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Liver

OPTN/SRTR 2018 Annual Data Report: Liver

Abstract

Data on adult liver transplants performed in the US in 2018 are notable for (1) continued growth in numbers of new waitlist registrants (11,844) and transplants performed (8250); (2) continued increase in the transplant rate (54.5 per 100 waitlist-years); (3) a precipitous decline in waitlist registrations and transplants for hepatitis-C-related indications; (4) increases in waitlist registrants and recipients with alcoholic liver disease and with clinical profiles consistent with non-alcoholic fatty liver disease; (5) increased use of hepatitis C virus antibody-positive donor livers; and (6) continued improvement in graft survival despite changing recipient characteristics such as older age and higher rates of obesity and diabetes. Variability in transplant rates remained by candidate race, hepatocellular carcinoma status, urgency status, and geography. The volume of pediatric liver transplants was relatively unchanged. The highest rate of pretransplant mortality persisted for children aged younger than 1 year. Children underwent transplant at higher acuity than in the past, as evidenced by higher model for end-stage liver disease/pediatric end-stage liver disease scores and listings at status 1A and 1B at transplant. 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 2018 to 11,844, compared with 11,513 in 2017 and 11,340 in 2016 (Figure LI 1). In contrast, the number of candidates waiting at the end of the year continued a downward trend from its peak of 15,366 in 2011 to 12,820 in 2018 (Figure LI 2). Regarding actively listed candidates, 222 more were added to the list in 2018 than in 2017 (11,389 versus 11,167); 411 fewer were waiting at the end of 2018 than at the end of 2017 (10,236 versus 10,647). This is in part explained by more transplants performed (8250 in 2018 versus 8082 in 2017, a net increase of 168, Figure LI 52).

The proportion of older (aged ≥65 years) candidates continued to increase, comprising 24.1% of the adult waitlist population in 2018, almost twice the proportion 10 years earlier (Figure LI 3). A reciprocal 10% decrease occurred in the proportion of candidates aged 50-64 years over the past 5 years, although this age group continued to make up over half of the adult waitlist population.

The proportion of candidates listed with a primary diagnosis of hepatitis C virus (HCV) continued to decline sharply, while the proportions with alcoholic liver disease and other/unknown diagnosis increased; the latter category included many candidates with non-alcoholic fatty liver disease (Figure LI 6). As HCV continued to be represented on the liver transplant waiting list among patients with hepatocellular carcinoma (HCC) as the primary diagnosis, the trend for HCV shown in Figure LI 6 should be interpreted in this context. In 2018, HCC was the primary diagnosis for 10.5% of waitlist candidates.

Regarding medical urgency, peak model for end-stage liver disease (MELD) scores were ≥35 for 10.1% of liver transplant candidates, 30-34 for 11.9%, and 15-29 for 44.1%; 1.7% were listed as status 1A (Figure LI 7). The proportion of candidates with body mass index (BMI) ≥40 kg/m2 continued to increase, but not dramatically (Figure LI 8); BMI was >35 kg/m2 for approximately one in six candidates (17%), conventionally categorized as morbid obesity, acknowledging that not all excess weight in these patients is adiposity.

Despite fewer waitlist registrants with HCV infection, the proportion of adults willing to accept HCV+ donors increased from 19.8% in 2016 to 34.6% in 2018, likely reflecting the willingness of HCV-uninfected patients to accept HCV-positive donors in the direct acting antiviral (DAA) era (Figure LI 9).

Waiting List Outcomes

The overall deceased donor transplant rate among active adult waitlist candidates was 54.5 per 100 waitlist-years, continuing a rising trend since 2012 (Figure LI 10). The increase occurred regardless of age, sex, or geography (including metropolitan versus non-metropolitan areas and distance from candidate residence to transplant program) (Figure LI 10, Figure LI 12, Figure LI 13, Figure LI 14). The differences in transplant rates by race narrowed, although a 10% gap remained between Hispanic and Asian candidates (48.1 and 44.0 per 100 waitlist-years, respectively) and white and black candidates (56.0 and 62.5 per 100 waitlist-years, respectively) (Figure LI 11). Differences in underlying liver disease and listing MELD scores may explain this observation, but further analysis is warranted.

The gap in transplant rates between HCC and non-HCC candidates persisted, although it has been steadily narrowing since 2006 (Figure LI 12). The transplant rate was 66%-71% higher for HCC than for non-HCC candidates (82.5 versus 48.3 per 100 waitlist-years for women; 92.4 versus 55.8 per 100 waitlist-years for men).

Figure LI 15 shows 3-year outcomes for adults listed for liver transplant in 2015: 58.7% underwent transplant (including 2.3% from a living donor), 11.8% died, and 19.4% were removed from the list without undergoing transplant, leaving 10.1% still waiting. These statistics were similar to those reported in the 2017 ADR, albeit with an incremental increase in transplant probability and reduction in waitlist mortality compared with previous years.

The overall median waiting time (time from listing to transplant) was 10.8 months, but this varied widely by medical urgency category (Figure LI 16). The time from listing to liver transplant was shortest for patients listed as status 1A (median 0.20 months, 6.0 days) followed closely by those with MELD ≥35 (median 0.23 months, 7.0 days); the median waiting time was 8.54 months for candidates with MELD 15-35 (Figure LI 16). Deceased donor transplant rates within a given time period after listing were virtually unchanged compared with 2017 (Figure LI 17). Geographic differences in deceased donor transplant rates persisted, ranging from 32% to 86% at 3 years by donation service area (DSA) (Figure LI 18), and 29% to 80% by state (Figure LI 19).

