OPTN/SRTR 2020 Annual Data Report: Deceased Organ Donation (DOD)

Abstract

SRTR uses data collected by OPTN to calculate metrics such as donation rate, organ yield, and rate of organs recovered for transplant but not transplanted. In 2020, there were 12,588 deceased donors, an increase from 11,870 in 2019; this number has been increasing since 2010. The number of deceased donor transplants increased to 33,303 in 2020, from 32,313 in 2019; this number has been increasing since 2012. The increase may be due in part to the rising number of deaths of young people amid the ongoing opioid epidemic. The number of organs transplanted included 18,410 kidneys, 962 pancreata, 8350 livers, 91 intestines, 3722 hearts, and 2463 lungs. Compared with 2019, transplants of all organs except pancreata and lung transplants increased in 2020, which is remarkable despite the pandemic caused by the SARS-CoV2 virus. In 2020, 4870 kidneys, 294 pancreata, 861 livers, 3 intestines, 39 hearts, and 115 lungs were discarded. The number of discards was similar to that of the previous year. In 2019, 4,324 kidneys, 346 pancreata, 867 livers, 5 intestines, 31 hearts, and 148 lungs were discarded. These numbers suggest an opportunity to increase numbers of transplants by reducing discards. Despite the pandemic, there was no dramatic increase in number of discards and an increase in total number of donors and transplants.

Introduction

This chapter reports data collected by the Organ Procurement and Transplantation Network (OPTN) to describe changes in deceased donor characteristics over the last decade, deceased organ donor metrics such as donation rate, organ yield, and rate of organs recovered for transplant but not transplanted. These metrics are currently produced by the Scientific Registry of Transplant Recipients (SRTR) and some, such as organ yield, are used for organ procurement organization (OPO) quality assessment by OPTN. Some data described in this chapter are also used by the Centers for Medicare & Medicaid Services (CMS) to develop its own quality assessment of OPOs. In 2019, the federal government ordered the revision of OPO quality metrics “in order to establish more transparent, reliable, and enforceable objective metrics for evaluating an OPO’s performance.”¹ This federal order also aims to reduce organ discards nationally. CMS has approved new metrics to assess OPO quality.¹ The impact of new metrics to assess OPO quality will be seen after they are implemented on August 1, 2022.

Definitions of Terms Related to Deceased Organ Donation

• DBD: Donations after brain death

• DCD: Donations after circulatory death

• Discards: Organs recovered for transplant but not transplanted

• Discard rate: Number of discards divided by number of organs recovered for transplant

• Donation rate: Number of eligible donors per 100 eligible deaths

• Donor: A person from whom at least one organ was recovered for transplant, regardless of whether the organ was transplanted

• Eligible death: As per OPTN policy 1.2, in place before 2017, death of a person 70 years or younger who is legally declared brain dead according to hospital policy and does not exhibit any of the following indications: tuberculosis, HIV with specified conditions, Creutzfeldt-Jacob disease, herpetic septicemia, rabies, reactive hepatitis B surface antigen, any retrovirus infection, active malignant neoplasms (except primary central nervous system tumors and skin cancers), Hodgkin disease, multiple myeloma, leukemia, miscellaneous carcinomas, aplastic anemia, agranulocytosis, fungal and viral encephalitis, gangrene of bowel, extreme immaturity, or positive serologic or viral culture findings for HIV. On January 1, 2017, a new eligible death definition was enacted. Per this definition, eligible death is death of a person 75 years or younger who is legally declared brain dead according to state or local law, and has a body weight of 5 kg or more, a body mass index (BMI) of 50 kg/m² or lower, and at least one kidney, liver, heart, or lung deemed to meet the eligible data definitions, per the new OPTN policy 1.2

• Eligible donor: A donor whose death met the definition of eligible death

• Organs authorized for recovery: Authorization requested and given for recovery of specific organs from a donor. Recovery of organs for transplant must be authorized by the individual(s) authorizing the donation (donor or surrogate decision maker), consistent with applicable state law

• Organs recovered per donor (ORPD): Total number of organs recovered for transplant, divided by the number of donors, not limited to eligible deaths

• Organs transplanted per donor (OTPD): Total number of organs transplanted, divided by the number of donors, not limited to eligible deaths (eg, OTPD for kidneys is the total number of kidneys transplanted, divided by the total number of all donors)

