys recovered for transplant and not transplanted by donor hypertension status
Figure KI 45. Rates of kidneys recovered for transplant and not transplanted by donor terminal creatinine
Figure KI 46. Rates of kidneys recovered for transplant and not transplanted by donor biopsy status
Figure KI 47. Rates of kidneys recovered for transplant and not transplanted by donor cause of death
Figure KI 48. Rates of kidneys recovered for transplant and not transplanted by donor HCV status
Figure KI 49. Rates of kidneys recovered for transplant and not transplanted, by donor risk of disease transmission
Figure KI 50. Rates of kidneys recovered for transplant and not transplanted by DCD status
Figure KI 51. Rates of kidneys recovered for transplant and not transplanted by KDPI
Figure KI 52. Donor-specific components of the kidney donor risk index
Figure KI 53. Average kidney donor risk index
Figure KI 54. Average kidney donor risk index by biopsy status
Figure KI 55. Cause of death among deceased kidney donors

Living donation

Figure KI 56. Kidney transplants from living donors by donor relation
Figure KI 57. Living kidney donors by age
Figure KI 58. Living kidney donors by sex
Figure KI 59. Living kidney donors by race
Figure KI 60. Intended living kidney donor procedure type
Figure KI 61. Rehospitalization among living kidney donors, 2013-2017
Figure KI 62. Kidney complications among living kidney donors, 2013-2017
Figure KI 63. BMI among living kidney donors

Transplant

Figure KI 64. Total kidney transplants
Figure KI 65. Total kidney transplants by age
Figure KI 66. Total kidney transplants by sex
Figure KI 67. Total kidney transplants by race
Figure KI 68. Total kidney transplants by diagnosis
Figure KI 69. Kidney transplants by kidney donor profile index (KDPI)
Figure KI 70. Induction agent use in adult kidney transplant recipients
Figure KI 71. Immunosuppression regimen use in adult kidney transplant recipients
Figure KI 72. C/PRA at time of kidney transplant in adult deceased donor recipients
Figure KI 73. C/PRA at time of kidney transplant in adult living donor recipients
Figure KI 74. Total HLA A, B, and DR mismatches among adult kidney transplant recipients, 2014-2018
Figure KI 75. Annual adult kidney transplant center volumes, by percentile
Figure KI 76. Distribution of adult kidney transplants by annual center volume

Outcomes

Figure KI 77. Graft failure among adult deceased donor kidney transplant recipients
Figure KI 78. Death-censored graft failure among adult deceased donor kidney transplant recipients
Figure KI 79. Death with function among adult deceased donor kidney transplant recipients
Figure KI 80. Graft failure among adult living donor kidney transplant recipients
Figure KI 81. Death-censored graft failure among adult living donor kidney transplant recipients
Figure KI 82. Death with function among adult living donor kidney transplant recipients
Figure KI 83. Graft survival among adult deceased donor kidney transplant recipients, 2013, by diagnosis
Figure KI 84. Graft survival among adult deceased donor kidney transplant recipients, 2013, by KDPI
Figure KI 85. Graft survival among adult deceased donor kidney transplant recipients, 2013, by DCD status
Figure KI 86. Graft survival among adult deceased donor kidney transplant recipients, 2013, by biopsy status
Figure KI 87. Graft survival among adult deceased donor kidney transplant recipients, 2013, by metropolitan vs. non-metropolitan recipient residence
Figure KI 88. Graft survival among adult deceased donor kidney transplant recipients, 2013, by recipients' distance from transplant center
Figure KI 89. Graft survival among adult living donor kidney transplant recipients, 2013, by age
Figure KI 90. Graft survival among adult living donor kidney transplant recipients, 2013, by race
Figure KI 91. Graft survival among adult living donor kidney transplant recipients, 2013, by diagnosis
Figure KI 92. Graft survival among adult living donor kidney transplant recipients, 2013, by metropolitan vs. non-metropolitan recipient residence
Figure KI 93. Graft survival among adult living donor kidney transplant recipients, 2013, by recipients' distance from transplant center
Figure KI 94. Distribution of eGFR at 12 months posttransplant among adult deceased donor kidney transplant recipients
Figure KI 95. Distribution of eGFR at 12 months posttransplant among adult living donor kidney transplant recipients
Figure KI 96. Recipients alive with a functioning kidney graft on June 30 of the year, by age at transplant
Figure KI 97. Incidence of acute rejection by 1 year posttransplant among adult kidney transplant recipients by age, 2016-2017
Figure KI 98. Incidence of acute rejection by 1 year posttransplant among adult kidney transplant recipients by induction agent 2016-2017
Figure KI 99. Posttransplant diabetes among adult kidney transplant recipients
Figure KI 100. Posttransplant diabetes within 1 year among adult kidney transplant recipients by BMI at transplant
Figure KI 101. Incidence of PTLD among adult kidney transplant recipients by recipient EBV status at transplant, 2012-2016
Figure KI 102. Incidence of PTLD among adult kidney transplant recipients by induction agent at transplant, 2012-2016
Figure KI 103. Patient survival among adult deceased donor kidney transplant recipients, 2013, by age
Figure KI 104. Patient survival among adult deceased donor kidney transplant recipients, 2013, by diagnosis
Figure KI 105. Patient survival among adult deceased donor kidney transplant recipients, 2013, by KDPI
Figure KI 106. Patient survival among adult deceased donor kidney transplant recipients, 2013, by biopsy status
Figure KI 107. Patient survival among adult deceased donor kidney transplant recipients, 2013, by metropolitan vs. non-metropolitan recipient residence
Figure KI 108. Patient survival among adult deceased donor kidney transplant recipients, 2013, by recipients' distance from transplant center
Figure KI 109. Patient survival among adult living donor kidney transplant recipients, 2013, by age
Figure KI 110. Patient survival among adult living donor kidney transplant recipients, 2013, by diagnosis
Figure KI 111. Patient survival among adult living donor kidney transplant recipients, 2013, by race
Figure KI 112. Patient survival among adult living donor kidney transplant recipients, 2013, by metropolitan vs. non-metropolitan recipient residence
Figure KI 113. Patient survival among adult living donor kidney transplant recipients, 2013, by recipients' distance from transplant center