Pretransplant mortality rates for adults in 2018 were similar to rates in 2017 for all subgroups, including age, race/ethnicity, diagnosis, urgency category, and geography, with an overall pretransplant mortality rate of 13.2 per 100 waitlist-years (Figure LI 20, Figure LI 21, Figure LI 22, Figure LI 23, Figure LI 24, Figure LI 25, Figure LI 26). As expected, waitlist mortality rates were higher among older candidates (age ≥65 years), candidates listed with acute liver failure versus other etiologies, and candidates at greater medical urgency including status 1A and MELD ≥35. In 2018, the mortality rate for candidates with MELD ≥35 was 221.7 per 100 waitlist-years, compared with 162.7 for status 1A candidates (Figure LI 23). Mortality among candidates listed at status 1A or MELD ≥35 continued to decrease since implementation of the regional share 35 policy in 2013. Six-month mortality after waitlist removal was 54.0% among candidates with MELD ≥35, compared with 13.0% among status 1A candidates (Figure LI 29). Compared with 2017, this metric improved among candidates at higher medical urgency categories, including status 1A and MELD ≥35, as well as MELD 30-34, and for most age groups except ≥65 years (Figure LI 30). Reducing waitlist mortality further remains a challenge for policy makers in their effort to improve the organ distribution and allocation system.

Waitlist mortality rates varied geographically (Figure LI 28), ranging from 6.5 to 37.4 per 100 waitlist-years by DSA. This variation did not necessarily mirror transplant rates, suggesting that waitlist outcomes were not determined simply by organ availability. Other factors such as access to healthcare in general and to high-quality specialty care for liver disease, referral and waitlist registration practices, and pretransplant patient management may also contribute.

Donation

The total of 7766 deceased donors in 2018 represents an increase of 135 over 2017. The number and proportion of donors aged 18-34 years plateaued in 2018, at 33% of donated livers (Figure LI 31, Figure 33). Over the past decade, fewer pediatric (age <18 years) livers were used for adult liver transplants, from 12.4% in 2008 to 8.5% in 2018 (Figure LI 33). Overall, 47% of pediatric donor livers were allocated to adults (Figure LI 37). The distribution of donor age, sex, and race was otherwise largely unchanged (Figure LI 33, Figure 34, Figure LI 35). Concomitant with the availability of effective HCV therapy and increases in anoxic brain deaths (likely due to drug overdose), use of HCV-antibody-positive donor livers has increased steadily since 2013, to 8.3% of transplanted livers in 2018 (Figure LI 32, Figure LI 36, Figure LI 44).

The organ discard rate (percentage of organs recovered for transplant and not transplanted) was 8.4%, continuing a downward trend since 2012 (Figure LI 39). While discard rates remained generally higher for older donors, they were similar between donors aged 50-64 and ≥65 years (Figure LI 38). The discard rate for donation-after-brain-death organs continued a steady decline, reaching an all-time low of 6.4% (Figure LI 43). HCV-antibody-positive donor livers were no more likely to be discarded than HCV-antibody-negative livers (7.6% versus 8.5%), reflecting widespread use of these organs in the DAA era and a dramatic turnabout for what was previously a strong risk factor for organ discard (Figure LI 41). Many HCV-positive livers are from younger donors and are otherwise considered high quality. Relatedly, US Public Health Service high-risk organs were also less likely to be discarded than non-high-risk organs (Figure LI 42).

The 34 more living donors in 2018 represented a 9.5% increase over 2017, driven by an increase in the number of unrelated directed donors (Figure LI 45). The demographic and BMI characteristics of living donors did not change substantially over time (Figure LI 46, Figure LI 47, Figure LI 48, Figure LI 51). Compared with previous years, fewer living donor liver transplants were left-lobe donations (20.9%) (Figure LI 49).

Transplants

In 2018, 8250 liver transplants were performed in the US, more than in any previous year (Figure LI 52). This represented a 2.1% increase over 2017 (8082) and a 31% increase from 10 years earlier (6319 in 2008). Almost all (95.6%) were deceased donor transplants. The fraction of living donor liver transplants has increased in the past decade, from 3.1% in 2008 to 4.4% in 2018 (Table LI 10). Liver transplants performed in patients with a previous liver transplant decreased from 7.3% (417) in 2008 to 4.1% (312) in 2018 (Table LI 10). During this time period, multi-organ transplants involving the liver increased (7.2% to 9.7%), in particular simultaneous liver-kidney transplants (6.4% to 8.6%). The proportion of donation after circulatory death (DCD) transplants also increased from 4.8% in 2008 to 6.9% in 2018 (Table LI 10).

Characteristics of adult transplant recipients in 2018 were similar to those of waitlist registrants (Figure LI 53, Figure LI 54, Figure LI 55). Liver recipients were most commonly aged 50-64 years, male, and white. The increase in numbers of transplants occurred in most age groups and both sexes, with the exception of recipients aged 50-64 years (Figure LI 53). Between 2017 and 2018, the number of Hispanic transplant recipients increased by 11.1% and Asian recipients by 15.2%, and changed marginally for white (+0.2%) and black (-5.7%) recipients (Figure LI 55). These trends likely reflect disease etiology and severity, although further analysis is necessary.

