OPTN/SRTR 2020 Annual Data Report: Pancreas

Abstract

The number of pancreas transplants decreased in 2020 to 962, compared with 1015 in 2019, at least partly due to the COVID-19 pandemic. The number of simultaneous pancreas-kidney (SPK) and pancreas transplant alone (PTA) transplants decreased by 5.2% and 12.1%, respectively, while pancreas after kidney transplants (PAKs) increased 9.1%. New waitlist registrations decreased to 1585 in 2020, compared with 1771 in 2019. The decrease in waitlist registrations was predominately driven by SPK and PAK, down by 11.7% and 16.9%, respectively. The proportion of type 2 diabetes patients on the waiting list increased to 20.1% in 2020, compared with 17.6% in 2019. Waiting times increased in SPK and PTA, with last calculated median months to transplant at 14.1 months for SPK (up from 12.3 months) and 42.4 months for PTA (up from 22.3 months). Data on 1-year transplant graft failure, published for the first time in about a decade, show that for transplants performed in 2019, graft failure rates were 6.9% for SPK, 10.3% for PTA, and 6.8% for PAK, compared with 9.5% for SPK, 7.6% for PTA, and 16.2% for PAK for transplants performed in 2018. Other short- and long-term outcomes, including patient survival, kidney graft survival, and acute rejection-free survival, continued to show consistent improvement over the past decade.

Introduction

The year 2020 was a difficult year for transplantation in general and pancreas transplantation in particular. The impact of COVID-19 was profound in pancreas transplant activity, with many centers temporarily suspending pancreas transplants during the second quarter of 2020. Evaluations and waitlist additions suffered a setback as well, and the new era of virtual evaluations in a complex area such as pancreas transplant was challenging for many centers to adopt.

The first full year of follow-up data after uniform definitions of pancreas graft failure were adopted in early 2018 were published in 2019. One-year pancreas graft survival was promising, at 93% for SPK and PAK and 90% for PTA. Continued monitoring and improvement of this parameter is needed to position pancreas transplant as an attractive option for insulin-dependent diabetes patients with or without kidney dysfunction.

The proportion of patients with type 2 diabetes undergoing SPK transplant continued to increase, reaching 23.0% in 2020. The proportion of type 2 diabetes patients amongst waitlist additions has seen a corresponding increase. Outcomes of pancreas transplant in type 2 diabetes patients need further study, and selection criteria for transplant need to be refined as we gain more experience in this population.

Median time to pancreas transplant increased slightly for SPK from 12 months to 14 months and significantly for PTA from 22 months to more than 40 months. This discrepancy is concerning and will likely be addressed in future allocation policy changes, specifically continuous distribution.

Notable Organ Procurement and Transplantation Network (OPTN) Pancreas Transplantation Committee activities in 2020 included:

1. Elimination of the use of donor service area (DSA) and region in pancreas allocation policy - The policy replaces DSA and region with a 250-nautical mile fixed circle and adds proximity points to candidates’ total allocation scores. The policy was implemented in March 2021 and, therefore, the effects of this policy change are not seen in this year’s Annual Data Report.

2. Continuous distribution of pancreas - This project will change allocation from a classification-based system to a point-based system. This is a four-phase project. At the time of this writing, the committee completed the first phase of the project, in which attributes were identified and categorized. A concept paper detailing this project was sent out for public comment in summer 2021.

Waiting List

The number of adult candidates added to the waiting list dropped sharply for SPK in 2020, compared with 2019 (1307 vs 1479, Fig PA 1), while they were largely unchanged for PAK and PTA. However, waitlist additions in 2020 for SPK were still higher than in any year since 2012, except for 2019, suggesting that 2019 was a banner year (Figure PA 1). Prevalent adult listings dropped in all three categories in 2020, compared with 2019: SPK (3046 vs 3140), PAK (403 vs 410), and PTA (508 vs 547) (Figure PA 2).

The age distribution of adults on the waiting list showed a break in the trend of increasing proportion of older candidates (age >55) (10.1% in 2020 vs 10.7% in 2019). Overall, no noticeable changes were observed in the other age categories (Figure PA 3). Male candidates have always outnumbered females; however, the gap narrowed to the closest margin in a decade in 2020 (53.4% male vs 46.6% female) (Figure PA 4). White candidates continued to decline in numbers (54.0% in 2020), with a corresponding increase in Black (25.9%), Asian (3.7%), and Hispanic (14.9%) candidates (Figure PA 5).