Pediatric transplant

Figure KI 114. New pediatric candidates added to the kidney transplant waiting list
Figure KI 115. Pediatric candidates listed for kidney transplant on December 31 each year
Figure KI 116. Distribution of pediatric candidates waiting for kidney transplant by age
Figure KI 117. Distribution of pediatric candidates waiting for kidney transplant by race
Figure KI 118. Distribution of pediatric candidates waiting for kidney transplant by diagnosis
Figure KI 119. Distribution of pediatric candidates waiting for kidney transplant by sex
Figure KI 120. Distribution of pediatric candidates waiting for kidney transplant by waiting time
Figure KI 121. Distribution of pediatric candidates waiting for kidney transplant by C/PRA
Figure KI 122. Primary cause of ESRD in pediatric candidates waiting for kidney transplant by age, 2014-2018
Figure KI 123. Three-year outcomes for newly listed pediatric candidates waiting for kidney transplant, 2015
Figure KI 124. Deceased donor kidney transplant rates among pediatric waitlist candidates by age
Figure KI 125. Deceased donor kidney transplant rates among pediatric waitlist candidates by C/PRA
Figure KI 126. Deceased donor kidney transplant rates among pediatric waitlist candidates by metropolitan vs. non-metropolitan residence
Figure KI 127. Deceased donor kidney transplant rates among pediatric waitlist candidates by distance from listing center
Figure KI 128. Pretransplant mortality rates among pediatrics waitlisted for kidney transplant by age
Figure KI 129. Pretransplant mortality rates among pediatrics waitlisted for kidney transplant by metropolitan vs. non-metropolitan residence
Figure KI 130. Pretransplant mortality rates among pediatrics waitlisted for kidney transplant by distance from listing center
Figure KI 131. Pediatric kidney transplants by donor type
Figure KI 132. Pediatric kidney transplants from living donors by relation
Figure KI 133. Percent of pediatric kidney transplants from living donors by recipient age
Figure KI 134. Number of centers performing pediatric and adult kidney transplants by center's age mix
Figure KI 135. Pediatric kidney recipients at programs that perform 5 or fewer pediatric transplants annually
Figure KI 136. Induction agent use in pediatric kidney transplant recipients
Figure KI 137. Immunosuppression regimen use in pediatric kidney transplant recipients
Figure KI 138. Induction use by C/PRA among pediatric kidney transplant recipients, 2014-2018
Figure KI 139. Total HLA A, B, and DR mismatches among pediatric kidney transplant recipients, 2014-2018
Figure KI 140. Distribution of eGFR at 12 months posttransplant among pediatric deceased donor kidney-alone transplant recipients
Figure KI 141. Distribution of eGFR at 12 months posttransplant among pediatric living donor kidney-alone transplant recipients
Figure KI 142. Graft failure among pediatric deceased donor kidney-alone transplant recipients
Figure KI 143. Death-censored graft failure among pediatric deceased donor kidney-alone transplant recipients
Figure KI 144. Death with function among pediatric deceased donor kidney-alone transplant recipients
Figure KI 145. Graft failure among pediatric living donor kidney-alone transplant recipients
Figure KI 146. Death-censored graft failure among pediatric living donor kidney-alone transplant recipients
Figure KI 147. Death with function among pediatric living donor kidney-alone transplant recipients
Figure KI 148. Graft survival among pediatric kidney transplant recipients by age and donor type, 2009-2013
Figure KI 149. Incidence of acute rejection by 1 year posttransplant among pediatric kidney transplant recipients by age, 2016-2017
Figure KI 150. Incidence of acute rejection by 1 year posttransplant among pediatric kidney transplant recipients by induction agent 2016-2017
Figure KI 151. Incidence of PTLD among pediatric kidney transplant recipients by recipient EBV status at transplant, 2006-2016
Figure KI 152. Patient survival among pediatric kidney transplant recipients, 2009-2013, by recipient age and donor type

Table List

Waiting list

Table KI 1. Reasons for inactive status among new adult kidney transplant listings, 2018
Table KI 2. Demographic characteristics of adults on the kidney transplant waiting list on December 31, 2008, December 31, 2013 and December 31, 2018
Table KI 3. Clinical characteristics of adults on the kidney transplant waiting list on December 31, 2008, December 31, 2013 and December 31, 2018
Table KI 4. Listing characteristics of adults on the kidney transplant waiting list on December 31, 2008, December 31, 2013 and December 31, 2018
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 in the first year after donation, 2014-2018, by number of days after donation