The number of adult liver transplants performed for alcohol-related liver disease and other/unknown disease (often non-alcoholic steatohepatitis) continued to rise in 2018, representing the two most common diagnoses (Figure LI 56). Less stringent sobriety requirements and an increasing acceptance of alcoholic hepatitis as an indication for liver transplant likely contributed to the rise in transplants for alcohol-related liver disease. Liver transplants for HCC, the third most common diagnosis, remained stable in 2018 compared with 2017 (-0.4%). The number of transplants for HCV continued to decline steeply since a peak in 2014 (Figure LI 56). In 2018, HCV was the primary diagnosis for 10.4% (858) of recipients, compared with 24.0% (1612) in 2014. Fewer liver transplants were performed for HCV than for cholestatic liver disease in 2018, although patients with HCV continued to be represented among transplant recipients with a primary diagnosis of HCC.

In 2018, more than a third (34.6%) of adult recipients had a BMI consistent with obesity (≥30 kg/m2), 13.9% were morbidly obese (BMI ≥35 kg/m2), and 29.2% had diabetes (Figure LI 57, Table LI 9). Prevalence of obesity and of diabetes among transplant recipients has increased markedly over the past 10 years.

From 2008 to 2018, the proportion of adult liver transplants covered by public insurance increased (22.3% to 31.0% for Medicare; 13.2% to 15.4% for Medicaid), while fewer transplants were covered by private insurance (60.8% to 49.0%) (Table LI 8). Medical urgency also changed during this period, with greater proportions of patients being hospitalized (32.5%, 2018; 28.6%, 2008) and/or with MELD ≥35 (22.0%, 2018; 11.9%, 2008) at the time of transplant (Table LI 9).

The majority (69.4%) of recipients did not receive an induction agent (Figure LI 58). The predominant immunosuppressive regimen in adult liver recipients remained the combination of tacrolimus, mycophenolate, and steroids (62.8%), followed by tacrolimus and mycophenolate (18.6%) (Figure LI 59).

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 20 to 35 (Figure LI 60) 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 Mississippi (MSOP, median MELD 21.5). The median for all DSAs remained 28.0, unchanged from 2016 and 2017, and higher than in previous years (Figure LI 61). Although the interquartile range (IQR) of median MELDs by DSA had decreased in 2017 (IQR 27.5-29.3), it widened in 2018 (IQR 25.5-30.0), suggesting persistent geographic variability in recipient MELD scores (Figure LI 61). Policy changes to liver allocation with the goal of broader organ sharing have been proposed and widely debated; what will eventually be implemented and how effectively it will reduce variability remain to be seen.

MELD exception scores have been another focus of policy debate; large variability in proportions of patients receiving exception scores triggered recent changes in allocation policy and formation of a National Liver Review Board in an effort to better standardize exceptions. In 2018, 34.3% of non-status 1A adult transplant recipients underwent transplant with MELD exception points (Figure LI 62). The DSAs with the lowest proportions of recipients with exception scores at transplant were in Hawaii (HIOP) (9.1%) and North Carolina (NCCM) (16.2%), and the highest was in Northern California (CADN) (50.9%).

Cold ischemia time continued to decrease for all MELD strata, with the overall median less than 6 hours (Figure LI 63), but this tended to be longer for recipients with higher MELD scores. Figure LI 64 shows the distribution of total numbers of HLA, B, and DR mismatches among liver-kidney recipients, which has not changed recently.

As the total number of transplants grew nationwide, distribution of the additional organs affected transplant program volume, which appeared to have grown mostly at medium to large programs (Figure LI 65). In 2018, 126 transplant programs performed adult liver transplants, and the median program volume had increased to 52.5 transplants per year (IQR 25-96). The 33 programs with an annual volume of >95 liver transplants performed over half (52.6%) of the adult liver transplants in 2018.

Outcomes

Short- and long-term graft outcomes continued to improve in 2018. Graft failure occurred in 6.7% of deceased donor liver transplant recipients at 6 months and in 8.8% at 1 year for transplants performed in 2017, in 16.0% at 3 years for transplants performed in 2015, in 23.5% at 5 years for transplants performed in 2013, and in 43.6% at 10 years for transplants performed in 2008 (Figure LI 67). Among living donor liver transplants, graft failure occurred in 6.4% at 6 months and in 7.8% at 1 year for transplants performed in 2017, in 14.6% at 3 years for transplants performed in 2015, in 26.5% at 5 years for transplants performed in 2013, and in 32.6% at 10 years for transplants performed in 2008 (Figure LI 68).

Five-year graft survival outcomes for deceased donor recipients varied in the expected direction by recipient age (Figure LI 69), urgency category (Figure LI 71), BMI (Figure LI 75), DCD (Figure LI 72), and re-transplant status (Figure LI 73). Unlike in previous years, 5-year survival outcomes for liver transplant recipients with HCV were comparable to outcomes for recipients with other etiologies of liver disease (Figure LI 70), likely reflecting availability of effective HCV therapy. Short-term graft survival for recipients with HCC exception points was higher than for non-HCC recipients (90.3% versus 88.1% at 1 year), while 5-year graft survival was similar (76.6% versus 76.4%) (Figure LI 74). Among living donor recipients, 5-year graft survival outcomes were more favorable for those with non-HCC diagnoses and MELD <20 (Figure LI 78, Figure LI 79).

