OPTN/SRTR 2020 Annual Data Report: Liver

Abstract

This year was marked by the COVID-19 pandemic, which altered transplant program activity and affected waitlist and transplant outcomes. Still, 8906 liver transplants were performed, an all-time high, across 142 centers in the United States, and pretransplant as well as graft and patient survival metrics, continued to improve. Living donation activity decreased after several years of growth. As of June 30, 2020, 98989 liver transplant recipients were alive with a functioning graft, and in the context of increasing liver transplant volume, the size of both the adult and pediatric liver transplant waitlists have decreased.

On February 4, 2020, shortly before the pandemic began, a new liver distribution policy based on acuity circles was implemented, replacing donor service area- and region-based boundaries. A policy change to direct pediatric livers to pediatric recipients led to an increase in deceased donor transplant rates and a decrease in pretransplant mortality rate among children, although the absolute number of pediatric transplants did not increase in 2020.

Among adults, alcohol-associated liver disease became the predominant indication for liver transplant in 2020. After implementation of the National Liver Review Board and lower waitlist priority for most exception cases in 2019, fewer liver transplants were being performed via exception points, and the transplant rate between those with and without hepatocellular carcinoma has equalized. Women continue to experience higher pretransplant mortality and lower rates of liver transplant than men.

Adult Transplant

Waiting List Registration

A total of 24936 candidates were listed for liver transplant, with 12409 newly added and 13164 removed during the year (Figure LI 1, Figure LI 2, Table LI 4). As the number of transplants in the past decade has consistently increased, the size of the waitlist has decreased, albeit slightly, with 11772 candidates still waiting on December 31, 2020 (Table LI 4).

The proportion of older (aged ≥65 years) candidates continued to increase, representing 21.7% of the adult waiting list in 2020, compared with 9.4% in 2010 (Figure LI 3). The sex and racial composition of the waiting list has remained relatively unchanged: 61.6% male, 38.4% female, 68.7% White, 7.0% Black, 17.9% Hispanic, and 4.8% Asian (Figure LI 4, Figure LI 5).

Alcohol-associated liver disease and other/unknown diagnosis (often representing liver disease due to non-alcoholic steatohepatitis) are now the leading indications for liver transplant listing, whereas the proportions of acute liver failure, cholestatic liver disease and, especially, hepatitis C virus (HCV) have declined (Figure LI 6). Candidates with a primary diagnosis of hepatocellular carcinoma (HCC) composed 10.9% of new waiting list registrations, which has nearly doubled over the past decade.

The severity of liver disease, based on the first active laboratory model for end-stage liver disease (MELD) during the calendar year, has increased, with a greater proportion of listings with MELD 25-34 (12.0%), MELD 35-40 (3.4%), and MELD 40+ (3.0%) (Figure LI 7). Candidates with body mass index (BMI) ≥35 kg/m² composed 17.8% of the waiting list, representing the only BMI category with a steadily increasing trend (Figure LI 8). In 2020, 3.2% of candidates had a history of liver transplant (Figure LI 10).

Compared with 2015, the number of liver candidates willing to accept HCV-positive donors increased nearly three-fold (60.2% vs 21.0%), reflecting a distinct shift in attitudes over the past five years owing to the availability of direct-acting antiviral (DAA) therapy (Figure LI 11).

Waiting List Outcomes

The overall deceased donor transplant rate among adult waiting list candidates has risen to 65.2 per 100 waiting list-years in 2020 from 35.7 per 100 waiting list-years in 2009 (Figure LI 12). The increase occurred across all age-groups, major racial/ethnic groups, blood types, and places of residence (metropolitan vs non-metropolitan) (Figure LI 13, Figure LI 14, Figure LI 15, Figure LI 18). Women continued to experience a lower deceased donor transplant rate than men (59.9 vs 68.6 per 100 waiting list-years) (Figure LI 17). The gap between candidates with and without HCC exception points continued to narrow (79.0 vs 63.7 per 100 waiting list-years), reflecting the May 2020 policy lowering waitlist priority for exception cases (Figure LI 16).

Of the adults listed for liver transplant in 2017, 58.0% received a transplant (including 2.3% from a living donor), 10.1% died, and 23.4% were removed from the list for other reasons without undergoing transplant, leaving 8.6% still waiting (Figure LI 19). In a competing-risk framework for time from listing to transplant, the median waiting time among patients listed in 2020 decreased across the board, with patients listed as status 1A waiting a median of 0.13 months (4.0 days), those with MELD ≥35 waiting 0.16 months (5.0 days), and those with MELD 15-34 waiting 4.2 months (Figure LI 20). In absolute terms, of candidates listed in 2019, 32.8% received a deceased donor liver transplant within 3 months, while 39.4% received one within 6 months, and 50.2% received one within 1 year. (Figure LI 21).

Geographic differences in deceased donor transplant rates persisted, ranging from 32% to 87% at 3 years by donation service area (DSA) (Figure LI 22) and 31% to 83% by state of residence (Figure LI 23). The highest rates were seen in South Carolina, Puerto Rico, Mississippi, Louisiana, and Indiana, and the lowest in South Dakota, North Dakota, Montana, Vermont, and Alaska, only one of which (South Dakota) has a transplant center.

The pretransplant mortality rate in 2020 was 12.2 per 100 waiting list-years, an all-time low (Figure LI 24). Higher rates of pretransplant mortality were observed among women than men (13.1 vs 11.6 deaths per 100 waiting list-years) (Figure LI 27). Pretransplant mortality was highest among those with acute liver failure (19.0 deaths per 100 waiting list-years) and lowest among those with HCV or HCC (9.1 deaths per 100 waiting list-years for both groups) (Figure LI 28). Overall, pretransplant mortality has improved in the higher MELD categories (ie, MELD 25 or greater), although it was still high for those with MELD 35-40 or 40+ (167 and 124 deaths per 100 waiting list-years, respectively) (Figure LI 30). Pretransplant mortality has decreased among candidates with HCC exceptions (Figure LI 31). DSA-level pretransplant mortality rates still varied, ranging from 6.0 to 21.7 deaths per 100 waiting list-years (Figure LI 32).

The most common reason for waiting list removal was deceased or living donor transplant (63.4%), followed by death or being too sick for transplant (18.0%), other reasons (10.9%), and condition improved and transplant no longer needed (6.9%) (Table LI 5). Deaths within 6 months after removal from the waiting list for reasons other than transplant increased to 18.2%, with higher rates among older age groups and MELD categories (Figure LI 33, Figure LI 34, Figure LI 35).

Donation

The number of deceased liver donors continue to increase, reaching an all-time high of 9211 in 2020, despite fewer pediatric donors (age <18) (Figure LI 36, Figure LI 39). The sex and racial composition of donors has remained relatively unchanged: 61.4% male, 38.6% female, 63.3% White, 17.8% Black, 15.1% Hispanic, and 2.8% Asian (Figure LI 40, Figure LI 41). HCV-positive organs made up 9.7% of deceased donor livers recovered in 2020 (Figure LI 38, Figure LI 42).

Overall, 9.5% of livers recovered were not transplanted; livers from older donors were less likely to be transplanted (Figure LI 44, Figure LI 45). Livers with positive hepatitis C antibody and those at increased risk of disease transmission were not more likely to be discarded (Figure LI 49, Figure LI 50). The discard rate of livers from donors after circulatory death (DCD) was lower than in previous years, but DCD livers remained much more likely to not be transplanted than livers recovered from donors after brain death (26.6% vs 7.1% (Figure LI 51). Amid the ongoing opioid epidemic in the United States, the proportion of donors with anoxic brain injury continued to rise, representing the leading cause of death among deceased donors (46.3%) (Figure LI 52).