• Organ yield metric: Ratio of observed to expected numbers of organs transplanted, with expected numbers based on national experience with similar donors

• Referrals: All deaths and imminent deaths reported to an OPO

Donors

In 2020, 12,681 individuals met the definition of eligible death according to OPTN policy, a slight increase from 12,153 in 2019 and 11,653 in 2018. In 2020, 21,424 imminent neurologic and eligible deaths were reported, a slight increase from 20,930 in 2019 and a decline from 21,259 in 2018, 22,258 in 2017, and 23,441 in 2016. The decline was anticipated due to changes in the OPTN definition of imminent neurologic and eligible deaths (Figure DD 2) (eg, changing the absence of three brainstem reflexes to the absence of spontaneous breathing and two other brain stem reflexes). There were 12,588 deceased donors in 2020, an increase from 11,870 deceased donors in 2019, 10,721 in 2018, and 10,286 in 2017; this number has been increasing since 2010. The number of deceased donor transplants increased to 33,303 in 2020, from 32,313 in 2019, 29,675 in 2018, and 28,582 in 2017; this number has been increasing since 2012. The increase may be due in part to the rising number of deaths of young people due to the ongoing opioid epidemic. In 2020, 5725 living donor transplants (ie, difference between overall transplants and deceased donor transplants) were performed, a decrease from 7391 in 2019 and 6843 in 2018; this number increased from 2016 to 2020. (Figure DD 2). The decline in living donor transplants is likely due to the COVID-19 pandemic.

Donations after brain death (DBDs) increased to 9364 in 2020, from 9152 in 2019, 8589 in 2018, and 8403 in 2017; this number has been increasing since 2012. Donations after circulatory death (DCDs) increased to 3224 in 2020, from 2718 in 2019, 2132 in 2018, and 1883 in 2017; this number has been increasing since 2009 (Figure DD 3). Potential reasons for the increases in DBD and DCD donors include rising numbers of deaths of young people due to the opioid epidemic and increasing use of organs from DBD donors.

Consistent with the increasing number of DBD and DCD donations, 90,310 organs were authorized in 2020, an increase from 85,114 in 2019; this number has been increasing since 2010. In 2020, 44,426 organs were recovered, an increase from 43,717 in 2019; this number has been increasing since 2012. In 2020, 34,220 organs were transplanted, an increase from 33,302 in 2019; this number has been increasing since 2012. (Figure DD 4).

Donation Rate

OPTN policy requires that OPOs report all eligible deaths for performance assessment. However, any performance metric based solely on eligible deaths uses only a subset of potential donors, because successful donations can come from donors not meeting the eligible death definition (eg, DCD or donors older than 75 years). Recognizing this limitation, SRTR’s current donation rate measures how often a person with an eligible death becomes a donor. However, the 2020 data excludes the period of March 13 to June 12, 2020, due to the start of the COVID-19 pandemic (Figure DD 5 and 6). In 2020, the donation rate was 71.1 eligible donors per 100 eligible deaths (Figure DD 6), a slight decrease from 71.9 in 2019 and an increase from 71.0 in 2018 and 69.6 in 2017. However, the 2017 changes to OPTN policy 1.2, defining eligible deaths, preclude drawing firm conclusions about differences in donation rates between 2019 and previous years. Unadjusted donation rates varied by donation service area (DSA), ranging from 51.6 to 88.9 eligible donors per 100 eligible deaths (Figure DD 5). This range is slightly wider than the 56.2 to 86.8 seen in 2019 and 56.2 to 90.1 seen in 2018. Risk-adjusted donation rates are presented for each OPO semiannually in OPO reports on the SRTR website.

As expected, donation rates varied by organ. In 2020, the highest rate was for kidneys, followed by liver, heart, lung, and pancreas. The kidney donation rate was 66.6 eligible donors per 100 eligible deaths in 2020, down from 67.1 in 2019 and up from 64.9 in 2018 and 63.1 in 2017. In 2020 the next highest donation rate after kidneys was liver, at 61.8 donors per 100 eligible deaths in 2020, down from 64.6 in 2019, 64.1 in 2018, and 63.6 in 2017.