As of June 30, 2018, 88,715 liver transplant recipients were alive with a functioning graft, including 77,626 who underwent liver transplant as adults (Figure LI 82). Within 1 year, 11.9% of liver transplant recipients in 2016-2017 experienced at least one episode of acute rejection, occurring more commonly among younger recipients (Figure LI 83). Approximately 1% of adult liver recipients developed posttransplant lymphoproliferative disorder over 5 years, with double the incidence among recipients lacking antibodies against Epstein-Barr virus (EBV) (Figure LI 85). Adult patient survival after deceased and living donor liver transplant (Figure LI 86, Figure LI 87, Figure LI 88, Figure LI 89, Figure LI 90, Figure LI 91, Figure LI 92, Figure LI 93, Figure LI 94, Figure LI 95) largely mirrored graft survival. Whereas recipients with alcoholic liver disease experienced the highest 5-year graft survival outcomes (79.2%), 5-year patient survival outcomes were best among recipients with cholestatic liver disease (83.3%) (Figure LI 87).

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 2018, and the highest rate of pretransplant mortality persisted for children aged younger than 1 year. This rate was persistently higher than rates for all adults, despite increasing use of split grafts, high rates of exception scores, and living donation. Children are undergoing transplant at higher acuity than the past, as evidenced by higher MELD/pediatric end-stage liver disease (PELD) scores and listings at status 1A and 1B. Higher acuity at transplant is likely due to lack of access to suitable donor organs, as dictated by current policy, 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 2018, 700 new active candidates were added to the pediatric liver transplant waiting list (Figure LI 96), very few (15) as inactive. The number of prevalent candidates (on the list on December 31 of the given year) continued a slow decrease to 527 overall, 372 active and 155 inactive (Figure LI 97). Children aged 1-5 years (31.0%) and 11 years or older (29.9%) made up the largest age groups, followed by ages younger than 1 year, 23.7%, and 6-10 years, 15.3% (Figure LI 98). White candidates continued to make up the largest racial/ethnic group on the waiting list in 2018 (50.2%), followed by Hispanic (23.2%), black (15.1%), and Asian candidates (8.4%) (Figure LI 99). As of December 31, 2018, most (67.2%) candidates had been waiting for less than 1 year, 11.5% for 1 to less than 2 years, 10.5% for 2 to less than 4 years, and 10.8% for 4 or more years (Figure LI 101). The shift to shorter waiting times was due to increased medical urgency in the pediatric population. Considerably more candidates on the waiting list had MELD/PELD scores above 35 (21.5% in 2018 vs. 9.8% in 2007), many of whom received MELD/PELD exception scores. In addition, more candidates were at status 1A/1B as their most severe status during the year (25.8% in 2018 vs. 18.2% in 2007) (Figure LI 102).

For pediatric liver waitlist candidates from 2008 to 2018, sex, race, diagnosis, and geographic distributions changed little (Table LI 13, Table LI 14). The proportion of candidates aged younger than 1 year 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 36.3% in 2018 compared with 13.6% a decade earlier (Table LI 14). Waiting time shifted such that 55.9% of candidates waited less than 1 year in 2018, compared with 38.8% in 2008 (Table LI 15). Proportions of candidates listed for multi-organ transplants including liver have increased over time. Proportions of liver-kidney transplant candidates have remained stable at 2.5% of pediatric liver transplant candidates over the past decade. The proportion of liver-pancreas-intestine transplant candidates increased from 7.3% in 2008 to 12.6% in 2018 (Table LI 15). Among candidates removed from the waiting list in 2018, 69.5% underwent deceased donor transplant, 8.4% underwent living donor transplant, 4.3% died, 11.9% were removed from the list because their condition improved, and 2.7% were considered too sick to undergo transplant (Table LI 17). Among newly listed candidates in 2015, just over 66% underwent deceased donor transplant within 3 years, 10.4% underwent living donor transplant, 4.7% died, 11.3% were removed from the list, and 7.3% were still waiting (Figure LI 103). In 2018, the rate of deceased donor transplant among active pediatric candidates continued to increase, reaching 96.9 per 100 active waitlist-years compared with 61.2 in 2007 (Figure LI 104). Rates were highest for candidates aged younger than 1 year, 207.5 per 100 active waitlist-years. The lowest rates were for candidates aged 11 years or older, 60.7 per 100 active waitlist-years. Regarding medical urgency status, as expected, transplant rates were highest for status 1A (1170.0 per 100 active waitlist-years) and status 1B candidates (259.7 per 100 active waitlist-years) (Figure LI 106). Among candidates listed with MELD/PELD scores, rates were similar for those with MELD/PELD ≥35 and MELD/PELD 30-34; 100.8 and 154.1 transplants per 100 active waitlist years, respectively, compared with 75.6 for those with MELD/PELD <15 (Figure LI 105). Pretransplant mortality decreased for all age groups, to 6.5 deaths per 100 waitlist-years in 2017-2018 (Figure LI 109). The pretransplant mortality rate was highest for candidates aged younger than 1 year, at 17.1 deaths per 100 waitlist-years in 2017-2018, and lowest for candidates aged 6-10 years, at 3.6.