In 2020, 485 living donor liver transplants were performed, a 6% decrease compared with the year before (n=516), which was likely an effect of the COVID pandemic (Figure LI 54). Most donors were related to or directed to the recipient, with a small but growing proportion of nondirected living donation (12.0%) as well as paired donation (2.9%). Most living donors were 18 to 54 years old, with a minority being over 55 years (5.5%) (Figure LI 55). Living donors were more likely to be women (58.0%) and White (79.4%) (Figure LI 56, Figure LI 57). In most cases, the right lobe of the liver was used (76.2%), an overall increasing trend in the past decade (Figure LI 58). The readmission rate for living liver donors (2015-2019) was 9.0% at 6 months and 11.0% at 12 months (Figure LI 53). Reported events among liver donors (2016-2020) included biliary complications (2.6%), vascular complications requiring intervention (0.8%), reoperation (2.1%), and other complications requiring intervention (5.3%) (Table LI 6). Of these donors, 0.9% experienced Clavien Grade 1 complications, while 1.5% had Clavien Grade 2, and 0.4% had Clavien Grade 3 complications (Table LI 6).

Transplants

In 2020, despite the COVID-19 pandemic, 8906 liver transplants were performed in the United States, more than in any previous year (Figure LI 60, Figure LI 61). Adults represented 94.4% of liver transplant recipients, with 7979 deceased donor and 425 living donor liver transplants. The proportion of patients 65 years or older continued to grow, making up 22.4% (Figure LI 62). Among liver transplant recipients, 63.2% were male; 70.0% were White, 16.8% were Hispanic, 7.3% were Black, and 4.3% were Asian (Figure LI 63, Figure LI 64, Table LI 8). Coincident with the increased prevalence of nonalcoholic steatohepatitis, 39.3% were obese (BMI ≥30 kg/m²) (Table LI 8), and 28.9% had diabetes (Table LI 9). Compared with a decade before, a smaller proportion (4.3% vs 6.3%) of recipients had a prior liver transplant (Table LI 10). Half of adult liver transplants were covered by private insurance (50.8%), followed by Medicare (28.9%) and Medicaid (16.3%).

Among adults, alcohol-associated liver disease was the most common indication for liver transplant, surpassing the other/unknown category (often nonalcoholic steatohepatitis) (35.2% vs 34.6%) (Figure LI 65, Table LI 9). The proportion of liver transplant for HCV continued to fall, representing only 6.7% of transplants, from 26.6% in 2010. Liver transplants for HCC, the third most common diagnosis, declined further, to 12.6%, likely related to interim changes in the allocation of exception points and decreasing prevalence of patients with HCV infection at risk of HCC. With regard to medical urgency, 20.9% of adults received transplants with MELD ≥35, 18.3% with MELD 30-34, 52.0% with MELD 15-29, 6.4% with MELD <15, and 2.4% as status 1A (Table LI 9). The proportion of patients hospitalized at transplant was 37.2%, with 14.4% in the intensive care unit (Table LI 9). Waiting time was much shorter in 2020 than in prior years: 43.8% waited fewer than 31 days, while 68.6% waited fewer than 6 months, and 85.6% waited less than 1 year (Table LI 10).

Multiorgan transplants accounted for 10.1%, most of which were simultaneous liver-kidney transplants (9.1%) (Table LI 10). Very few adult recipients received split livers (0.8%). The proportion of patients receiving DCD livers continued to increase, up to 9.9%, compared with 4.6% in 2010 (Table LI 10). From 2018 to 2020, 9.7% of transplanted deceased donor livers carried HCV antibodies, with over half having negative HCV nucleic acid testing (Table LI 11).

Within the continental United States, geographic variability in organ availability may be measured in terms of median allocation MELD. Among adult deceased donor liver transplant recipients, the median MELD ranged from 18 to 33 by DSA (Figure LI 68). The median DSA-level MELD at transplant was 27, with an interquartile range of 24-29, a measure of spread among the DSAs, similar to 2019 (Figure LI 69). Although preliminary, these data suggest that the allocation changes employing acuity circles implemented early in 2020 did not have a measurable impact on reducing geographic variability among DSAs.

The National Liver Review Board was established in May 2019 to better standardize exceptions. The “point escalator” previously granted for qualifying candidates was replaced with a static score, for most, 3 points below the center’s median allocation MELD at transplant. In 2020, 22.5% of adult liver transplants were allocated by exception points, compared with 28.7% in 2019 and 34.3% in 2018 (Figure LI 126). This decline was driven by a decrease in non-HCC exceptions, which made up 5.4% of cases, compared with 10.3% in 2019 and 12.9% in 2018 (Table LI 9).

In 2020, 119 programs performed adult liver transplants, and the median transplant program volume increased from 55 in 2019 (IQR, 24-104) to 66 in 2020 (IQR, 24-101) (Figure LI 72). The bottom quartile of transplant centers in terms of volume performed fewer than 25 liver transplants, whereas the top quartile performed more than 100 liver transplants.

There were no noticeable changes in posttransplant immunosuppression. Induction therapy was used in 28.0% of adult liver transplants, and 71.6% of adult liver transplant recipients received steroid-containing immunosuppressive regimens (Figure LI 66, Figure LI 67).

Outcomes

As of June 30, 2020, 98842 liver transplant recipients were alive with a functioning graft, of whom 87030 received a liver transplant as adults (Figure LI 89).

Both short- and long-term outcomes after liver transplant continued to improve. Graft failure occurred in 5.9% of deceased donor liver transplant recipients at 6 months and 7.9% at 1 year for transplants performed in 2019, in 14.7% at 3 years for transplants in 2017, in 20.7% at 5 years for transplants in 2015, and in 40.6% at 10 years for transplants in 2010 (Figure LI 74). Outcomes were similar, if not better, for living donor liver transplant recipients, with graft failure occurring in 4.9% at 6 months, 7.4% at 1 year, 12.2% at 3 years, 23.7% at 5 years, and 36.7% at 10 years (Figure LI 75). Patient survival demonstrated similar patterns, with 4.6% mortality at 6 months, 6.4% at 1 year, 13.1% at 3 years, 18.8% at 5 years, and 38.2% at 10 years (Figure LI 76).

Five-year graft survival rates among deceased donor liver transplant recipients exceeded 75% across most categories, except for those ≥65 years (74.0%), MELD 40+ (74.5%), and DCD liver recipients (74.2%) (Figure LI 77, Figure LI 79, Figure LI 80). Five-year graft outcomes were equivalent between those with and without HCC exception points (Figure LI 81). Whereas deceased donor liver transplant recipients with a primary diagnosis of HCC had 5-year survival rates comparable to other disease etiologies (77.0%), living donor liver transplant recipients with HCC demonstrated worse 5-year survival rates (70.1%) (Figure LI 78, Figure LI 86). Patient outcomes after deceased donor and living donor liver transplant largely mirrored that of graft survival (Figure LI 93, Figure LI 94, Figure LI 95, Figure LI 97, Figure LI 98). Within 1 year, 11.5% of adult liver transplant recipients in 2018-2019 reported at least one episode of acute rejection, most often among recipients aged 18-34 (19.6%) (Figure LI 90). About 1% of adult liver recipients developed posttransplant lymphoproliferative disorder over 5 years; among Epstein-Barr virus-negative recipients, the incidence was doubled (Figure LI 92).

Pediatric Transplant

Summary

Pediatric liver transplant candidates were prioritized for pediatric donors as part of the acuity circles policy implemented in February 2020. This allowed offers to be prioritized to children nationally before being offered to adults within a 500 nautical mile acuity circle. In 2020, pediatric waitlist mortality decreased to its lowest rate since 2011, accounted for primarily by a decrease in waitlist mortality in infants <1 year old. Simultaneously, in 2020, adult waitlist pretransplant mortality rates continued to improve despite this change. Even though pretransplant mortality rates for children improved in 2020, 33 children still died on the waitlist or were removed for being too sick to transplant. The utilization of exception scores decreased between 2019 and 2020 and the number of technical variant liver transplants has not changed significantly over the last decade. Overall, living donor recipients have better long-term graft and patient survival compared to deceased donor recipients, but the proportion of recipients undergoing living donor transplant decreased in 2020 compared to 2019. While long-term patient survival continues to improve, 15.9% of pediatric liver transplant recipients transplanted in 2010 did not survive to 2020. Finally, addressing racial disparities in pediatric liver transplantation must remain forefront, with higher pretransplant mortality rates noted for Black, Hispanic and Asian registrants compared to White registrants.