Transplant

Table KI 8. Demographic characteristics of adult kidney transplant recipients, 2018
Table KI 9. Clinical characteristics of adult kidney transplant recipients, 2018
Table KI 10. Transplant characteristics of adult kidney transplant recipients, 2018
Table KI 11. Adult deceased donor kidney donor-recipient serology matching, 2016-2018
Table KI 12. Adult living donor kidney donor-recipient serology matching, 2016-2018

Pediatric transplant

Table KI 13. Reasons for inactive status among new pediatric kidney transplant listings, 2018
Table KI 14. Demographic characteristics of pediatric candidates on the kidney transplant waiting list on December 31, 2008, December 31, 2013, and December 31, 2018
Table KI 15. Clinical characteristics of pediatric candidates on the kidney transplant waiting list on December 31, 2008, December 31, 2013, and December 31, 2018
Table KI 16. Listing characteristics of pediatric candidates on the kidney transplant waiting list on December 31, 2008, December 31, 2013, and December 31, 2018
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, 2016-2018
Table KI 20. Clinicial characteristics of pediatric kidney transplant recipients, 2016-2018
Table KI 21. Transplant characteristics of pediatric kidney transplant recipients, 2016-2018
Table KI 22. Pediatric deceased donor kidney donor-recipient serology matching, 2016-2018
Table KI 23. Pediatric living donor kidney donor-recipient serology matching, 2016-2018

Table KI 1. Reasons for inactive status among new adult kidney transplant listings, 2018
Candidates first listed as inactive. Each listing is counted separately. LD, living donor.

Reasons for inactive status	N	Percent
Candidate work-up incomplete	6131	66.8%
Insurance issues	677	7.4%
Too well	660	7.2%
Too sick	624	6.8%
Weight inappropriate	284	3.1%
Candidate choice	263	2.9%
Candidate for LD transplant only	263	2.9%
Transplant pending	152	1.7%
Medical non-compliance	47	0.5%
Unknown	32	0.3%
Inappropriate substance abuse	28	0.3%
Candidate could not be contacted	10	0.1%
Physician/surgeon unavailable	1	0.0%

Table KI 2. Demographic characteristics of adults on the kidney transplant waiting list on December 31, 2008, December 31, 2013 and December 31, 2018
Candidates waiting for transplant on December 31 of the given year, regardless of first listing date; multiple listings are collapsed. Distance is computed from candidate's home zip code to the transplant center.

Characteristic	2008, N	2008, Percent	2013, N	2013, Percent	2018, N	2018, Percent
Age: 18-34 years	8045	10.6%	9068	9.3%	7584	8.2%
Age: 35-49 years	22,473	29.5%	25,530	26.3%	22,222	24.1%
Age: 50-64 years	32,770	43.0%	42,242	43.5%	40,412	43.8%
Age: ≥ 65 years	12,873	16.9%	20,225	20.8%	21,976	23.8%
Sex: Female	31,779	41.7%	39,246	40.4%	35,578	38.6%
Sex: Male	44,382	58.3%	57,819	59.6%	56,616	61.4%
Race/ethnicity: White	29,561	38.8%	35,898	37.0%	33,130	35.9%
Race/ethnicity: Black	26,541	34.8%	33,208	34.2%	29,724	32.2%
Race/ethnicity: Hispanic	13,374	17.6%	18,638	19.2%	18,970	20.6%
Race/ethnicity: Asian	5592	7.3%	7769	8.0%	8745	9.5%
Race/ethnicity: Other/unknown	1093	1.4%	1552	1.6%	1625	1.8%
Geography: Metropolitan	65,092	85.5%	83,757	86.3%	80,569	87.4%
Geography: Non-metro	11,069	14.5%	13,308	13.7%	11,625	12.6%
Distance: < 50 miles	52,864	69.4%	67,261	69.3%	64,026	69.4%
Distance: 50-<100 miles	10,792	14.2%	13,457	13.9%	13,441	14.6%
Distance: 100-<150 miles	4969	6.5%	6491	6.7%	5947	6.5%
Distance: 150-<250 miles	4667	6.1%	6012	6.2%	5290	5.7%
Distance: ≥ 250 miles	2135	2.8%	3319	3.4%	3162	3.4%
Distance: Unknown	734	1.0%	525	0.5%	328	0.4%
All candidates	76,161	100.0%	97,065	100.0%	92,194	100.0%

Table KI 3. Clinical characteristics of adults on the kidney transplant waiting list on December 31, 2008, December 31, 2013 and December 31, 2018
Candidates waiting for transplant on December 31 of the given year, regardless of first listing date; multiple listings are collapsed. CKD, cystic kidney disease; GN, glomerulonephritis. *Diabetes status based on diagnosis and comorbid conditions.