Transplant

The number of pediatric liver transplants peaked at 613 in 2008 and was 563 in 2018 (Figure LI 113). The number of pediatric living donor liver transplants was 62 in 2018, with half from donors closely related to the recipients (Figure LI 114). Recipients aged younger than 6 years underwent the highest proportion of transplants from living donors, 13.9% (Figure LI 115). In 2018, 21 programs were performing pediatric-only liver transplants, compared with 88 performing adult-only transplants and 28 performing transplants in both adults and children (Figure LI 116). In 2018, 6.0% of transplants in candidates aged 0-10 years, 7.3% in those aged younger than 15 years, and 9.1% in those aged younger than 18 years were performed at programs with volumes of five or fewer pediatric transplants in that year (Figure LI 117). In 2018, 19.2% of liver transplants in pediatric recipients were split-liver transplants, compared with 14.4% a decade ago (Figure LI 118). Among adults, the proportion of split-liver transplants has remained stable at approximately 1%. The proportion of pediatric transplant recipients who underwent transplant by exception was 74.2%, compared with 34.3% among adult recipients (Figure LI 119). Among pediatric transplant recipients 2016-2018, percentages with exception points by DSA ranged from 19.4% to 100% in seven DSAs, with a mean of 74.6% (Figure LI 120). Despite intense use of exception scores, split grafts, and living donors, rates of pretransplant mortality were highest of all age groups for candidates aged younger than 1 year.

In 2018, median cold ischemia time was similar for allocation MELD/PELD >15 at approximately 6 hours (Figure LI 121). Over the past decade, recipient age, sex, and racial distributions have changed little, although fewer recipients were aged younger than 1 year (25.3% in 2016-2018 compared with 30.3% in 2006-2008) (Table LI 18). Cholestatic biliary atresia remained the leading cause of liver failure (33.1%) (Table LI 19). Most pediatric liver transplant recipients were not hospitalized before transplant (62.4%) and fewer were in the intensive care unit, 18.5% in 2016-2018 versus 26.9% in 2006-2008. Regarding medical urgency status, over the past decade, proportions of recipients undergoing transplant at status 1B increased. The proportion undergoing transplant with a MELD/PELD of 30 or higher increased from 29.0% to 41.6% over the past 10 years. MELD/PELD exception use increased from 26.0% in 2006-2008 to 45.3% in 2016-2018. Types of liver transplant procedures in pediatric recipients changed little over the past decade; 62.4% of patients received a whole liver in 2016-2018 and 19.5% 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) (Table LI 20). Use of split livers increased from 13.1% in 2006-2008 to 18.1% in 2016-2018. ABO-incompatible liver transplants occurred in 5.2% of recipients in 2016-2018, increased from 2.9% in the earlier era. Over the past decade, proportions of pediatric liver transplant recipients undergoing a liver-alone transplant increased from 84.5% in 2006-2008 to 91.2% in 2016-2018 (Table LI 20).

Immunosuppression and Outcomes

In 2018, 56.2% of pediatric liver transplant recipients received no induction therapy, 30.1% received interleukin-2 receptor antagonists, and 14.0% received a T-cell depleting agent (Figure LI 122). The most commonly used initial immunosuppression regimens were tacrolimus and steroids (42.2%) and tacrolimus, mycophenolate mofetil, and steroids (35.3%) (Figure LI 123).

Graft survival continued to improve over the past decade among pediatric recipients of deceased donor and living donor livers. Graft failure occurred in 6.6% at 6 months and in 7.0% at 1 year among deceased donor liver transplants performed in 2017, in 12.4% at 3 years for transplants performed in 2015, in 18.5% at 5 years for transplants performed in 2013, and in 26.9% at 10 years for transplants performed in 2008 (Figure LI 125). Graft failure occurred in 4.5% of recipients at 6 months and in 6.0% at 1 year posttransplant among living donor transplants performed in 2016-2017, in 7.6% at 3 years for transplants performed in 2014-2015, in 11.8% at 5 years for transplants performed in 2012-2013, and in 15.6% at 10 years for transplants performed in 2008-2009 (Figure LI 126). By age, 5-year graft survival was 80.3% for recipients aged younger than 1 year, 80.5% for ages 1-5 years, 87.3% for ages 6-10 years, and 82.7% for ages 11-17 years (Figure LI 127). Five-year graft survival was 83.9% for recipients who underwent transplant with MELD/PELD <15, compared with approximately 79% for recipients who underwent transplant as status 1A/1B (Figure LI 129). Five-year graft survival was 83.2% for recipients of a first liver transplant, compared with 69.6% for re-transplant recipients (Figure LI 130). In 2016-2017, incidence of acute rejection by 1 year posttransplant was 23.1% overall, varying from 26.1% in recipients aged 1-5 years to 17.8% in those aged 6-10 years (Figure LI 131). Regarding use of induction agents and acute rejection, rates ranged from 18.4% among recipients who received interleukin-2 receptor antagonists to 25.3% among those who did not report induction therapy (Figure LI 132). Incidence of posttransplant lymphoproliferative disorder was 4.6% at 5 years posttransplant for recipients who were EBV negative and 2.7% for those who were positive (Figure LI 133). Among pediatric liver transplants 2009-2013, overall 5-year patient survival was 88.4%, varying from 87.2% for recipients aged 1-5 years to 92.2% for those aged 6-10 years (Figure LI 134). By primary diagnosis, metabolic disease and cholestatic biliary atresia were associated with superior patient survival (Figure LI 135). Of deceased donor transplant recipients in 2012-2017, 5.8% died within 1 year of transplant with cardio/cerebrovascular complications as the leading cause of death (Figure LI 136). Of deceased donor transplant recipients in 2011-2013, 9.8% died within 5 years of transplant (Figure LI 137). The leading causes of death were graft failure (1.5%) and cardio/cerebrovascular complications (1.1%) (Figure LI 137).