Waiting List

In 2020, 616 new registrants were added to the pediatric liver transplant waiting list (Figure LI 102). Children <1 year (28.9%) and 1-5 years (28.8%) made up the largest age groups, followed by 12-17 (27.4%) and 6-11 years (14.8%) (Figure LI 104). White registrants continued to make up the largest racial/ethnic group on the waitlist in 2020 (45.4%), followed by Hispanic (26.2%), Black (17.6%), and Asian registrants (7.7%) (Figure LI 105). For pediatric liver waitlist registrants, between 2010 to 2020, sex, race, diagnosis, and geographic distributions did not change substantially (Table LI 13, Table LI 14).

Waiting time has not changed significantly in the past decade with 54.4% of candidates waiting less than 1 year in 2020, 15.3% waiting 1-2 years and 30.3% waiting 2 or more years until transplant (Table LI 15). The proportion of registrants listed for multi-organ transplant continues to increase over the last decade: liver-kidney registrants increased from 1.5% to 3.8%, liver-pancreas-intestine registrants from 8.3% to 13.8% and liver-heart registrants from 0.2% to 1.5% (Table LI 15). Among registrants removed from the waitlist in 2020: 67.4% underwent deceased donor transplant and 9.8% underwent living donor transplant. In 2020, fewer registrants died on the waitlist (n=17, 2.5%) compared to 2019 (n=29, 3.9%), 11.0% were removed because their condition improved, and 2.4% were considered too sick for transplant (Table LI 17).

Pretransplant mortality decreased to its lowest rate since 2011 at 4.9 deaths per 100 waitlist-years in 2020 accounted for primarily by a decrease in mortality rate for infants less than 1 year old; from 12.1 to 6.4 deaths per 100 waitlist-years between 2019 and 2020 (Figures LI 114 and 115). However, 17 registrants still died on the waitlist and 16 were too sick to transplant in 2020 (Table LI 17). While the pretransplant mortality rate remained the highest for registrants younger than 1 year, the gap narrowed in 2020 with the next highest pretransplant mortality rate being 5.7 deaths per 100 waitlist-years for 6-11 year olds (Figure LI 115). Pretransplant mortality rates were highest in Asian followed by Black and Hispanic registrants with the lowest mortality rate for White registrants (Figure LI 116).

Transplants

In 2020, 502 pediatric liver transplants were performed in the United States, the lowest number in the past decade and a decrease of 8.9% from 2019 (Figure LI 118). The overall number of pediatric transplants decreased for 0-11 year olds, but increased for 12-17 year olds (Figure LI 120). Recipient demographics including age at the time of transplant, race or ethnicity, insurance type and geography have remained similar over the past decade (Table LI 18). Biliary atresia remaining the leading indication for transplant (33.2%) followed by other/unknown diagnosis (21.6%), metabolic (17.3%), other cholestatic condition (13.1%), acute liver failure (7.7%) and hepatoblastoma (7.1%) (Table LI 19). From 2018-2020, 5.6% (n=90) of recipients received an ABO incompatible graft and 0.3% (n=5) received a graft from a donor after circulatory death. The majority of recipients were liver only transplants (91.8%), followed by liver-intestine-pancreas (4%), liver-kidney (3.2%) and liver-intestine (0.2%) (Table LI 20).

Sixty-one percent of recipients between 0-17 years old had an exception PELD or MELD score at the time of transplant, decreasing from 74.7% the year prior (Figure LI 126). The utilization of exception scores continued to vary by donation service area ranging from 20-100% of transplanted recipients (Figure LI 127). Over the last decade, there has been no change in living donor transplants and fewer total recipients underwent living donor transplant in 2020 (n=66, 12.7% of total transplants) compared to 2019 (n=82, 14.5% of total transplants). Over the last decade there has been some shift from living related donors to more unrelated and non-directed (altruistic) living donors (Table LI 17, Figure LI 121). There has been no increase in the use of technical variant grafts over the last decade and in 2020 63.1% were whole liver transplants, 19.9% were partial liver and 16.9% were split liver transplants (Figure LI 125). Fewer patients were transplanted for acute liver failure and more patients were transplanted for metabolic conditions in 2018-2020 compared to 2008-2010. This is also reflected in fewer patients being transplanted at Status 1A and more patients being transplanted at Status 1B over the last decade. The plurality of recipients (43.8%) were transplanted at a MELD/PELD 30 (Table LI 19).

In 2020, 63.5% of pediatric liver transplant recipients received no induction therapy (Figure LI 128). The most common initial immunosuppression regimens were tacrolimus, MMF, and steroids (38.6%) and tacrolimus and steroids (36.9%) (Figure LI 129).

Outcomes

Within 1 year of transplant, 26% of transplant recipients in 2018-2019 had at least one episode of rejection (Figure LI 137). By 5 years out from transplant 4.2% of recipients developed posttransplant lymphoproliferative disorder (Figure LI 138).

Graft failure occurred in 7.6% of deceased donor recipients at 6 months, 9.3% at 1 year, 11.6% at 3 years, 14.2% at 5 years, and 20.9% at 10 years from transplant (Figure LI 131). Graft failure was generally lower in living donor recipients, occurring in 3.8% at 6 months, 7.6% at 1 year, 5.6% at 3 years, 8.9% at 5 years and 25.4% at 10 years out from transplant (Figure LI 132). Five-year graft survival was highest for recipients who were 6-11 years old at the time of transplant (88.8%) followed by 12-17 (86.3%), <1 year (83.5%) and 1-5 year olds (80.7%) for deceased donor recipients (Figure LI 133). By diagnosis, five-year graft survival was highest for deceased donor recipients with biliary atresia (87.5%), followed by metabolic conditions (86.3%), acute liver failure (83.9%), other/unknown (81.2%), other cholestatic (80.4%) and hepatoblastoma (77.7%) (Figure LI 134). Deceased donor recipients transplanted at a PELD/MELD between 35-39 had the lowest five-year graft survival at 72.9% (Figure LI 135). At all time points, living donor recipients had better graft survival compared to deceased donor recipients, with a five-year graft survival of 90.1% compared to 83.8%, respectively (Figure LI 136)

Recipient mortality continued to improve over the last decade, though still remains notable. Death occurred in 3.8% of deceased and living donor recipients at 6 months, 5.6% at 1 year, 8.5% at 3 years, 9.1% at 5 years, and 15.9% at 10 years from transplant (Figure LI 139). Five-year patient survival was highest for recipients who were 6-11 years old at the time of transplant (92.0%) followed by <1 year (91.5%), 12-17 (89.4%) and 1-5 year olds (88.4%) for deceased donor recipients (Figure LI 141). By diagnosis, five-year patient survival was highest for deceased donor recipients with biliary atresia (93.5%), followed by acute liver failure (92.9%), metabolic conditions (92.1%), other/unknown (87.1%), other cholestatic (85.7%) and hepatoblastoma (82.6%) (Figure LI 142). At all time points, living donor recipients had better patient survival compared to deceased donor recipients, with a five-year patient survival of 93.6% compared to 89.9%, respectively (Figure LI 143).