Characteristic	2008, N	2008, Percent	2013, N	2013, Percent	2018, N	2018, Percent
Diagnosis: Diabetes	24,231	31.8%	34,289	35.3%	35,177	38.2%
Diagnosis: Hypertension	19,119	25.1%	23,961	24.7%	19,916	21.6%
Diagnosis: GN	11,163	14.7%	13,614	14.0%	12,999	14.1%
Diagnosis: CKD	6357	8.3%	7896	8.1%	7837	8.5%
Diagnosis: Other	15,291	20.1%	17,305	17.8%	16,265	17.6%
Diabetes*	31,150	40.9%	43,569	44.9%	43,096	46.7%
Blood type: A	21,797	28.6%	27,993	28.8%	25,714	27.9%
Blood type: B	12,218	16.0%	15,621	16.1%	15,218	16.5%
Blood type: AB	2200	2.9%	2711	2.8%	2436	2.6%
Blood type: O	39,946	52.4%	50,740	52.3%	48,826	53.0%
CPRA: < 1%	34,017	44.7%	57,308	59.0%	55,949	60.7%
CPRA: 1-< 20%	13,545	17.8%	8556	8.8%	9085	9.9%
CPRA: 20-< 80%	13,709	18.0%	14,815	15.3%	15,438	16.7%
CPRA: 80-< 98%	6270	8.2%	6114	6.3%	5228	5.7%
CPRA: 98-100%	6177	8.1%	9239	9.5%	6359	6.9%
CPRA: Unknown	2443	3.2%	1033	1.1%	135	0.1%
All candidates	76,161	100.0%	97,065	100.0%	92,194	100.0%

Table KI 4. Listing characteristics of adults on the kidney transplant waiting list on December 31, 2008, December 31, 2013 and December 31, 2018
Candidates waiting for transplant on December 31 of the given year, regardless of first listing date; and multiple listings are collapsed. KDPI, kidney donor profile index. *Prior to 2014, includes willingness to accept expanded criteria donor (ECD) kidney. KDPI >85% is local non-zero HLA mismatch only.

Characteristic	2008, N	2008, Percent	2013, N	2013, Percent	2018, N	2018, Percent
Transplant history: First	63,832	83.8%	83,173	85.7%	81,276	88.2%
Transplant history: Retransplant	12,329	16.2%	13,892	14.3%	10,918	11.8%
Wait time: < 1 year	24,109	31.7%	27,659	28.5%	27,158	29.5%
Wait time: 1-< 2 years	18,127	23.8%	20,776	21.4%	18,123	19.7%
Wait time: 2-< 3 years	12,130	15.9%	15,461	15.9%	13,952	15.1%
Wait time: 3-< 4 years	7862	10.3%	11,503	11.9%	10,193	11.1%
Wait time: 4-< 5 years	5023	6.6%	7756	8.0%	7723	8.4%
Wait time: ≥ 5 years	8910	11.7%	13,910	14.3%	15,045	16.3%
Will accept KDPI*>85%	33,965	44.6%	47,322	48.8%	43,565	47.3%
Tx type: Kidney alone	73,483	96.5%	94,108	97.0%	89,474	97.0%
Tx type: Kidney-pancreas	2203	2.9%	1992	2.1%	1588	1.7%
Tx type: Kidney-liver	385	0.5%	812	0.8%	907	1.0%
Tx type: Kidney-heart	84	0.1%	142	0.1%	205	0.2%
Tx type: Other	6	0.0%	11	0.0%	20	0.0%
All candidates	76,161	100.0%	97,065	100.0%	92,194	100.0%

Table KI 5. Kidney 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	2016	2017	2018
Patients at start of year	98,125	95,822	92,906
Patients added during year	30,850	30,899	33,879
Patients removed during year	33,105	33,755	34,591
Patients at end of year	95,871	92,966	92,194

Table KI 6. Removal reason among adult kidney 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	2016	2017	2018
Deceased donor transplant	13,501	14,074	14,784
Living donor transplant	5334	5535	6120
Transplant outside US	77	67	57
Patient died	4863	4425	4193
Patient refused transplant	467	514	445
Improved, transplant not needed	193	210	191
Too sick for transplant	4325	4459	4240
Other	4345	4471	4561

Table KI 7. Living kidney donor deaths in the first year after donation, 2014-2018, by number of days after donation
Living kidney donors. Numbers of deaths reported to OPTN or the Social Security Administration. Donation-related deaths are included in the Medical category.

Cause	0-30 days	31-90 days	91-365 days
Suicide	1	1	2
Accident/homicide	0	0	6
Overdose	0	1	0
Medical	3	0	1
Cancer	0	0	0
TOTAL	4	2	9

Table KI 8. Demographic characteristics of adult kidney transplant recipients, 2018
Kidney transplant recipients, including retransplants. Distance is computed from recipient's home zip code to the transplant center.

Characteristic	Deceased, N	Deceased, Percent	Living, N	Living, Percent	All, N	All, Percent
Age: 18-34 years	1657	11.0%	1030	16.7%	2687	12.6%
Age: 35-49 years	3981	26.4%	1708	27.7%	5689	26.8%
Age: 50-64 years	6130	40.7%	2314	37.5%	8444	39.7%
Age: ≥ 65 years	3311	22.0%	1116	18.1%	4427	20.8%
Sex: Female	6128	40.6%	2307	37.4%	8435	39.7%
Sex: Male	8951	59.4%	3861	62.6%	12,812	60.3%
Race/ethnicity: White	5754	38.2%	3993	64.7%	9747	45.9%
Race/ethnicity: Black	4932	32.7%	774	12.5%	5706	26.9%
Race/ethnicity: Hispanic	2896	19.2%	941	15.3%	3837	18.1%
Race/ethnicity: Asian	1185	7.9%	393	6.4%	1578	7.4%
Race/ethnicity: Other/unknown	312	2.1%	67	1.1%	379	1.8%
Insurance: Private	3406	22.6%	3273	53.1%	6679	31.4%
Insurance: Medicare	10,162	67.4%	2447	39.7%	12,609	59.3%
Insurance: Medicaid	1052	7.0%	273	4.4%	1325	6.2%
Insurance: Other government	328	2.2%	89	1.4%	417	2.0%
Insurance: Unknown	131	0.9%	86	1.4%	217	1.0%
Geography: Metropolitan	12,887	85.5%	5218	84.6%	18,105	85.2%
Geography: Non-metro	2192	14.5%	950	15.4%	3142	14.8%
Distance: < 50 miles	9979	66.2%	4075	66.1%	14,054	66.1%
Distance: 50-<100 miles	2439	16.2%	940	15.2%	3379	15.9%
Distance: 100-<150 miles	1002	6.6%	407	6.6%	1409	6.6%
Distance: 150-<250 miles	888	5.9%	328	5.3%	1216	5.7%
Distance: ≥ 250 miles	614	4.1%	321	5.2%	935	4.4%
Distance: Unknown	157	1.0%	97	1.6%	254	1.2%
All recipients	15,079	100.0%	6168	100.0%	21,247	100.0%