The proportion of candidates with type 2 diabetes continued to increase over the last 5 years, to 20.1% in 2020, compared with 9% in 2015 (Figure PA 6). As noted in previous reports, since the new pancreas allocation system was implemented in 2014, enthusiasm for performing transplants for type 2 diabetes patients continues to increase. As expected, the proportion of obese candidates has increased, with 22.1% of candidates in 2020 having a body mass index (BMI) of 30 kg/m² or higher; part of this increase may be attributable to the modifications to SPK wait time criteria implemented in 2019 (Figure PA 8).

The distribution of candidates by waiting time did not change noticeably from 2019, with 50% of candidates at fewer than 90 days and 19.4% with longer than 2 years (Figure PA 7). The proportion of blood type B candidates increased gradually over the last decade, from 12.9% in 2010 to 15.4% in 2020 (Figure PA 9).

SPK candidates continued to dominate, composing 77% of the list, whereas PAK candidates made up 10.2%, and PTA candidates accounted for 12.8% (Figure PA 10). Primary transplant candidates accounted for 94.7% of candidates (Figure PA 11).

Deceased donor transplant rates dropped sharply in 2020, to 40.2 per 100 waitlist years from 44.7 in 2019, partly due to the pandemic (Figure PA 12). This was predominately driven by SPK and, to a lesser extent, PTA transplants. PAK transplant rates were unchanged from the prior year (Figure PA 15). This was the first time it has dropped since 2014, and it will be monitored with interest for the next year. The decrease was more pronounced in type 2 diabetes candidates, presumably because they are older than the other groups (Figure PA 13).

Transplant rates decreased across all blood types in 2020. Notably, blood type B candidates had the lowest transplant rates over the last 4 years (Figure PA 14). As noted previously, blood type B candidates have increased as a proportion of candidates during the same period, presumably resulting in higher demand for blood type B donors and longer waiting times for blood type B candidates. The waiting times for blood type B candidates should be watched closely to see if the trend continues.

Three-year outcomes for patients listed from 2015 to 2017 showed that 39.8% of PAK, 50.8% of PTA, and 59.1% of SPK candidates underwent deceased donor transplants. Patients who died or were removed from the list accounted for 35.4% of PAKs, 32.2% of PTAs, and 23.6% of SPKs. Patients still waiting at the end of 3 years accounted for 24.7% of PAKs, 17% of PTAs, and 12% of SPKs (Figure PA 16 to Figure PA 18).

Median time to transplant in SPKs was 14.1 months in 2019-20, an increase from 12.3 months in 2017-2018. However, in PTAs, median time to transplant rose sharply, to 42.4 months in 2017-18, from 22.3 months in 2015-16. Median time for 2019-20 for PTAs could not be calculated because less than 50% had undergone transplant. This was true for the entire reporting period for PAKs (Figure PA 19).

Transplant rates varied by geographic region (Figure PA 20 to Figure PA 22). Overall, pre-transplant mortality rates rose to 6.1 deaths per 100 waitlist years in 2020, from 4.6 in 2019, presumably in part due to the pandemic (Figure PA 23). The increase in pre-transplant mortality was seen in all age-groups age 35 and older (Figure PA 24). Pre-transplant mortality rate increases were noted among Black and White candidates, though not among Asian and Hispanic candidates (Figure PA 25), in both males and females (Figure PA 26), and all transplant types (Figure PA 27).

Geographic variation in pre-transplant mortality rates did not follow a pattern, ranging from 0 to 34.6 deaths per 100 waitlist years in DSAs for the organ procurement organization (OPO) serving the candidate’s transplant center (Figure PA 28).

Death within 6 months of removal from the list rose to 8.5% in 2020, from 5.3% in 2019 (Figure PA 29). The rise was most pronounced in candidates aged 35 years and older (Figure PA 30) and was noted across all transplant types (Figure PA 31).