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. Adults willing to accept liver from HCV+ donor
Figure LI 10. Deceased donor liver transplant rates among adult waitlist candidates by age
Figure LI 11. Deceased donor liver transplant rates among adult waitlist candidates by race
Figure LI 12. Deceased donor liver transplant rates among adult waitlist candidates by sex and HCC exception status
Figure LI 13. Deceased donor liver transplant rates among adult waitlist candidates by metropolitan vs. non-metropolitan residence
Figure LI 14. Deceased donor liver transplant rates among adult waitlist candidates by distance from listing center
Figure LI 15. Three-year outcomes for adults waiting for liver transplant, new listings in 2015
Figure LI 16. Median months to liver transplant for waitlisted adults
Figure LI 17. Percentage of adults who underwent deceased donor liver transplant within a given time period of listing
Figure LI 18. Percentage of adults who underwent deceased donor liver transplant within 3 years of listing in 2015 by DSA
Figure LI 19. Percentage of adults who underwent deceased donor liver transplant within 3 years of listing in 2015 by state
Figure LI 20. Pretransplant mortality rates among adults waitlisted for liver transplant by age
Figure LI 21. Pretransplant mortality rates among adults waitlisted for liver transplant by race
Figure LI 22. Pretransplant mortality rates among adults waitlisted for liver transplant by diagnosis
Figure LI 23. Pretransplant mortality rates among adults waitlisted for liver transplant by high medical urgency
Figure LI 24. Pretransplant mortality rates among adults waitlisted for liver transplant by medical urgency
Figure LI 25. Pretransplant mortality rates among adults waitlisted for liver by metropolitan vs. non-metropolitan residence
Figure LI 26. Pretransplant mortality rates among adults waitlisted for liver, by distance from listing center
Figure LI 27. Pretransplant mortality rates among adults waitlisted for liver, by active/inactive status
Figure LI 28. Pretransplant mortality rates among adults waitlisted for liver transplant in 2017-2018, by DSA
Figure LI 29. Deaths within six months after removal among adult liver waitlist candidates, by MELD at removal
Figure LI 30. Deaths within six months after removal among adult liver waitlist candidates, by age at removal

Deceased donation

Figure LI 31. Deceased liver donor count by age
Figure LI 32. Deceased liver donor count by donor HCV antibody status
Figure LI 33. Distribution of deceased liver donors by age
Figure LI 34. Distribution of deceased liver donors by sex
Figure LI 35. Distribution of deceased liver donors by race
Figure LI 36. Distribution of deceased liver donors by donor HCV status
Figure LI 37. Percent of pediatric donor livers allocated to adult recipients, by DSA of donor hospital, 2014-2018
Figure LI 38. Rates of livers recovered for transplant and not transplanted by donor age
Figure LI 39. Rates of livers recovered for transplant and not transplanted by donor sex
Figure LI 40. Rates of livers recovered for transplant and not transplanted by donor race
Figure LI 41. Rates of livers recovered for transplant and not transplanted by donor HCV status
Figure LI 42. Rates of livers recovered for transplant and not transplanted, by donor risk of disease transmission
Figure LI 43. Rates of livers recovered for transplant and not transplanted by DCD status
Figure LI 44. Cause of death among deceased liver donors

Living donation

Figure LI 45. Liver transplants from living donors by donor relation
Figure LI 46. Living liver donors by age
Figure LI 47. Living liver donors by sex
Figure LI 48. Living liver donors by race
Figure LI 49. Living donor liver transplant graft type
Figure LI 50. Rehospitalization among living liver donors, 2013-2017
Figure LI 51. BMI among living liver donors

Transplant

Figure LI 52. Total liver transplants
Figure LI 53. Total liver transplants by age
Figure LI 54. Total liver transplants by sex
Figure LI 55. Total liver transplants by race
Figure LI 56. Total liver transplants by diagnosis
Figure LI 57. Total liver transplants by body mass index (BMI)
Figure LI 58. Induction agent use in adult liver transplant recipients
Figure LI 59. Immunosuppression regimen use in adult liver transplant recipients
Figure LI 60. Median MELD scores for adult deceased donor liver transplant recipients by DSA, 2018
Figure LI 61. Variation in DSA-level median MELD at transplant among adult liver recipients
Figure LI 62. Percent of adult liver transplant recipients using exceptions in 2018, by DSA
Figure LI 63. Donor liver cold ischemia among adult liver recipients by allocation MELD
Figure LI 64. Total HLA A, B, and DR mismatches among adult deceased donor liver-kidney transplant recipients, 2014-2018
Figure LI 65. Annual adult liver transplant center volumes, by percentile
Figure LI 66. Distribution of adult liver transplants by annual center volume