Table KI 9. Clinical characteristics of adult kidney transplant recipients, 2018
Kidney transplant recipients, including retransplants. CKD, cystic kidney disease; GN, glomerulonephritis.

Characteristic	Deceased, N	Deceased, Percent	Living, N	Living, Percent	All, N	All, Percent
Diagnosis: Diabetes	4948	32.8%	1422	23.1%	6370	30.0%
Diagnosis: Hypertension	3498	23.2%	986	16.0%	4484	21.1%
Diagnosis: GN	2339	15.5%	1483	24.0%	3822	18.0%
Diagnosis: CKD	1486	9.9%	1028	16.7%	2514	11.8%
Diagnosis: Other	2808	18.6%	1249	20.2%	4057	19.1%
Blood type: A	5224	34.6%	2359	38.2%	7583	35.7%
Blood type: B	2213	14.7%	853	13.8%	3066	14.4%
Blood type: AB	781	5.2%	251	4.1%	1032	4.9%
Blood type: O	6861	45.5%	2705	43.9%	9566	45.0%
Dialysis time: None	1765	11.7%	1955	31.7%	3720	17.5%
Dialysis time: < 1 year	1137	7.5%	1335	21.6%	2472	11.6%
Dialysis time: 1-< 3 years	2904	19.3%	1525	24.7%	4429	20.8%
Dialysis time: 3-< 5 years	3026	20.1%	531	8.6%	3557	16.7%
Dialysis time: ≥ 5 years	6247	41.4%	822	13.3%	7069	33.3%
CPRA: < 1%	8787	58.3%	4389	71.2%	13,176	62.0%
CPRA: 1-< 20%	1368	9.1%	625	10.1%	1993	9.4%
CPRA: 20-< 80%	2414	16.0%	886	14.4%	3300	15.5%
CPRA: 80-< 98%	1200	8.0%	197	3.2%	1397	6.6%
CPRA: 98-100%	1309	8.7%	67	1.1%	1376	6.5%
CPRA: Unknown	1	0.0%	4	0.1%	5	0.0%
All recipients	15,079	100.0%	6168	100.0%	21,247	100.0%

Table KI 10. Transplant characteristics of adult kidney transplant recipients, 2018
Kidney transplant recipients, including retransplants. DBD, donation after brain death; DCD, donation after circulatory death; KDPI, kidney donor profile index. DCD status and KDPI scores apply to deceased donor transplants only.

Characteristic	Deceased, N	Deceased, Percent	Living, N	Living, Percent	All, N	All, Percent
Wait time: None (preemptive)	113	0.7%	110	1.8%	223	1.0%
Wait time: < 1 year	6366	42.2%	3840	62.3%	10,206	48.0%
Wait time: 1-< 3 years	3728	24.7%	1642	26.6%	5370	25.3%
Wait time: 3-< 5 years	2580	17.1%	432	7.0%	3012	14.2%
Wait time: ≥ 5 years	2292	15.2%	144	2.3%	2436	11.5%
KDPI: ≤ 20%	3410	22.6%
KDPI: 21-34%	2448	16.2%
KDPI: 35-85%	8045	53.4%
KDPI: > 85%	1176	7.8%
DCD status: DBD	11,808	78.3%
DCD status: DCD	3271	21.7%
DGF: None	10,927	72.5%	6005	97.4%	16,932	79.7%
DGF: Yes	4152	27.5%	163	2.6%	4315	20.3%
Transplant history: First	13,461	89.3%	5567	90.3%	19,028	89.6%
Transplant history: Retransplant	1618	10.7%	601	9.7%	2219	10.4%
Tx type: Kidney only	13,366	88.6%	6166	100.0%	19,532	91.9%
Tx type: Kidney-pancreas	828	5.5%	0	0.0%	828	3.9%
Tx type: Kidney-liver	659	4.4%	2	0.0%	661	3.1%
Tx type: Kidney-heart	202	1.3%	0	0.0%	202	1.0%
Tx type: Kidney-lung	10	0.1%	0	0.0%	10	0.0%
Tx type: Other	14	0.1%	0	0.0%	14	0.1%
All recipients	15,079	100.0%	6168	100.0%	21,247	100.0%

Table KI 11. Adult deceased donor kidney donor-recipient serology matching, 2016-2018
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. Donor HCV NAT data are shown by recipient HCV antibody status. CMV, cytomegalovirus; EBV, Epstein-Barr virus; HBsAg, hepatitis B surace antigen; HCV, hepatitis C virus; HIV, human immunodeficiency virus; NAT, nucleic acid test.