Figure List

Waiting list

Figure LI 1. New adult candidates added to the liver transplant waiting list
Figure LI 2. All adult candidates on the liver transplant waiting list
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 first active lab MELD in the year
Figure LI 8. Distribution of adults waiting for liver transplant by BMI
Figure LI 9. Distribution of adults waiting for liver transplant by blood type
Figure LI 10. Distribution of adults waiting for liver transplant by prior transplant status
Figure LI 11. Adults willing to accept liver from HCV+ donor
Figure LI 12. Overall deceased donor liver transplant rates among adult waitlist candidates
Figure LI 13. Deceased donor liver transplant rates among adult waitlist candidates by age
Figure LI 14. Deceased donor liver transplant rates among adult waitlist candidates by race
Figure LI 15. Deceased donor liver transplant rates among adult waitlist candidates by blood type
Figure LI 16. Deceased donor liver transplant rates among adult waitlist candidates by HCC exception status
Figure LI 17. Deceased donor liver transplant rates among adult waitlist candidates by sex
Figure LI 18. Deceased donor liver transplant rates among adult waitlist candidates by metropolitan vs. non-metropolitan residence
Figure LI 19. Three-year outcomes for adults waiting for liver transplant, new listings in 2015-2017
Figure LI 20. Median months to liver transplant for waitlisted adults
Figure LI 21. Percentage of adults who underwent deceased donor liver transplant within a given time period of listing
Figure LI 22. Percentage of adults who underwent deceased donor liver transplant within 3 years of listing, 2017, by DSA
Figure LI 23. Percentage of adults who underwent deceased donor liver transplant within 3 years of listing, 2017, by state
Figure LI 24. Overall pretransplant mortality rates among adults waitlisted for liver transplant
Figure LI 25. Pretransplant mortality rates among adults waitlisted for liver transplant by age
Figure LI 26. Pretransplant mortality rates among adults waitlisted for liver transplant by race
Figure LI 27. Pretransplant mortality rates among adults waitlisted for liver transplant by sex
Figure LI 28. Pretransplant mortality rates among adults waitlisted for liver transplant by diagnosis
Figure LI 29. Pretransplant mortality rates among adults waitlisted for liver transplant by metropolitan vs. non-metropolitan residence
Figure LI 30. Pretransplant mortality rates among adults waitlisted for liver transplant by first active lab MELD in the year
Figure LI 31. Pretransplant mortality rates among adults waitlisted for liver by HCC exception status
Figure LI 32. Pretransplant mortality rates among adults waitlisted for liver transplant in 2020 by DSA
Figure LI 33. Deaths within six months after removal among adult liver waitlist candidates, overall
Figure LI 34. Deaths within six months after removal among adult liver waitlist candidates, by first active lab MELD in the year
Figure LI 35. Deaths within six months after removal among adult liver waitlist candidates, by age

Deceased donation

Figure LI 36. Overall deceased liver donor count
Figure LI 37. Deceased liver donor count by age
Figure LI 38. Deceased liver donor count by HCV status
Figure LI 39. Distribution of deceased liver donors by age
Figure LI 40. Distribution of deceased liver donors by sex
Figure LI 41. Distribution of deceased liver donors by race
Figure LI 42. Distribution of deceased liver donors by donor HCV status
Figure LI 43. Percent of pediatric donor livers allocated to adult recipients, by DSA of donor hospital, 2016-2020
Figure LI 44. Overall percent of livers recovered for transplant and not transplanted
Figure LI 45. Percent of livers recovered for transplant and not transplanted by donor age
Figure LI 46. Percent of livers recovered for transplant and not transplanted by donor sex
Figure LI 47. Percent of livers recovered for transplant and not transplanted by donor race
Figure LI 48. Percent of livers recovered for transplant and not transplanted by donor cause of death
Figure LI 49. Percent of livers recovered for transplant and not transplanted by donor HCV status
Figure LI 50. Percent of livers recovered for transplant and not transplanted, by donor risk of disease transmission
Figure LI 51. Percent of livers recovered for transplant and not transplanted by DCD status
Figure LI 52. Cause of death among deceased liver donors

Living donation

Figure LI 53. Rehospitalization among living liver donors, 2015-2019
Figure LI 54. Number of living liver transplants by donor relation
Figure LI 55. Living liver donors by age
Figure LI 56. Living liver donors by sex
Figure LI 57. Living liver donors by race
Figure LI 58. Living donor liver transplant graft type
Figure LI 59. BMI among living liver donors

Transplant

Figure LI 60. Overall liver transplants
Figure LI 61. Total liver transplants by donor type
Figure LI 62. Total liver transplants by age
Figure LI 63. Total liver transplants by sex
Figure LI 64. Total liver transplants by race
Figure LI 65. Total liver transplants by diagnosis
Figure LI 66. Induction agent use in adult liver transplant recipients
Figure LI 67. Immunosuppression regimen use in adult liver transplant recipients
Figure LI 68. Median MELD scores for adult deceased donor liver transplant recipients by DSA, 2020
Figure LI 69. Quartiles of median MELD at transplant across DSAs for adult deceased donor liver recipients.
Figure LI 70. Percent of adult liver transplant recipients using exceptions in 2020, by DSA
Figure LI 71. Total HLA A, B, and DR mismatches among adult deceased donor liver-kidney transplant recipients, 2016-2020
Figure LI 72. Annual adult liver transplant center volumes by percentile
Figure LI 73. Distribution of adult liver transplants by annual center volume

Outcomes

Figure LI 74. Graft failure among adult deceased donor liver transplant recipients
Figure LI 75. Graft failure among adult living donor liver transplant recipients
Figure LI 76. Patient death among adult liver transplant recipients
Figure LI 77. Graft survival among adult deceased donor liver transplant recipients, 2013-2015, by age
Figure LI 78. Graft survival among adult deceased donor liver transplant recipients, 2013-2015, by diagnosis
Figure LI 79. Graft survival among adult deceased donor liver transplant recipients, 2013-2015, by lab MELD
Figure LI 80. Graft survival among adult deceased donor liver transplant recipients, 2013-2015, by DCD status
Figure LI 81. Graft survival among adult deceased donor liver transplant recipients, 2013-2015, by HCC status
Figure LI 82. Graft survival among adult deceased donor liver transplant recipients, 2013-2015, by BMI
Figure LI 83. Graft survival among adult deceased donor liver transplant recipients, 2013-2015, by metropolitan vs. non-metropolitan recipient residence
Figure LI 84. Graft survival among adult living donor liver transplant recipients, 2013-2015, by age
Figure LI 85. Graft survival among adult living donor liver transplant recipients, 2013-2015, by race
Figure LI 86. Graft survival among adult living donor liver transplant recipients, 2013-2015, by diagnosis
Figure LI 87. Graft survival among adult living donor liver transplant recipients, 2013-2015, by lab MELD
Figure LI 88. Graft survival among adult living donor liver transplant recipients, 2013-2015, by metropolitan vs. non-metropolitan recipient residence
Figure LI 89. Recipients alive with a functioning liver graft on June 30 of the year, by age at transplant
Figure LI 90. Incidence of acute rejection by 1 year posttransplant among adult liver transplant recipients by age, 2018-2019
Figure LI 91. Incidence of acute rejection by 1 year posttransplant among adult liver transplant recipients by induction agent, 2018-2019
Figure LI 92. Incidence of PTLD among adult liver transplant recipients by recipient EBV status at transplant, 2014-2018
Figure LI 93. Patient survival among adult deceased donor liver transplant recipients, 2013-2015, by age
Figure LI 94. Patient survival among adult deceased donor liver transplant recipients, 2013-2015, by diagnosis
Figure LI 95. Patient survival among adult deceased donor liver transplant recipients, 2013-2015, by medical urgency
Figure LI 96. Patient survival among adult deceased donor liver transplant recipients, 2013-2015, by metropolitan vs. non-metropolitan recipient residence
Figure LI 97. Patient survival among adult living donor liver transplant recipients, 2013-2015, by age
Figure LI 98. Patient survival among adult living donor liver transplant recipients, 2013-2015, by diagnosis
Figure LI 99. Patient survival among adult living donor liver transplant recipients, 2013-2015, by race
Figure LI 100. Patient survival among adult living donor liver transplant recipients, 2013-2015, by MELD score
Figure LI 101. Patient survival among adult living donor liver transplant recipients, 2013-2015, by metropolitan vs. non-metropolitan recipient residence