In 2020, the lowest donation rate was 9.9 for pancreata, a slight decline from 10.6 in 2019, and 10.7 in 2018 and 2017. In 2020, the donation rate for heart was 28.4 eligible donors per 100 eligible deaths, a slight decrease from 29.5 in 2019, 29.4 in 2018, and 28.1 in 2017. In 2020, the donation rate for lung was 18.9 eligible donors per 100 eligible deaths, a decline from 20.8 in 2019, 20.2 in 2018, and 19.8 in 2017 (Figure DD 6).

Organs Recovered per Donor

In 2020, 3.41 organs were recovered per donor, slightly lower than the 3.51 in 2019, 3.53 in 2018, and 3.54 in 2017 (Figure DD 7). The ORPD for all organs combined has been relatively stable over the past decade (Figure DD 7, Figure DD 8). Given that each donor can potentially donate two kidneys, the ORPD was highest for kidneys, at 1.88 in 2020, a slight increase from 1.87 in 2019, followed by livers, at 0.73 in 2020, a slight decline from 0.77 in 2019 (Figure DD 7, Figure DD 8). ORPDs have remained stable for kidneys and slightly decreased for livers over the past decade. The ORPD was 0.29 for heart, a slight decrease from 0.30 in 2019. The ORPD was 0.39 for lung, a decrease from 0.44 in 2019. These declines in ORPD may have been due to the COVID-19 pandemic; it remains to be seen if they will reverse in subsequent years (Figure DD 8). The ORPD was 0.09 for pancreata, a decrease from 0.11 in 2019 but this decline has been ongoing for the last decade. In 2020, the ORPD varied substantially by DSA, ranging from 2.46 to 3.90, with narrower breadth of range, from 2.88 to 4.12 in 2018 (Figure DD 9). The ORPD is an unadjusted number representing a mix of donor types, including young, old, DBDs, and DCDs, which explains some differences observed.

Organs Transplanted per Donor and Organ Yield

The number of OTPDs was 2.90 in 2020, a decrease from 3.01 in 2019, 3.06 in 2018, and 3.07 in 2017 (Figure DD 10). Given that each donor can potentially donate two kidneys, the OTPD was highest for kidneys, followed by livers (Figure DD 10, Figure DD 11). OTPD increased for lungs over the past decade but declined to 0.36 in 2020. OTPD decreased for pancreata over the past decade and was 0.07 in 2020 (Figure DD 11). In 2020, the OTPD for individual organs was 1.48 for kidney, 0.66 for liver, 0.36 for lung, 0.29 for heart, 0.07 for pancreas, and 0.007 for intestine, compared with 1.49 for kidney, 0.69 for liver, 0.41 for lung, 0.30 for heart, 0.08 for pancreas, and 0.006 for intestine in 2019. In addition to intestine, all OTPDs declined in 2020, likely due to the COVID-19 pandemic.

Numbers of deceased donor organs transplanted in 2020 were 18,410 (9113 left kidneys, 9021 right kidneys, and 276 en bloc kidneys), 962 pancreata, 8350 livers, 91 intestines, 3722 hearts, and 2463 lungs (Figure DD 30-37). In comparison, deceased donor organs transplanted in 2019 included 17,746 kidneys (8601 left kidneys, 8503 right kidneys, and 321 en bloc kidneys), 1018 pancreata, 8275 livers, 81 intestines, 3604 hearts, and 2607 lungs (Figure DD 30-37). Therefore, in 2020, the number of deceased donor organs transplanted increased for all organs except for pancreas and lungs. The number of deceased donor lungs transplanted may have decreased due to the COVID-19 pandemic. In a 2020 unadjusted analysis, not accounting for the mix of DBD and DCD donor types, OTPD varied substantially by DSA, ranging from 1.92 to 3.41, a narrower range than 2.08 to 3.60 in 2019, and a wider range than 2.26 to 3.56 in 2018 (Figure DD 12).

The OTPD from DBD donors was 3.25 in 2020, slightly down from 3.33 in 2019 and 3.34 in 2018. The OTPD from DCD donors was 1.89 in 2020, slightly down from 1.94 in 2019 and 2018 (Figure DD 13).

In 2020, the average number of kidneys transplanted per donor was 1.48 for DBD and 1.49 for DCD, compared with 1.48 DBD and 1.55 DCD in 2019 (Figure DD 14).