Outcomes

Figure LI 67. Graft failure among adult deceased donor liver transplant recipients
Figure LI 68. Graft failure among adult living donor liver transplant recipients
Figure LI 69. Graft survival among adult deceased donor liver transplant recipients, 2013, by age
Figure LI 70. Graft survival among adult deceased donor liver transplant recipients, 2013, by diagnosis
Figure LI 71. Graft survival among adult deceased donor liver transplant recipients, 2013, by medical urgency
Figure LI 72. Graft survival among adult deceased donor liver transplant recipients, 2013, by DCD status
Figure LI 73. Graft survival among adult deceased donor liver transplant recipients, 2013, by retransplant status
Figure LI 74. Graft survival among adult deceased donor liver transplant recipients, 2013, by HCC status
Figure LI 75. Graft survival among adult deceased donor liver transplant recipients, 2013, by BMI
Figure LI 76. Graft survival among adult deceased donor liver transplant recipients, 2013, by metropolitan vs. non-metropolitan recipient residence
Figure LI 77. Graft survival among adult deceased donor liver transplant recipients, 2013, by recipients' distance from transplant center
Figure LI 78. Graft survival among adult living donor liver transplant recipients, 2010-2013, by diagnosis
Figure LI 79. Graft survival among adult living donor liver transplant recipients, 2010-2013, by medical urgency
Figure LI 80. Graft survival among adult living donor liver transplant recipients, 2010-2013, by metropolitan vs. non-metropolitan recipient residence
Figure LI 81. Graft survival among adult living donor liver transplant recipients, 2010-2013, by recipients' distance from transplant center
Figure LI 82. Recipients alive with a functioning liver graft on June 30 of the year, by age at transplant
Figure LI 83. Incidence of acute rejection by 1 year posttransplant among adult liver transplant recipients by age, 2016-2017
Figure LI 84. Incidence of acute rejection by 1 year posttransplant among adult liver transplant recipients by induction agent 2016-2017
Figure LI 85. Incidence of PTLD among adult liver transplant recipients by recipient EBV status at transplant, 2012-2016
Figure LI 86. Patient survival among adult deceased donor liver transplant recipients, 2011-2013, by age
Figure LI 87. Patient survival among adult deceased donor liver transplant recipients, 2011-2013, by diagnosis
Figure LI 88. Patient survival among adult deceased donor liver transplant recipients, 2011-2013, by retransplant
Figure LI 89. Patient survival among adult deceased donor liver transplant recipients, 2011-2013, by medical urgency
Figure LI 90. Patient survival among adult deceased donor liver transplant recipients, 2011-2013, by metropolitan vs. non-metropolitan recipient residence
Figure LI 91. Patient survival among adult deceased donor liver transplant recipients, 2011-2013, by recipients' distance from transplant center
Figure LI 92. Patient survival among adult living donor liver transplant recipients, 2010-2013, by diagnosis
Figure LI 93. Patient survival among adult living donor liver transplant recipients, 2010-2013, by medical urgency
Figure LI 94. Patient survival among adult living donor liver transplant recipients, 2010-2013, by metropolitan vs. non-metropolitan recipient residence
Figure LI 95. Patient survival among adult living donor liver transplant recipients, 2010-2013, by recipients' distance from transplant center

Pediatric transplant

Figure LI 96. New pediatric candidates added to the liver transplant waiting list
Figure LI 97. Pediatric candidates listed for liver transplant on December 31 each year
Figure LI 98. Distribution of pediatric candidates waiting for liver transplant by age
Figure LI 99. Distribution of pediatric candidates waiting for liver transplant by race
Figure LI 100. Distribution of pediatric candidates waiting for liver transplant by sex
Figure LI 101. Distribution of pediatric candidates waiting for liver transplant by waiting time
Figure LI 102. Distribution of pediatric candidates waiting for liver transplant by medical urgency
Figure LI 103. Three-year outcomes for newly listed pediatric candidates waiting for liver transplant, 2015
Figure LI 104. Deceased donor liver transplant rates among pediatric waitlist candidates by age
Figure LI 105. Deceased donor liver transplant rates among pediatric waitlist candidates by MELD/PELD
Figure LI 106. Deceased donor liver transplant rates among pediatric waitlist candidates by Status 1A or 1B
Figure LI 107. Deceased donor liver transplant rates among pediatric waitlist candidates by metropolitan vs. non-metropolitan residence
Figure LI 108. Deceased donor liver transplant rates among pediatric waitlist candidates by distance from listing center
Figure LI 109. Pretransplant mortality rates among pediatrics waitlisted for liver transplant by age
Figure LI 110. Pretransplant mortality rates among pediatrics waitlisted for liver transplant by race
Figure LI 111. Pretransplant mortality rates among pediatrics waitlisted for liver transplant by metropolitan vs. non-metropolitan residence
Figure LI 112. Pretransplant mortality rates among pediatrics waitlisted for liver transplant by distance from listing center
Figure LI 113. Pediatric liver transplants by donor type
Figure LI 114. Pediatric liver transplants from living donors by relation
Figure LI 115. Percent of pediatric liver transplants from living donors by recipient age
Figure LI 116. Number of centers performing pediatric and adult liver transplants by center's age mix
Figure LI 117. Pediatric liver recipients at programs that perform 5 or fewer pediatric transplants annually
Figure LI 118. Split liver transplants in children and adults
Figure LI 119. Percent of adult and pediatric liver transplant recipients using exceptions
Figure LI 120. Percent of pediatric liver transplant recipients using exceptions, 2016-2018, by DSA
Figure LI 121. Donor liver cold ischemia among pediatric liver recipients by allocation MELD/PELD
Figure LI 122. Induction agent use in pediatric liver transplant recipients
Figure LI 123. Immunosuppression regimen use in pediatric liver transplant recipients
Figure LI 124. Total HLA A, B, and DR mismatches among pediatric deceased donor liver-kidney transplant recipients, 2014-2018
Figure LI 125. Graft failure among pediatric deceased donor liver transplant recipients
Figure LI 126. Graft failure among pediatric living donor liver transplant recipients
Figure LI 127. Graft survival among pediatric deceased donor liver transplant recipients, 2009-2013, by age
Figure LI 128. Graft survival among pediatric deceased donor liver transplant recipients, 2009-2013, by diagnosis
Figure LI 129. Graft survival among pediatric deceased donor liver transplant recipients, 2009-2013, by medical urgency
Figure LI 130. Graft survival among pediatric deceased donor liver transplant recipients, 2009-2013, by retransplant
Figure LI 131. Incidence of acute rejection by 1 year posttransplant among pediatric liver transplant recipients by age, 2016-2017
Figure LI 132. Incidence of acute rejection by 1 year posttransplant among pediatric liver transplant recipients by induction agent 2016-2017
Figure LI 133. Incidence of PTLD among pediatric liver transplant recipients by recipient EBV status at transplant, 2006-2016
Figure LI 134. Patient survival among pediatric deceased donor liver transplant recipients, 2009-2013, by age
Figure LI 135. Patient survival among pediatric deceased donor liver transplant recipients, 2009-2013, by diagnosis
Figure LI 136. One-year cumulative incidence of death by cause among pediatric liver recipients, 2012-2017
Figure LI 137. Five-year cumulative incidence of death by cause among pediatric liver recipients, 2011-2013