Pediatric transplant

Figure LI 102. New pediatric candidates added to the liver transplant waiting list
Figure LI 103. All pediatric candidates on the liver transplant waiting list
Figure LI 104. Distribution of pediatric candidates waiting for liver transplant by age
Figure LI 105. Distribution of pediatric candidates waiting for liver transplant by race
Figure LI 106. Distribution of pediatric candidates waiting for liver transplant by sex
Figure LI 107. Three-year outcomes for newly listed pediatric candidates waiting for liver transplant, 2015-2017
Figure LI 108. Overall deceased donor liver transplant rates among pediatric waitlist candidates
Figure LI 109. Deceased donor liver transplant rates among pediatric waitlist candidates by age
Figure LI 110. Deceased donor liver transplant rates among pediatric waitlist candidates by race
Figure LI 111. Deceased donor liver transplant rates among pediatric waitlist candidates by allocation MELD/PELD
Figure LI 112. Deceased donor liver transplant rates among pediatric waitlist candidates by Status 1A or 1B
Figure LI 113. Deceased donor liver transplant rates among pediatric waitlist candidates by metropolitan vs. non-metropolitan residence
Figure LI 114. Overall pretransplant mortality rates among pediatric candidates waitlisted for liver
Figure LI 115. Pretransplant mortality rates among pediatric candidates waitlisted for liver transplant by age
Figure LI 116. Pretransplant mortality rates among pediatric candidates waitlisted for liver transplant by race
Figure LI 117. Pretransplant mortality rates among pediatric candidates waitlisted for liver transplant by metropolitan vs. non-metropolitan residence
Figure LI 118. Overall pediatric liver transplants
Figure LI 119. Pediatric liver transplants by donor type
Figure LI 120. Pediatric liver transplants by recipient age
Figure LI 121. Pediatric liver transplants from living donors by relation
Figure LI 122. Percent of pediatric liver transplants from living donors by recipient age
Figure LI 123. Number of centers performing pediatric and adult liver transplants by center's age mix
Figure LI 124. Pediatric liver recipients at programs that perform 5 or fewer pediatric transplants annually
Figure LI 125. Split or partial liver transplants in children
Figure LI 126. Percent of pediatric and adult liver transplant recipients allocated by exception
Figure LI 127. Percent of pediatric liver transplant recipients using exceptions, 2018-2020, by DSA
Figure LI 128. Induction agent use in pediatric liver transplant recipients
Figure LI 129. Immunosuppression regimen use in pediatric liver transplant recipients
Figure LI 130. Total HLA A, B, and DR mismatches among pediatric deceased donor liver-kidney transplant recipients, 2015-2019
Figure LI 131. Graft failure among pediatric deceased donor liver transplant recipients
Figure LI 132. Graft failure among pediatric living donor liver transplant recipients
Figure LI 133. Graft survival among pediatric deceased donor liver transplant recipients, 2013-2015, by age
Figure LI 134. Graft survival among pediatric deceased donor liver transplant recipients, 2013-2015, by diagnosis
Figure LI 135. Graft survival among pediatric deceased donor liver transplant recipients, 2013-2015, by lab MELD/PELD score
Figure LI 136. Graft survival among pediatric liver transplant recipients, 2013-2015, by donor type
Figure LI 137. Incidence of acute rejection by 1 year posttransplant among pediatric liver transplant recipients by age, 2018-2019
Figure LI 138. Incidence of PTLD among pediatric liver transplant recipients by recipient EBV status at transplant, 2008-2018
Figure LI 139. Patient death among pediatric liver transplant recipients
Figure LI 140. Overall patient survival among pediatric deceased donor liver transplant recipients, 2013-2015
Figure LI 141. Patient survival among pediatric deceased donor liver transplant recipients, 2013-2015, by recipient age
Figure LI 142. Patient survival among pediatric deceased donor liver transplant recipients, 2013-2015, by diagnosis
Figure LI 143. Patient survival among pediatric liver transplant recipients, 2013-2015, by donor type

Table List

Waiting list

Table LI 1. Demographic characteristics of adults on the liver transplant waiting list on December 31, 2010 and December 31, 2020
Table LI 2. Clinical characteristics of adults on the liver transplant waiting list on December 31, 2010 and December 31, 2020
Table LI 3. Listing characteristics of adults on the liver transplant waiting list on December 31, 2010 and December 31, 2020
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, 2016-2020
Table LI 7. Living liver donor deaths in the first year after donoation, 2016-2020, by number of days after donation

Transplant

Table LI 8. Demographic characteristics of adult liver transplant recipients, 2010 and 2020
Table LI 9. Clinical characteristics of adult liver transplant recipients, 2010 and 2020
Table LI 10. Transplant characteristics of adult liver transplant recipients, 2010 and 2020
Table LI 11. Adult deceased donor liver donor-recipient serology matching, 2018-2020
Table LI 12. Adult living donor liver donor-recipient serology matching, 2018-2020

Pediatric transplant

Table LI 13. Demographic characteristics of pediatric candidates on the liver transplant waiting list on December 31, 2010 and December 31, 2020
Table LI 14. Clinical characteristics of pediatric candidates on the liver transplant waiting list on December 31, 2010 and December 31, 2020
Table LI 15. Listing characteristics of pediatric candidates on the liver transplant waiting list on December 31, 2010 and December 31, 2020
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, 2008-2010 and 2018-2020
Table LI 19. Clinical characteristics of pediatric liver transplant recipients, 2008-2010 and 2018-2020
Table LI 20. Transplant characteristics of pediatric liver transplant recipients, 2008-2010 and 2018-2020
Table LI 21. Pediatric liver donor-recipient serology matching, 2018-2020
Table LI 22. Pediatric liver donor-recipient serology matching for living donors, 2018-2020

Table LI 1. Demographic characteristics of adults on the liver transplant waiting list on December 31, 2010 and December 31, 2020
Candidates waiting for transplant on December 31 of the given year, regardless of first listing date. Distance is computed from candidate's home zip code to the transplant center.

Characteristic	2010, N	2010, Percent	2020, N	2020, Percent
Age: 18-34 years	686	4.3%	591	5.0%
Age: 35-49 years	2649	16.5%	1898	16.1%
Age: 50-64 years	10,400	64.8%	5867	49.9%
Age: ≥ 65 years	2308	14.4%	3409	29.0%
Sex: Female	6218	38.8%	4596	39.1%
Sex: Male	9825	61.2%	7169	60.9%
Race/ethnicity: White	11,249	70.1%	7969	67.7%
Race/ethnicity: Black	1130	7.0%	799	6.8%
Race/ethnicity: Hispanic	2714	16.9%	2217	18.8%
Race/ethnicity: Asian	791	4.9%	612	5.2%
Race/ethnicity: Other/unknown	159	1.0%	168	1.4%
Geography: Metropolitan	13,578	84.6%	10,069	85.6%
Geography: Non-metro	2465	15.4%	1696	14.4%
Distance: < 50 miles	9245	57.6%	7033	59.8%
Distance: 50-<100 miles	2708	16.9%	2110	17.9%
Distance: 100-<150 miles	1387	8.6%	1010	8.6%
Distance: 150-<250 miles	1279	8.0%	861	7.3%
Distance: ≥ 250 miles	1311	8.2%	718	6.1%
Distance: Unknown	113	0.7%	33	0.3%
All candidates	16,043	100.0%	11,765	100.0%

Table LI 2. Clinical characteristics of adults on the liver transplant waiting list on December 31, 2010 and December 31, 2020
Candidates waiting for transplant on December 31 of the given year, regardless of first listing date. HCC, hepatocellular carcinoma; HCV, hepatitis C virus.