Apart from kidney donors, OTPD was higher from DBD than from DCD donors (Figure DD 14, Figure DD 15, Figure DD 16, Figure DD 17, Figure DD 18, Figure DD 19). The OTPD for kidneys has been higher from DCD than from DBD donors since 2008 and now is the same for both (Figure DD 14). Compared with 2019, the average number of DCD and DBD liver transplants per donor decreased slightly in 2020 (Figure DD 16). For pancreas transplants, DBD transplants per donor declined over the last decade (Figure DD 15). For intestine transplants, DBD donors increased slightly in 2020 over 2019 but remain considerably lower than 2009 (Figure 17). For heart and lung transplants, DBD transplants per donor increased over the last decade but declined slightly in 2020 from 2019, likely due to the COVID-19 pandemic. Innovative recovery methods for heart transplants, using DCD donors has increased in 2020 with OTPD of 0.03.

In 2020, among kidney donors, OTPD varied by kidney donor profile index (KDPI), at 1.94, 1.86, 1.55, and 0.62 for KDPI <0.20, 0.21-0.34, 0.35-0.85, and >0.85, respectively (Figure DD 20). The number of kidneys transplanted increased slightly for KDPI >0.34 each year since 2016 but declined in 2020 from 2019. In 2019, among kidney donors, OPTD was 1.93, 1.85, 1.57, and 0.65 and 1.95, 1.86, 1.57, and 0.64 in 2018 for KDPI <0.20, 0.21-0.34, 0.35-0.85, and >0.85, respectively (Figure DD 20).

The yield metric shown in Figure DD 21, Figure DD 22, Figure DD 23, Figure DD 24, Figure DD 25, and Figure DD 26 compares the number of organs transplanted (observed) in 2019-20 with the number expected to be transplanted based on national experience with similar donors (expected). A ratio, expressed as observed/expected organs transplanted, of less than 1 indicates that fewer organs were transplanted than expected. A ratio of more than 1 indicates that more organs were transplanted than expected. However, the 2020 data excludes the period from March 13 to June 12, 2020 due to the start of the pandemic. In 2019-20 (excluding March 13 to June 12, 2020), the mean observed/expected ratio ranged from 0.85 to 1.12 for kidneys, 0.40 to 3.03 for pancreata, 0.69 to 1.21 for livers, 0.00 to 5.68 for intestines, 0.83 to 1.28 for hearts, and 0.66 to 1.48 for lungs. In 2018-19, the mean observed/expected ratio ranged from 0.87 to 1.08 for kidneys, 0.37 to 2.21 for pancreata, 0.76 to 1.17 for livers, 0.00 to 4.24 for intestines, 0.82 to 1.25 for hearts, and 0.61 to 1.55 for lungs.

Organs Recovered for Transplant but Not Transplanted

The number of organs recovered for transplant but not transplanted is calculated by subtracting the number of organs transplanted from the number of organs recovered for transplant. The percentage of organs not transplanted is then calculated by dividing the number of organs not transplanted by the number of organs recovered for transplant. The percentage in 2020 for all organs combined was 15.0 per recovered organ, higher than 14.3 in 2019 and 13.2 in 2018 and 2017 (Figure DD 27). This trend in increasing annual discards has persisted since 2018. In 2020, the percentages for kidney, pancreata, liver, intestine, heart, and lung were 21.2, 23.2, 9.3, 3.1, 1.0 and 5.3 per recovered organ, respectively. The number of discards for kidneys increased the most in 2020 (Figure DD 27). In 2020, 2290 left kidneys, 2399 right kidneys, 181 en bloc kidneys, 294 pancreata, 861 livers, 3 intestines, 39 hearts, and 115 lungs were discarded. In 2019, 2044 left kidneys, 2146 right kidneys, 135 en bloc kidneys, 346 pancreata, 876 livers, 5 intestines, 31 hearts, and 148 lungs were discarded.² Thus, the absolute number of discards for kidneys and hearts increased from 2019 to 2020, and decreased for all other organs.