Donations

The number of deceased pancreas donors decreased to 1256 in 2020, after rising steadily from 1250 in 2014 to 1363 in 2019 (Figure PA 32). Decreased numbers of deceased donors was seen in all donor age-groups (Figure PA 33), although as a percentage, age-groups younger than 30 saw a slight increase and accounted for 71.3% of all donors in 2020 (Figure PA 34). The proportion of pediatric (younger than 18 years) donors was 18.9%. The ratio of male to female donors remained fairly steady, at about 70:30 (Figure PA 35). The proportion of White donors remained steady, at 60%, while Black donors were up slightly in 2020, to 20.4%, from 18.7% in 2019, and Hispanic donors remained steady, at 17.1% (Figure PA 36). The largest proportion of donors had a BMI of 18.5 to 25 kg/m², accounting for 55.3%. This group gradually increased over the last 3 years, while those with a BMI of 25 to 30 kg/m² saw a corresponding drop, now accounting for 29.5% of donors. No notable trends were observed in the low-BMI (<18.5) or obese (>30) categories (Figure PA 37). Anoxic brain injury as cause of death increased over the last few years and plateaued at 38.3% of donors in 2020. Head trauma victims are still the largest group, at 49.8% (Figure PA 38).

The discard rate for pancreata recovered for transplant was 23.4% in 2020, slightly lower than the prior year but still at a high level (Figure PA 39). As expected, discard rates are 100% in the oldest age-group (>55), but the increase in discard rates in those 40 to 54 years is concerning, at 56.5% in 2020, from 27.4% in 2018, although in the years prior it was about 50% (Figure PA 40). Rates of discard were similar in males and females (Figure PA 41). Discard rates remained steady across White, Black, and Hispanic ethnicities/races, with Asian and “other race” curves skewed by small numbers (Figure PA 42). As expected, discard rates were highest and increased for obese donors, at 84.6% in those with a BMI of 35 to 40 kg/m² and 66.7% higher than 40 kg/m², although the numbers were small in the latter group (Figure PA 43).

Discard rates were slightly higher when stratified by donor risk of disease transmission, with 25.8% for increased-risk donors and 22.6% for standard-risk donors, with elimination of the term “increased risk”; it will be interesting to see if this gap narrows in the future (Figure PA 44).

The average pancreas donor risk index (PDRI) decreased from 2019 to 2020 in all three categories of transplants and in 2020 was 1.01 for PAK, 1.06 for PTA, and 1.05 for SPK (Figure PA 46). By component of PDRI, the proportion of Black donors increased in 2020, while the proportion of overweight/obese donors (BMI >25) and cerebrovascular accident (CVA) death donors decreased (Figure PA 45).

Transplants

In 2020, the overall number of pancreas transplants dropped from 1015 reported in 2019 to 962 and is near the nadir of 947 reported in 2015 (Figure PA 47). Unlike previous increases in SPK that were accounting for the steady increase in pancreas transplant numbers since the nadir in 2015, there was a precipitous drop, from 872 SPKs in 2019 to 827 in 2020 (Figure PA 48). The drop in transplant numbers corresponds to the onset of the COVID-19 pandemic and likely reflects the hesitation of many transplant programs to proceed with pancreas transplants because increasing COVID-19 infections limited the availability of resources. The overall rate of solid organ transplants rebounded after the first wave of infections. In general, pancreas transplants require initial management in the intensive care setting, as well as longer hospitalizations and increased likelihood of readmission. It will be important to see if the number of pancreas transplants performed correlates with COVID-19 incidence over time and rebounds with decreases in COVID-19 incidence.

There has been no substantial change in the age distribution of pancreas transplant recipients, with most recipients (62.4%) 35 to 54 years (Figure PA 49). Despite the decrease in the number of pancreas transplants performed in 2020, the percentage of transplants performed in type 2 diabetes patients increased slightly, to 21.3% (Figure PA 52) and reflects the growing interest in pancreas transplant for this indication. Notably, the relative percentage of pancreas transplants performed in Black, Asian, and Hispanic recipients compared with White recipients increased over the last 5 years and correlates with increases in pancreas transplants in type 2 diabetes patients (Figure PA 51).