Characteristic	2010, N	2010, Percent	2020, N	2020, Percent
Diagnosis: Acute liver failure	388	2.4%	151	1.3%
Diagnosis: HCV	4952	30.9%	1411	12.0%
Diagnosis: Alcoholic liver disease	3560	22.2%	3782	32.1%
Diagnosis: Cholestatic disease	1516	9.4%	954	8.1%
Diagnosis: HCC	767	4.8%	1327	11.3%
Diagnosis: Other/unknown	4860	30.3%	4140	35.2%
Blood type: A	6088	37.9%	4607	39.2%
Blood type: B	1805	11.3%	1162	9.9%
Blood type: AB	375	2.3%	270	2.3%
Blood type: O	7775	48.5%	5726	48.7%
Medical urgency: Status 1A	2	0.0%	2	0.0%
Medical urgency: MELD ≥ 35	58	0.4%	47	0.4%
Medical urgency: MELD 30-34	136	0.8%	58	0.5%
Medical urgency: MELD 15-29	4571	28.5%	3971	33.8%
Medical urgency: MELD < 15	8300	51.7%	5087	43.2%
Medical urgency: Inactive	2976	18.6%	2600	22.1%
Exception status: None	14,539	90.6%	9577	81.4%
Exception status: HCC	1088	6.8%	1903	16.2%
Exception status: Other	416	2.6%	285	2.4%
All candidates	16,043	100.0%	11,765	100.0%

Table LI 3. Listing characteristics of adults on the liver transplant waiting list on December 31, 2010 and December 31, 2020
Candidates waiting for transplant on December 31 of the given year, regardless of first listing date.

Characteristic	2010, N	2010, Percent	2020, N	2020, Percent
Transplant history: First	15,566	97.0%	11,486	97.6%
Transplant history: Retransplant	477	3.0%	279	2.4%
Wait time: < 1 year	6016	37.5%	5365	45.6%
Wait time: 1-< 2 years	2672	16.7%	2474	21.0%
Wait time: 2-< 3 years	1935	12.1%	1259	10.7%
Wait time: 3-< 4 years	1401	8.7%	786	6.7%
Wait time: 4-< 5 years	1008	6.3%	460	3.9%
Wait time: ≥ 5 years	3011	18.8%	1421	12.1%
Tx type: Liver alone	15,368	95.8%	10,790	91.7%
Tx type: Liver-kidney	594	3.7%	861	7.3%
Tx type: Liver-pancreas-intestine	33	0.2%	46	0.4%
Tx type: Liver-heart	23	0.1%	40	0.3%
Tx type: Other	25	0.2%	28	0.2%
All candidates	16,043	100.0%	11,765	100.0%

Table LI 4. Liver transplant waitlist activity among adults
Candidates listed at more than one center are counted once per listing. 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	2018	2019	2020
Patients at start of year	13,590	13,087	12,527
Patients added during year	12,418	12,766	12,409
Patients removed during year	12,897	13,307	13,164
Patients at end of year	13,111	12,546	11,772

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

Removal reason	2018	2019	2020
Deceased donor transplant	7295	7850	7914
Living donor transplant	338	442	425
Transplant outside US	2	1	1
Patient died	1288	1303	1195
Patient refused transplant	138	114	117
Improved, transplant not needed	974	890	902
Too sick for transplant	1252	1112	1173
Other	1610	1595	1437

Table LI 6. Complications among living liver donors, 2016-2020
Complications reported on the OPTN Living Donor Registration Form. Clavien Grade 1, bilious Jackson Pratt drainage more than 10 days; Clavien Grade 2, interventional procedure (endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, percutaneous drainage, etc.); Clavien Grade 3, surgical intervention. Clavien grades refer to biliary complications. Domino liver donors excluded.

Level	N	Pct
Biliary complication: Yes	54	2.6%
Biliary complication: No	2032	97.3%
Biliary complication: Unknown	2	0.1%
Clavien Grade: 1	18	0.9%
Clavien Grade: 2	31	1.5%
Clavien Grade: 3	9	0.4%
Vascular complication, requiring intervention: Yes	17	0.8%
Vascular complication, requiring intervention: No	2069	99.1%
Vascular complication, requiring intervention: Unknown	2	0.1%
Other complication, requiring intervention: Yes	111	5.3%
Other complication, requiring intervention: No	1975	94.6%
Other complication, requiring intervention: Unknown	2	0.1%
Re-operation: Yes	43	2.1%
Re-operation: No	2042	97.8%
Re-operation: Unknown	3	0.1%

Table LI 7. Living liver donor deaths in the first year after donoation, 2016-2020, by number of days after donation
Living liver donors. Number of deaths reported to OPTN or Social Security Administration. Donation-related deaths are included in the Medical category.

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

Table LI 8. Demographic characteristics of adult liver transplant recipients, 2010 and 2020
Liver transplant recipients, including retransplants. Distance is computed from recipient's home zip code to the transplant center.

Characteristic	2010, N	2010, Percent	2020, N	2020, Percent
Age: 18-34 years	352	6.1%	606	7.2%
Age: 35-49 years	1020	17.8%	1751	20.8%
Age: 50-64 years	3643	63.6%	4054	48.2%
Age: ≥ 65 years	716	12.5%	1993	23.7%
Sex: Female	1962	34.2%	3090	36.8%
Sex: Male	3769	65.8%	5314	63.2%
Race/ethnicity: White	4054	70.7%	5887	70.0%
Race/ethnicity: Black	587	10.2%	614	7.3%
Race/ethnicity: Hispanic	746	13.0%	1413	16.8%
Race/ethnicity: Asian	261	4.6%	364	4.3%
Race/ethnicity: Other/unknown	83	1.4%	126	1.5%
BMI: < 18.5 kg/m2	132	2.3%	142	1.7%
BMI: 18.5-< 25 kg/m2	1634	28.5%	2242	26.7%
BMI: 25-< 28 kg/m2	1274	22.2%	1646	19.6%
BMI: 28-< 30 kg/m2	692	12.1%	1037	12.3%
BMI: 30-< 35 kg/m2	1253	21.9%	1876	22.3%
BMI: ≥ 35 kg/m2	744	13.0%	1429	17.0%
BMI: Unknown	2	0.0%	32	0.4%
Insurance: Private	3298	57.5%	4266	50.8%
Insurance: Medicare	1379	24.1%	2427	28.9%
Insurance: Medicaid	814	14.2%	1373	16.3%
Insurance: Unknown	240	4.2%	338	4.0%
Geography: Metropolitan	4784	83.5%	6979	83.0%
Geography: Non-metro	947	16.5%	1425	17.0%
Distance: < 50 miles	3223	56.2%	4794	57.0%
Distance: 50-<100 miles	946	16.5%	1543	18.4%
Distance: 100-<150 miles	546	9.5%	785	9.3%
Distance: 150-<250 miles	477	8.3%	633	7.5%
Distance: ≥ 250 miles	476	8.3%	577	6.9%
Distance: Unknown	63	1.1%	72	0.9%
All recipients	5731	100.0%	8404	100.0%

Table LI 9. Clinical characteristics of adult liver transplant recipients, 2010 and 2020
Liver transplant recipients, including retransplants. HCC, hepatocellular carcinoma; HCV, hepatitis C virus.