Use of DCD Organs and High KDPI Kidneys

Use of DCD organs varied across OPOs, from 0% to 44.4% of all deceased donors, in 2020 (Figure DD 28). In 2019, the percentage of DCD donor organs among deceased donor transplant recipients varied across DSAs, from 0% to 45% a slight wider range than in 2020.² In 2020, the percentage of kidney donors with KDPI higher than 85% also varied across DSAs, from 0.70 to 15.18, a narrower range than 0 to 16.8 in 2019.² (Figure DD 29).

Disposition of Organs

The disposition of each organ from actual donors is described in Figure DD 30, Figure DD 31, Figure DD 32, Figure DD 33, Figure DD 34, Figure DD 35, Figure DD 36, and Figure DD 37. For left and right kidneys, the most common reason for discard was “no recipient located, list exhausted,” followed by “biopsy findings.” For pancreas, the most common reasons were “other” and “anatomical abnormalities.” For livers, the most common reason was “biopsy findings,” followed by “other, specify.” The most common reasons for the three intestines discarded were “recipient determined to be unsuitable for transplantation in the operating room.” For hearts, the most common reason was “other, specify.” For lungs, the most common reason was “other, specify” and “poor organ function.” These reasons are similar to those in 2019.² Donor characteristics from 2020 are compared with those in 2010 in Table DD 1. The most remarkable difference was the increase in HIV-positive donors, to 21 in 2019 from none in 2009. This increase is due to the 2013 HIV Organ Policy Equity (HOPE) Act, which modified rules about organ donation between HIV-positive individuals and authorized use of these organs as part of clinical research. Other remarkable differences were an increase in anoxia as cause of donor death, from 24.4% in 2010 to 47.0% in 2020, and decreases in stroke (38.4% to 24.9%) and head trauma (34.2% to 24.8%). The percentage of DCD donors increased from 11.9% in 2010 to 25.6% in 2020. The increase in numbers of donors 18 to 49 years (4239 to 7183) and those with anoxia as cause of death (1942 to 5922) may be due to the opioid epidemic.

References

1. Trump DJ. Executive Order on Advancing American Kidney Health 2019, issued 2019 July 10. Available at https://www.whitehouse.gov/presidential-actions/executive-order-advancing-american-kidney-health.

2. Centers for Medicare & Medicaid Services. Organ Procurement Organizations Conditions for Coverage: Revisions to the Outcome Measure Requirements for Organ Procurement Organizations. 2021 [cited 2021 August 26, 2021]; Available from: https://www.cms.gov/files/document/112020-opo-final-rule-cms-3380-f.pdf.

Figure List

DOD

Figure DD 1. Relationship between deaths, donations, and transplants
Figure DD 2. Overall counts of eligible deaths, donors, and transplants, 2009-2020
Figure DD 3. Overall counts of deceased donors, DBD donors, and DCD donors, 2009-2020
Figure DD 4. Overall counts of authorized, recovered and transplanted organs, 2009-2020
Figure DD 5. Eligible Donors per 100 eligible deaths by DSA, 1/1/2020-3/12/2020 and 6/13/2020-12/31/2020
Figure DD 6. Overall and organ-specific eligible donors per 100 eligible deaths, 1/1/2020-3/12/2020 and 6/13/2020-12/31/2020
Figure DD 7. Organs recovered per donor, all organs and kidney
Figure DD 8. Organs recovered per donor, pancreas, liver, intestine, heart, and lung
Figure DD 9. Organs recovered per donor by DSA, 2020
Figure DD 10. Organs transplanted per donor, all organs and kidney
Figure DD 11. Organs transplanted per donor, pancreas, liver, intestine, heart, and lung
Figure DD 12. Organs transplanted per donor, by DSA, 2020
Figure DD 13. Organs transplanted per donor, by DBD and DCD status
Figure DD 14. Kidneys transplanted per donor, by DBD and DCD status
Figure DD 15. Pancreata transplanted per donor, by DBD and DCD status
Figure DD 16. Livers transplanted per donor, by DBD and DCD status
Figure DD 17. Intestines transplanted per donor, by DBD and DCD status
Figure DD 18. Hearts transplanted per donor, by DBD and DCD status
Figure DD 19. Lungs transplanted per donor, by DBD and DCD status
Figure DD 20. Kidneys transplanted per donor, by KDPI
Figure DD 21. Observed-to-expected yield per kidney, 1/1/2019-3/12/2020 and 6/13/2020-12/31/2020
Figure DD 22. Observed-to-expected yield per pancreas, 1/1/2019-3/12/2020 and 6/13/2020-12/31/2020
Figure DD 23. Observed-to-expected yield per liver, 1/1/2019-3/12/2020 and 6/13/2020-12/31/2020
Figure DD 24. Observed-to-expected yield per intestine, 1/1/2019-3/12/2020 and 6/13/2020-12/31/2020
Figure DD 25. Observed-to-expected yield per heart, 1/1/2019-3/12/2020 and 6/13/2020-12/31/2020
Figure DD 26. Observed-to-expected yield per lung, 1/1/2019-3/12/2020 and 6/13/2020-12/31/2020
Figure DD 27. Organs recovered for transplant and not transplanted
Figure DD 28. The percentage of DCD donors across DSAs from all donors, 2020
Figure DD 29. The percentage of kidney donors with KDPI greater than 85% among deceased donor kidney transplant recipients across DSAs, 2020
Figure DD 30. Organ use chart for reported left kidneys, 2020
Figure DD 31. Organ use chart for reported right kidneys, 2020
Figure DD 32. Organ use chart for reported en bloc kidneys, 2020
Figure DD 33. Organ use chart for pancreas, 2020
Figure DD 34. Organ use chart for liver, 2020
Figure DD 35. Organ use chart for intestine, 2020
Figure DD 36. Organ use chart for heart, 2020
Figure DD 37. Organ use chart for lung, 2020