Donor	Recipient	CMV	EBV	HBsAg	HCV antibody	HCV NAT
D-	R-	13.6%	0.7%	97.4%	90.3%	91.5%
D-	R+	25.8%	7.5%	1.5%	3.6%	4.2%
D-	R unk	0.3%	0.7%	0.9%	1.2%	1.2%
D+	R-	17.9%	7.0%	0.1%	2.2%	1.0%
D+	R+	41.2%	81.0%	0.0%	2.7%	2.1%
D+	R unk	0.5%	3.1%	0.0%	0.1%	0.1%
D unk	R-	0.1%	0.0%	0.1%	0.0%	0.0%
D unk	R+	0.4%	0.1%	0.0%	0.0%	0.0%
D unk	R unk	0.0%	0.0%	0.0%	0.0%	0.0%

Table KI 12. Adult living donor kidney donor-recipient serology matching, 2016-2018
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. Donor HCV NAT data are shown by recipient HCV antibody status. CMV, cytomegalovirus; EBV, Epstein-Barr virus; HBsAg, hepatitis B surface antigen; HCV, hepatitis C virus; HIV, human immunodeficiency virus; NAT, nucleic acid test.

Donor	Recipient	CMV	EBV	HBsAg	HCV antibody	HCV NAT
D-	R-	25.4%	1.3%	96.3%	94.3%	86.0%
D-	R+	21.2%	7.1%	0.9%	1.8%	1.7%
D-	R unk	0.3%	0.2%	0.9%	1.1%	0.9%
D+	R-	17.7%	7.9%	0.4%	0.5%	0.1%
D+	R+	32.8%	80.1%	0.0%	0.0%	0.0%
D+	R unk	0.4%	1.8%	0.0%	0.0%	0.0%
D unk	R-	1.0%	0.2%	1.4%	2.2%	10.9%
D unk	R+	1.3%	1.2%	0.0%	0.0%	0.2%
D unk	R unk	0.0%	0.2%	0.0%	0.1%	0.2%

Table KI 13. Reasons for inactive status among new pediatric kidney transplant listings, 2018
Candidates first listed as inactive. Each listing is counted separately. LD, living donor.

Reasons for inactive status	N	Percent
Candidate work-up incomplete	343	51.4%
Candidate for LD transplant only	104	15.6%
Too well	95	14.2%
Candidate choice	46	6.9%
Too sick	29	4.3%
Weight inappropriate	17	2.5%
Medical non-compliance	14	2.1%
Insurance issues	12	1.8%
Transplant pending	7	1.0%

Table KI 14. Demographic characteristics of pediatric candidates on the kidney transplant waiting list on December 31, 2008, December 31, 2013, and December 31, 2018
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. Distance is computed from candidate's home zip code to the transplant center.

Characteristic	2008, N	2008, Percent	2013, N	2013, Percent	2018, N	2018, Percent
Age: < 1 year	6	0.7%	4	0.5%	3	0.3%
Age: 1-5 years	146	17.6%	177	20.0%	212	19.9%
Age: 6-10 years	152	18.3%	183	20.7%	246	23.1%
Age: 11-17 years	527	63.4%	520	58.8%	602	56.6%
Sex: Female	337	40.6%	344	38.9%	411	38.7%
Sex: Male	494	59.4%	540	61.1%	652	61.3%
Race/ethnicity: White	353	42.5%	378	42.8%	433	40.7%
Race/ethnicity: Black	185	22.3%	207	23.4%	220	20.7%
Race/ethnicity: Hispanic	250	30.1%	242	27.4%	309	29.1%
Race/ethnicity: Asian	32	3.9%	39	4.4%	73	6.9%
Race/ethnicity: Other/unknown	11	1.3%	18	2.0%	28	2.6%
Geography: Metropolitan	727	87.5%	756	85.5%	927	87.2%
Geography: Non-metro	104	12.5%	128	14.5%	136	12.8%
Distance: < 50 miles	552	66.4%	582	65.8%	700	65.9%
Distance: 50-<100 miles	138	16.6%	133	15.0%	144	13.5%
Distance: 100-<150 miles	65	7.8%	75	8.5%	76	7.1%
Distance: 150-<250 miles	47	5.7%	50	5.7%	83	7.8%
Distance: ≥ 250 miles	25	3.0%	35	4.0%	55	5.2%
Distance: Unknown	4	0.5%	9	1.0%	5	0.5%
All candidates	831	100.0%	884	100.0%	1063	100.0%

Table KI 15. Clinical characteristics of pediatric candidates on the kidney transplant waiting list on December 31, 2008, December 31, 2013, and December 31, 2018
Candidates aged younger than 18 years waiting for transplant on December 31, 2008, December 31, 2013, and December 31, 2018, regardless of first listing date; multiple listings are collapsed. Candidates listed as children who turned 18 before the cohort date are excluded. FSGS, focal segmental glomerulosclerosis; GN, glomerulonephritis; CAKUT, congenital anomalies of the kidney and urinary tract.