Characteristic	2010, N	2010, Percent	2020, N	2020, Percent
Diagnosis: Acute liver failure	246	4.3%	212	2.5%
Diagnosis: HCV	1525	26.6%	566	6.7%
Diagnosis: Alcoholic liver disease	964	16.8%	2957	35.2%
Diagnosis: Cholestatic disease	493	8.6%	700	8.3%
Diagnosis: HCC	988	17.2%	1063	12.6%
Diagnosis: Other/unknown	1515	26.4%	2906	34.6%
Blood type: A	2073	36.2%	3099	36.9%
Blood type: B	799	13.9%	1113	13.2%
Blood type: AB	282	4.9%	418	5.0%
Blood type: O	2577	45.0%	3774	44.9%
Medical condition: Hospitalized in ICU	767	13.4%	1206	14.4%
Medical condition: Hospitalized, not ICU	1147	20.0%	1920	22.8%
Medical condition: Not hospitalized	3817	66.6%	5243	62.4%
Medical condition: Hospitalization unknown	0	0.0%	35	0.4%
Medical urgency: Status 1A	246	4.3%	202	2.4%
Medical urgency: MELD ≥ 35	1009	17.6%	1755	20.9%
Medical urgency: MELD 30-34	643	11.2%	1534	18.3%
Medical urgency: MELD 15-29	3649	63.7%	4369	52.0%
Medical urgency: MELD < 15	184	3.2%	538	6.4%
Medical urgency: Unknown	0	0.0%	6	0.1%
HCC exception	1364	23.8%	1390	16.5%
Other MELD exception	621	10.8%	452	5.4%
Diabetes	1442	25.2%	2429	28.9%
All recipients	5731	100.0%	8404	100.0%

Table LI 10. Transplant characteristics of adult liver transplant recipients, 2010 and 2020
Liver transplant recipients, including retransplants. DBD, donation after brain death; DCD, donation after circulatory death.

Characteristic	2010, N	2010, Percent	2020, N	2020, Percent
Wait time: < 31 days	1914	33.4%	3677	43.8%
Wait time: 31-60 days	635	11.1%	704	8.4%
Wait time: 61-90 days	455	7.9%	482	5.7%
Wait time: 3-< 6 months	849	14.8%	903	10.7%
Wait time: 6-< 12 months	847	14.8%	1426	17.0%
Wait time: 1-< 2 years	562	9.8%	765	9.1%
Wait time: 2-< 3 years	175	3.1%	214	2.5%
Wait time: ≥ 3 years	294	5.1%	233	2.8%
Donor type: Deceased	5516	96.2%	7979	94.9%
Donor type: Living	215	3.8%	425	5.1%
Procedure: Whole liver	5454	95.2%	7914	94.2%
Procedure: Partial liver	205	3.6%	420	5.0%
Procedure: Split liver	72	1.3%	70	0.8%
DCD status: DBD	5468	95.4%	7574	90.1%
DCD status: DCD	263	4.6%	830	9.9%
Transplant history: First	5368	93.7%	8045	95.7%
Transplant history: Retransplant	363	6.3%	359	4.3%
Tx type: Liver only	5304	92.5%	7556	89.9%
Tx type: Liver-kidney	382	6.7%	762	9.1%
Tx type: Liver-intestine-pancreas	24	0.4%	18	0.2%
Tx type: Other	21	0.4%	68	0.8%
All recipients	5731	100.0%	8404	100.0%

Table LI 11. Adult deceased donor liver donor-recipient serology matching, 2018-2020
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-	14.2%	0.6%	95.0%	73.7%	76.1%
D-	R+	22.0%	5.9%	3.4%	14.9%	16.0%
D-	R unk	0.3%	1.3%	1.4%	1.7%	1.7%
D+	R-	23.1%	6.0%	0.1%	6.2%	3.8%
D+	R+	39.3%	74.8%	0.0%	3.3%	2.3%
D+	R unk	0.6%	11.2%	0.0%	0.2%	0.1%
D unk	R-	0.2%	0.0%	0.0%	0.0%	0.0%
D unk	R+	0.3%	0.1%	0.0%	0.0%	0.0%
D unk	R unk	0.0%	0.1%	0.0%	0.0%	0.0%

Table LI 12. Adult living donor liver donor-recipient serology matching, 2018-2020
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-	30.2%	1.2%	95.0%	85.7%	83.6%
D-	R+	24.7%	10.8%	2.2%	10.7%	10.9%
D-	R unk	0.2%	1.5%	1.0%	1.2%	1.2%
D+	R-	14.5%	5.8%	0.2%	0.4%	0.0%
D+	R+	27.8%	70.1%	0.0%	0.3%	0.0%
D+	R unk	0.3%	6.9%	0.0%	0.1%	0.0%
D unk	R-	1.1%	0.2%	1.7%	1.3%	3.8%
D unk	R+	1.2%	1.7%	0.0%	0.2%	0.2%
D unk	R unk	0.0%	1.7%	0.0%	0.1%	0.2%

Table LI 13. Demographic characteristics of pediatric candidates on the liver transplant waiting list on December 31, 2010 and December 31, 2020
Candidates aged younger than 18 years waiting for transplant on December 31 of given year, regardless of first listing date. 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	2010, N	2010, Percent	2020, N	2020, Percent
Age: < 1 year	47	8.8%	42	12.4%
Age: 1-5 years	186	35.0%	118	34.7%
Age: 6-10 years	132	24.8%	83	24.4%
Age: 11-17 years	167	31.4%	97	28.5%
Sex: Female	273	51.3%	175	51.5%
Sex: Male	259	48.7%	165	48.5%
Race/ethnicity: White	269	50.6%	141	41.5%
Race/ethnicity: Black	78	14.7%	60	17.6%
Race/ethnicity: Hispanic	144	27.1%	104	30.6%
Race/ethnicity: Asian	30	5.6%	23	6.8%
Race/ethnicity: Other/unknown	11	2.1%	12	3.5%
Geography: Metropolitan	457	85.9%	294	86.5%
Geography: Non-metro	75	14.1%	46	13.5%
Distance: < 50 miles	265	49.8%	165	48.5%
Distance: 50-<100 miles	71	13.3%	62	18.2%
Distance: 100-<150 miles	48	9.0%	35	10.3%
Distance: 150-<250 miles	61	11.5%	30	8.8%
Distance: ≥ 250 miles	78	14.7%	42	12.4%
Distance: Unknown	9	1.7%	6	1.8%
All candidates	532	100.0%	340	100.0%

Table LI 14. Clinical characteristics of pediatric candidates on the liver transplant waiting list on December 31, 2010 and December 31, 2020
Candidates aged younger than 18 years waiting for transplant on December 31 of the given year, regardless of first listing date. Candidates listed as children who turned 18 before the cohort date are excluded. Pediatric candidates aged 12 to 17 years can be assigned MELD or PELD scores.

Characteristic	2010, N	2010, Percent	2020, N	2020, Percent
Diagnosis: Acute liver failure	44	8.3%	20	5.9%
Diagnosis: Cholestatic biliary atresia	169	31.8%	129	37.9%
Diagnosis: Other cholestatic	52	9.8%	44	12.9%
Diagnosis: Hepatoblastoma	7	1.3%	3	0.9%
Diagnosis: Metabolic	61	11.5%	34	10.0%
Diagnosis: Other/unknown	199	37.4%	110	32.4%
Blood type: A	160	30.1%	96	28.2%
Blood type: B	71	13.3%	40	11.8%
Blood type: AB	9	1.7%	7	2.1%
Blood type: O	292	54.9%	197	57.9%
Medical urgency: Status 1A	1	0.2%	0	0.0%
Medical urgency: Status 1B	4	0.8%	14	4.1%
Medical urgency: MELD/PELD ≥ 30	71	13.3%	55	16.2%
Medical urgency: MELD/PELD 15-29	93	17.5%	67	19.7%
Medical urgency: MELD/PELD < 15	157	29.5%	80	23.5%
Medical urgency: Inactive	206	38.7%	124	36.5%
Exception status: None	434	81.6%	258	75.9%
Exception status: Granted	98	18.4%	82	24.1%
All candidates	532	100.0%	340	100.0%

Table LI 15. Listing characteristics of pediatric candidates on the liver transplant waiting list on December 31, 2010 and December 31, 2020
Candidates aged younger than 18 years waiting for transplant on December 31 of the given year, regardless of first listing date. Candidates listed as children who turned 18 before the cohort date are excluded.