Table List

DOD

Table DD 1. Characteristics of deceased donors, 2010 and 2020
Table DD 2. Characteristics of deceased donors whose cause of death was anoxia, 2010 and 2020
Table DD 3. Characteristics of deceased donors whose cause of death was stroke, 2010 and 2020
Table DD 4. Characteristics of deceased donors whose cause of death was CNS tumor, 2010 and 2020
Table DD 5. Characteristics of deceased donors whose cause of death was head trauma, 2010 and 2020
Table DD 6. Characteristics of deceased donors whose cause of death was other or unknown, 2010 and 2020

Table DD 1. Characteristics of deceased donors, 2010 and 2020
Note: The way citizenship data is collected changed in 2012, so differences may be misleading.

Characteristic	2010, N	2010, Percent	2020, N	2020, Percent
KDPI: <20%	1760	22.2%	2291	18.2%
KDPI: 21-34%	940	11.8%	1595	12.7%
KDPI: 35-85%	3544	44.6%	5872	46.6%
KDPI: >85%	1352	17.0%	2074	16.5%
KDPI: Unknown/missing	347	4.4%	756	6.0%
HIV: Not Positive			12,564	99.8%
HIV: Positive			24	0.2%
HCV: Not Positive	7612	95.8%	11,772	93.5%
HCV: Positive	331	4.2%	816	6.5%
Citizenship: US	7809	98.3%	11,155	88.6%
Citizenship: Non-US	1	0.0%	290	2.3%
Citizenship: Other/unkown	133	1.7%	1143	9.1%
COD: Anoxia	1942	24.4%	5922	47.0%
COD: Stroke	3049	38.4%	3134	24.9%
COD: Head Trauma	2720	34.2%	3123	24.8%
COD: CNS Tumor	35	0.4%	38	0.3%
COD: Other/unkown	197	2.5%	371	2.9%
Sex: Female	3260	41.0%	4786	38.0%
Sex: Male	4683	59.0%	7802	62.0%
Age: <18 years	841	10.6%	860	6.8%
Age: 18-34 years	2169	27.3%	3554	28.2%
Age: 35-49 years	2070	26.1%	3629	28.8%
Age: 50-64 years	2194	27.6%	3726	29.6%
Age: ≥65 years	669	8.4%	819	6.5%
Ethnicity: Non-Latino/unkown	6843	86.2%	10,716	85.1%
Ethnicity: Latino	1100	13.8%	1872	14.9%
Race: White	6313	79.5%	10,094	80.2%
Race: Black	1393	17.5%	1999	15.9%
Race: Asian	182	2.3%	323	2.6%
Race: Other/unkown	55	0.7%	172	1.4%
DCD status: DBD	7000	88.1%	9364	74.4%
DCD status: DCD	943	11.9%	3224	25.6%