Characteristic	2008, N	2008, Percent	2013, N	2013, Percent	2018, N	2018, Percent
Diagnosis: FSGS	110	13.2%	91	10.3%	82	7.7%
Diagnosis: GN	86	10.3%	73	8.3%	69	6.5%
Diagnosis: CAKUT	215	25.9%	313	35.4%	390	36.7%
Diagnosis: Other	420	50.5%	407	46.0%	522	49.1%
Blood type: A	248	29.8%	280	31.7%	319	30.0%
Blood type: B	132	15.9%	140	15.8%	182	17.1%
Blood type: AB	26	3.1%	28	3.2%	29	2.7%
Blood type: O	425	51.1%	436	49.3%	533	50.1%
CPRA: < 1%	429	51.6%	560	63.3%	742	69.8%
CPRA: 1-< 20%	98	11.8%	55	6.2%	81	7.6%
CPRA: 20-< 80%	97	11.7%	119	13.5%	130	12.2%
CPRA: 80-< 98%	81	9.7%	51	5.8%	53	5.0%
CPRA: 98-100%	67	8.1%	94	10.6%	57	5.4%
CPRA: Unknown	59	7.1%	5	0.6%	0	0.0%
All candidates	831	100.0%	884	100.0%	1063	100.0%

Table KI 16. Listing characteristics of pediatric candidates on the kidney transplant waiting list on December 31, 2008, December 31, 2013, and December 31, 2018
Candidates aged younger than 18 years waiting for transplant on December 31, 2008, December 31, 2013, and December 31, 2018, regardless of first listing date; multiple listings are collapsed. Candidates listed as children who turned 18 before the cohort date are excluded.

Characteristic	2008, N	2008, Percent	2013, N	2013, Percent	2018, N	2018, Percent
Transplant history: First	608	73.2%	686	77.6%	910	85.6%
Transplant history: Retransplant	223	26.8%	198	22.4%	153	14.4%
Wait time: < 1 year	474	57.0%	494	55.9%	560	52.7%
Wait time: 1-< 2 years	188	22.6%	189	21.4%	239	22.5%
Wait time: 2-< 3 years	77	9.3%	84	9.5%	112	10.5%
Wait time: 3-< 4 years	53	6.4%	47	5.3%	62	5.8%
Wait time: 4-< 5 years	21	2.5%	21	2.4%	35	3.3%
Wait time: ≥ 5 years	18	2.2%	49	5.5%	55	5.2%
Tx type: Kidney alone	814	98.0%	864	97.7%	1045	98.3%
Tx type: Kidney-liver	14	1.7%	14	1.6%	11	1.0%
Tx type: Kidney-heart	1	0.1%	2	0.2%	5	0.5%
Tx type: Other	2	0.2%	4	0.5%	2	0.2%
All candidates	831	100.0%	884	100.0%	1063	100.0%

Table KI 17. Kidney 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	2016	2017	2018
Patients at start of year	1518	1500	1576
Patients added during year	953	1048	1005
Patients removed during year	970	968	996
Patients at end of year	1501	1580	1585

Table KI 18. Removal reason among pediatric kidney 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	2016	2017	2018
Deceased donor transplant	598	617	596
Living donor transplant	273	254	301
Transplant outside US	0	0	1
Patient died	28	17	25
Patient refused transplant	1	3	0
Improved, transplant not needed	7	6	10
Too sick for transplant	23	15	9
Other	40	56	54

Table KI 19. Demographic characteristics of pediatric kidney transplant recipients, 2016-2018
Pediatric kidney transplant recipients, including retransplants. Distance is computed from recipient's home zip code to the transplant center.

Characteristic	Deceased, N	Deceased, Percent	Living, N	Living, Percent	All, N	All, Percent
Age: 1-5 years	283	19.2%	227	29.9%	510	22.8%
Age: 6-10 years	286	19.4%	141	18.6%	427	19.1%
Age: 11-17 years	907	61.4%	391	51.5%	1298	58.1%
Sex: Female	630	42.7%	295	38.9%	925	41.4%
Sex: Male	846	57.3%	464	61.1%	1310	58.6%
Race/ethnicity: White	552	37.4%	527	69.4%	1079	48.3%
Race/ethnicity: Black	324	22.0%	65	8.6%	389	17.4%
Race/ethnicity: Hispanic	475	32.2%	132	17.4%	607	27.2%
Race/ethnicity: Asian	79	5.4%	23	3.0%	102	4.6%
Race/ethnicity: Other/unknown	46	3.1%	12	1.6%	58	2.6%
Insurance: Private	391	26.5%	420	55.3%	811	36.3%
Insurance: Medicare	390	26.4%	127	16.7%	517	23.1%
Insurance: Medicaid	581	39.4%	173	22.8%	754	33.7%
Insurance: Other government	93	6.3%	31	4.1%	124	5.5%
Insurance: Unknown	21	1.4%	8	1.1%	29	1.3%
Geography: Metropolitan	1236	83.7%	634	83.5%	1870	83.7%
Geography: Non-metro	240	16.3%	125	16.5%	365	16.3%
Distance: < 50 miles	903	61.2%	448	59.0%	1351	60.4%
Distance: 50-<100 miles	246	16.7%	133	17.5%	379	17.0%
Distance: 100-<150 miles	152	10.3%	66	8.7%	218	9.8%
Distance: 150-<250 miles	98	6.6%	59	7.8%	157	7.0%
Distance: ≥ 250 miles	62	4.2%	46	6.1%	108	4.8%
Distance: Unknown	15	1.0%	7	0.9%	22	1.0%
All recipients	1476	100.0%	759	100.0%	2235	100.0%

Table KI 20. Clinicial characteristics of pediatric kidney transplant recipients, 2016-2018
Kidney transplant recipients, including retransplants. Diagnosis categories follow North American Pediatric Renal Trials and Collaborative Studies recommendations. FSGS, focal segmental glomerulosclerosis; GN, glomerulonephritis; CAKUT, congenital anomalies of the kidney and urinary tract.