Characteristic	2010, N	2010, Percent	2020, N	2020, Percent
Transplant history: First	476	89.5%	311	91.5%
Transplant history: Retransplant	56	10.5%	29	8.5%
Wait time: < 1 year	259	48.7%	185	54.4%
Wait time: 1-< 2 years	90	16.9%	52	15.3%
Wait time: 2-< 3 years	28	5.3%	31	9.1%
Wait time: 3-< 4 years	30	5.6%	21	6.2%
Wait time: 4-< 5 years	24	4.5%	17	5.0%
Wait time: ≥ 5 years	101	19.0%	34	10.0%
Tx type: Liver alone	460	86.5%	273	80.3%
Tx type: Liver-kidney	8	1.5%	13	3.8%
Tx type: Liver-pancreas-intestine	44	8.3%	47	13.8%
Tx type: Liver-heart	1	0.2%	5	1.5%
Tx type: Other	19	3.6%	2	0.6%
All candidates	532	100.0%	340	100.0%

Table LI 16. Liver transplant waitlist activity among pediatric candidates
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	2018	2019	2020
Patients at start of year	546	517	461
Patients added during year	734	686	617
Patients removed during year	763	741	676
Patients at end of year	517	462	402

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

Removal reason	2018	2019	2020
Deceased donor transplant	511	483	455
Living donor transplant	62	82	66
Transplant outside US	0	0	0
Patient died	33	29	17
Patient refused transplant	1	1	3
Improved, transplant not needed	91	87	74
Too sick for transplant	20	15	16
Other	45	44	45

Table LI 18. Demographic characteristics of pediatric liver transplant recipients, 2008-2010 and 2018-2020
Pediatric liver transplant recipients, including retransplants. Distance is computed from recipient's home zip code to the transplant center.

Characteristic	2008-10, N	2008-10, Percent	2018-20, N	2018-20, Percent
Age: < 1 year	515	29.5%	448	27.7%
Age: 1-5 years	673	38.6%	585	36.2%
Age: 6-10 years	238	13.6%	229	14.2%
Age: 11-17 years	319	18.3%	354	21.9%
Sex: Female	869	49.8%	789	48.8%
Sex: Male	876	50.2%	827	51.2%
Race/ethnicity: White	894	51.2%	795	49.2%
Race/ethnicity: Black	302	17.3%	270	16.7%
Race/ethnicity: Hispanic	399	22.9%	381	23.6%
Race/ethnicity: Asian	108	6.2%	125	7.7%
Race/ethnicity: Other/unknown	42	2.4%	45	2.8%
Insurance: Private	732	41.9%	595	36.8%
Insurance: Medicare	13	0.7%	17	1.1%
Insurance: Medicaid	798	45.7%	792	49.0%
Insurance: Other government	139	8.0%	133	8.2%
Insurance: Unknown	63	3.6%	79	4.9%
Geography: Metropolitan	1424	81.6%	1360	84.2%
Geography: Non-metro	321	18.4%	256	15.8%
Distance: < 50 miles	807	46.2%	807	49.9%
Distance: 50-<100 miles	264	15.1%	242	15.0%
Distance: 100-<150 miles	172	9.9%	164	10.1%
Distance: 150-<250 miles	191	10.9%	159	9.8%
Distance: ≥ 250 miles	270	15.5%	206	12.7%
Distance: Unknown	41	2.3%	38	2.4%
All recipients	1745	100.0%	1616	100.0%

Table LI 19. Clinical characteristics of pediatric liver transplant recipients, 2008-2010 and 2018-2020
Pediatric liver transplant recipients, including retransplants. Pediatric candidates aged 12 to 17 years can be assigned MELD or PELD scores.

Characteristic	2008-10, N	2008-10, Percent	2018-20, N	2018-20, Percent
Diagnosis: Acute liver failure	190	10.9%	125	7.7%
Diagnosis: Cholestatic biliary atresia	572	32.8%	537	33.2%
Diagnosis: Other cholestatic	225	12.9%	212	13.1%
Diagnosis: Hepatoblastoma	105	6.0%	114	7.1%
Diagnosis: Metabolic	204	11.7%	279	17.3%
Diagnosis: Other/unknown	449	25.7%	349	21.6%
Blood type: A	598	34.3%	551	34.1%
Blood type: B	243	13.9%	198	12.3%
Blood type: AB	54	3.1%	48	3.0%
Blood type: O	850	48.7%	819	50.7%
Medical condition: Hospitalized in ICU	445	25.5%	281	17.4%
Medical condition: Hospitalized, not ICU	309	17.7%	278	17.2%
Medical condition: Not hospitalized	991	56.8%	1057	65.4%
Medical urgency: Status 1A	264	15.1%	173	10.7%
Medical urgency: Status 1B	221	12.7%	359	22.2%
Medical urgency: MELD/PELD ≥ 30	481	27.6%	707	43.8%
Medical urgency: MELD/PELD 15-29	526	30.1%	209	12.9%
Medical urgency: MELD/PELD < 15	249	14.3%	163	10.1%
Medical urgency: Unknown	4	0.2%	5	0.3%
Any MELD/PELD exception	521	29.9%	757	46.8%
All recipients	1745	100.0%	1616	100.0%

Table LI 20. Transplant characteristics of pediatric liver transplant recipients, 2008-2010 and 2018-2020
Pediatric liver transplant recipients, including retransplants. DBD, donation after brain death; DCD, donation after circulatory death.

Characteristic	2008-10, N	2008-10, Percent	2018-20, N	2018-20, Percent
Wait time: < 31 days	720	41.3%	502	31.1%
Wait time: 31-60 days	286	16.4%	257	15.9%
Wait time: 61-90 days	179	10.3%	189	11.7%
Wait time: 3-< 6 months	265	15.2%	313	19.4%
Wait time: 6-< 12 months	157	9.0%	182	11.3%
Wait time: 1-< 2 years	89	5.1%	102	6.3%
Wait time: 2-< 3 years	23	1.3%	34	2.1%
Wait time: ≥ 3 years	22	1.3%	37	2.3%
Wait time: Unknown	4	0.2%	0	0.0%
ABO: Compatible/identical	1682	96.4%	1526	94.4%
ABO: Incompatible	63	3.6%	90	5.6%
Donor type: Deceased	1556	89.2%	1409	87.2%
Donor type: Living	189	10.8%	207	12.8%
Procedure: Whole liver	1114	63.8%	989	61.2%
Procedure: Partial liver	342	19.6%	320	19.8%
Procedure: Split liver	289	16.6%	307	19.0%
DCD status: DBD	1732	99.3%	1611	99.7%
DCD status: DCD	13	0.7%	5	0.3%
Transplant history: First	1580	90.5%	1511	93.5%
Transplant history: Retransplant	165	9.5%	105	6.5%
Tx type: Liver only	1522	87.2%	1483	91.8%
Tx type: Liver-kidney	37	2.1%	52	3.2%
Tx type: Liver-intestine-pancreas	147	8.4%	64	4.0%
Tx type: Liver-intestine	18	1.0%	3	0.2%
Tx type: Other	21	1.2%	14	0.9%
All recipients	1745	100.0%	1616	100.0%

Table LI 21. Pediatric liver donor-recipient serology matching, 2018-2020
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-	32.6%	18.9%
D-	R+	19.2%	12.5%
D-	R unk	0.7%	0.8%
D+	R-	30.2%	36.9%
D+	R+	16.5%	28.6%
D+	R unk	0.5%	2.0%
D unk	R-	0.1%	0.1%
D unk	R+	0.1%	0.2%
D unk	R unk	0.0%	0.0%

Table LI 22. Pediatric liver donor-recipient serology matching for living donors, 2018-2020
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-	34.8%	7.7%
D-	R+	10.6%	5.3%
D-	R unk	0.5%	0.0%
D+	R-	26.6%	59.4%
D+	R+	23.2%	24.6%
D+	R unk	0.5%	1.0%
D unk	R-	3.9%	0.5%
D unk	R+	0.0%	1.4%
D unk	R unk	0.0%	0.0%