Table List

Waiting list

Table LI 1. Demographic characteristics of adults on the liver transplant waiting list on December 31, 2008 and December 31, 2018
Table LI 2. Clinical characteristics of adults on the liver transplant waiting list on December 31, 2008 and December 31, 2018
Table LI 3. Listing characteristics of adults on the liver transplant waiting list on December 31, 2008 and December 31, 2018
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, 2014-2018
Table LI 7. Living liver donor deaths in the first year after donation, 2014-2018, by number of days after donation

Transplant

Table LI 8. Demographic characteristics of adult liver transplant recipients, 2008 and 2018
Table LI 9. Clinical characteristics of adult liver transplant recipients, 2008 and 2018
Table LI 10. Transplant characteristics of adult liver transplant recipients, 2008 and 2018
Table LI 11. Adult deceased donor liver donor-recipient serology matching, 2016-2018
Table LI 12. Adult living donor liver donor-recipient serology matching, 2016-2018

Pediatric transplant

Table LI 13. Demographic characteristics of pediatric candidates on the liver transplant waiting list on December 31, 2008 and December 31, 2018
Table LI 14. Clinical characteristics of pediatric candidates on the liver transplant waiting list on December 31, 2008 and December 31, 2018
Table LI 15. Listing characteristics of pediatric candidates on the liver transplant waiting list on December 31, 2008 and December 31, 2018
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, 2006-2008 and 2016-2018
Table LI 19. Clinical characteristics of pediatric liver transplant recipients, 2006-2008 and 2016-2018
Table LI 20. Transplant characteristics of pediatric liver transplant recipients, 2006-2008 and 2016-2018

A line plot for new adult candidates added to the liver transplant waiting list; the active category increases by 22.7% from 9.3 candidates (in thousands) at 2007 to 11.4 candidates (in thousands) at 2018; the inactive category increases by 92.8% from 0.2 candidates (in thousands) at 2007 to 0.5 candidates (in thousands) at 2018; and the all category increases by 24.4% from 9.5 candidates (in thousands) at 2007 to 11.8 candidates (in thousands) at 2018.

Figure LI 1. New adult candidates added to the liver transplant waiting list
A new candidate is one who first joined the list during the given year, without having been listed in a previous year. Previously listed candidates who underwent transplant and subsequently relisted are considered new. Candidates concurrently listed at multiple centers are counted once. Active and inactive patients are included.


A line plot for adults listed for liver transplant on december 31 each year; the active category decreases by 13.0% from 11.8 candidates (in thousands) at 2007 to 10.2 candidates (in thousands) at 2018; the inactive category decreases by 28.2% from 3.6 candidates (in thousands) at 2007 to 2.6 candidates (in thousands) at 2018; and the all category decreases by 16.6% from 15.4 candidates (in thousands) at 2007 to 12.8 candidates (in thousands) at 2018.

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


A line plot for distribution of adults waiting for liver transplant by age; the 18 to 34 category increases by 12.0% from 4.8 percent at 2007 to 5.4 percent at 2018; the 35 to 49 category decreases by 27.1% from 22.4 percent at 2007 to 16.3 percent at 2018; the 50 to 64 category decreases by 11.9% from 61.5 percent at 2007 to 54.2 percent at 2018; and the  greater than or equal to 65 category increases by 112.4% from 11.4 percent at 2007 to 24.1 percent at 2018.

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


A line plot for distribution of adults waiting for liver transplant by sex; the male category is 61.7 percent at 2007 and remains relatively constant with a value of 62.4 percent at 2018; and the female category is 38.3 percent at 2007 and remains relatively constant with a value of 37.6 percent at 2018.

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


A line plot for distribution of adults waiting for liver transplant by race; the white category is 72.2 percent at 2007 and remains relatively constant with a value of 68.5 percent at 2018; the black category is 7.4 percent at 2007 and remains relatively constant with a value of 7.4 percent at 2018; the hispanic category increases by 17.3% from 14.8 percent at 2007 to 17.4 percent at 2018; the asian category is 4.9 percent at 2007 and remains relatively constant with a value of 5.2 percent at 2018; and the other/unknown category increases by 96.5% from 0.8 percent at 2007 to 1.6 percent at 2018.

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