Characteristic	Deceased, N	Deceased, Percent	Living, N	Living, Percent	All, N	All, Percent
Diagnosis: FSGS	196	13.3%	75	9.9%	271	12.1%
Diagnosis: GN	129	8.7%	63	8.3%	192	8.6%
Diagnosis: CAKUT	496	33.6%	275	36.2%	771	34.5%
Diagnosis: Other	655	44.4%	346	45.6%	1001	44.8%
Blood type: A	447	30.3%	290	38.2%	737	33.0%
Blood type: B	176	11.9%	100	13.2%	276	12.3%
Blood type: AB	54	3.7%	23	3.0%	77	3.4%
Blood type: O	799	54.1%	346	45.6%	1145	51.2%
Dialysis time: None	342	23.2%	310	40.8%	652	29.2%
Dialysis time: < 1 year	310	21.0%	200	26.4%	510	22.8%
Dialysis time: 1-< 3 years	504	34.1%	170	22.4%	674	30.2%
Dialysis time: 3-< 5 years	154	10.4%	21	2.8%	175	7.8%
Dialysis time: ≥ 5 years	166	11.2%	58	7.6%	224	10.0%
CPRA: < 1%	1076	72.9%	555	73.1%	1631	73.0%
CPRA: 1-< 20%	142	9.6%	84	11.1%	226	10.1%
CPRA: 20-< 80%	196	13.3%	95	12.5%	291	13.0%
CPRA: 80-< 98%	30	2.0%	14	1.8%	44	2.0%
CPRA: 98-100%	32	2.2%	8	1.1%	40	1.8%
CPRA: Unknown	0	0.0%	3	0.4%	3	0.1%
All recipients	1476	100.0%	759	100.0%	2235	100.0%

Table KI 21. Transplant characteristics of pediatric kidney transplant recipients, 2016-2018
Kidney transplant recipients, including retransplants. DBD, donation after brain death; DCD, donation after circulatory death; DGF, delayed graft function; KDPI, kidney donor profile index. DCD status and KDPI scores apply to deceased donor transplants only.

Characteristic	Deceased, N	Deceased, Percent	Living, N	Living, Percent	All, N	All, Percent
Wait time: None (preemptive)	9	0.6%	41	5.4%	50	2.2%
Wait time: < 1 year	1021	69.2%	580	76.4%	1601	71.6%
Wait time: 1-< 3 years	347	23.5%	116	15.3%	463	20.7%
Wait time: 3-< 5 years	81	5.5%	17	2.2%	98	4.4%
Wait time: ≥ 5 years	18	1.2%	5	0.7%	23	1.0%
KDPI: ≤ 20%	1086	73.6%
KDPI: 21-34%	319	21.6%
KDPI: 35-85%	71	4.8%
DCD status: DBD	1417	96.0%
DCD status: DCD	59	4.0%
DGF: None	1354	91.7%	735	96.8%	2089	93.5%
DGF: Yes	122	8.3%	24	3.2%	146	6.5%
Transplant history: First	1352	91.6%	706	93.0%	2058	92.1%
Transplant history: Retransplant	124	8.4%	53	7.0%	177	7.9%
Tx type: Kidney only	1413	95.7%	759	100.0%	2172	97.2%
Tx type: Kidney-pancreas	1	0.1%	0	0.0%	1	0.0%
Tx type: Kidney-liver	50	3.4%	0	0.0%	50	2.2%
Tx type: Kidney-heart	7	0.5%	0	0.0%	7	0.3%
Tx type: Other	5	0.3%	0	0.0%	5	0.2%
All recipients	1476	100.0%	759	100.0%	2235	100.0%

Table KI 22. Pediatric deceased donor kidney donor-recipient serology matching, 2016-2018
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. CMV, cytomegalovirus; EBV, Epstein-Barr virus.

Donor	Recipient	CMV	EBV
D-	R-	23.4%	6.0%
D-	R+	15.2%	7.5%
D-	R unk	0.3%	0.1%
D+	R-	39.0%	37.4%
D+	R+	20.3%	47.5%
D+	R unk	0.4%	1.4%
D unk	R-	0.5%	0.0%
D unk	R+	0.7%	0.0%
D unk	R unk	0.0%	0.0%

Table KI 23. Pediatric living donor kidney donor-recipient serology matching, 2016-2018
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. CMV, cytomegalovirus; EBV, Epstein-Barr virus.

Donor	Recipient	CMV	EBV
D-	R-	39.5%	5.7%
D-	R+	8.3%	3.3%
D-	R unk	0.0%	0.1%
D+	R-	28.9%	51.5%
D+	R+	19.4%	34.9%
D+	R unk	0.3%	1.2%
D unk	R-	2.6%	2.4%
D unk	R+	1.1%	0.8%
D unk	R unk	0.0%	0.1%