Immunosuppressive strategies for pancreas transplant have been remarkably stable over the last decade. Ninety percent of pancreas transplant patients receive a lymphodepleting agent (Figure PA 53) for induction therapy, reflecting the broad experience with higher rejection rates after pancreas transplant. Despite the beta cell toxicity and renal toxicity associated with tacrolimus, it has been the favored calcineurin inhibitor (CNI) for over a decade. Similarly, mycophenolate mofetil (MMF) remains the antiproliferative agent of choice for maintenance therapy (Figure PA 54). The percentage of patients maintained on a steroid-free regimen with tacrolimus/MMF was relatively stable, although it decreased from 27.2% in 2019 to 25.8% in 2020 (Figure PA 54). The proportion of pancreas transplant recipients in the “other” maintenance category decreased to 2.6%, considerably lower than the 12.4% reported in 2010. This gradual decrease suggests that target-of-rapamycin (TOR) inhibitors or costimulation blockade have not been widely adopted as alternative components of maintenance regimens (Figure PA 54), although this may be related to center reporting issues and data collection for less common immunosuppressive agents.

The vast majority of pancreas transplants continue to be performed in unsensitized PAK (79.2%), PTA (63.8%), and SPK (70.3%) recipients (Figure PA 55 to Figure PA 57). Most pancreas transplants in all categories are performed with four or more human leukocyte antigen (HLA) A, B, and DR mismatches (Figure PA 58), reflecting the prioritization of donor quality over HLA matching for solid organ pancreas transplants.

In 2020, large programs with annual volumes of 25 or more accounted for 25.7% of pancreas transplants, while moderate-sized programs with annual volumes of 11 to 24 accounted for 35.1%, smaller programs with annual volumes of 3 to 10 accounted for 35.1%, and only 4% were performed in low-volume centers (fewer than 3 transplants). These proportions have been relatively stable over the past decade (Figure PA 60).

Outcomes

The 2020 ADR marks the first year that the new definition of pancreas graft failure has been used for an entire year. This is important in that SRTR has not reported pancreas graft survival rates because of the lack of a uniform definition of graft failure. Although patient survival and kidney allograft survival in SPK and PAK patients have been accurately reported and have uniform definitions, pancreas graft survival was defined by reporting programs, leading to considerable variation. Some programs considered insulin independence to be the criterion for defining pancreas allograft success, while others defined it by C-peptide production. Some programs considered any use of oral hypoglycemic agents or insulin as an indication of graft failure. The new, uniform definition for pancreas graft failure includes any of the following: 1) A recipient’s transplanted pancreas is removed; 2) A recipient re-registers for a pancreas transplant; 3) A recipient registers for an islet transplant after undergoing pancreas transplant; 4) A recipient dies; or 5) A recipient’s total insulin use is greater than or equal to 0.5 units/kg/day for 90 consecutive days (OPTN Policy 1.2: Definitions). This latter definition may be problematic if the recipient’s starting insulin dose was less than 0.5 units/kg/day. Nonetheless, these more uniform definitions will facilitate better analysis of pancreas allograft outcomes by SRTR. Interestingly, the incidences of graft failure at 90 days did not change substantially for PTA and SPK from 2018, when there were no uniform definitions for graft failure, to 2019, when uniform definitions were available for part of the year, to 2020, when uniform definitions were available for the entire reporting period (Figure PA 61). For PAK, the incidence of pancreas graft failure in the first 90 days was 8.8%, 6.8%, and 4.7% in 2018, 2019, and 2020, respectively. For PTA, the incidence of graft failure in the first 90 days was 6.1%, 5.2%, and 6.5% in 2018, 2019, and 2020, respectively. Finally, for SPK, the incidence of pancreas graft failure in the first 90 days was 6.5%, 5.1%, and 7.2% in 2018, 2019, and 2020, respectively (Figure PA 61). One-year pancreas graft survival rates for pancreas transplants performed in 2020 using the uniform definitions of graft failure will not be available until the 2021 ADR.

Data for kidney allograft survival after SPK have been based on uniform definitions (ie, return to dialysis), unlike the variability in reporting pancreas allograft outcomes. Outcomes for kidney allografts after SPK remain outstanding, with 1-, 5-, and 10-year all-cause kidney failure at 4.2%, 13.2%, and 33.4%, respectively (Figure PA 63). Although the excellent longer-term kidney transplant outcomes associated with SPK can in part be attributed to the lower kidney donor profile index (KDPI) for kidneys associated with SPK, the long-term kidney allograft success rate after PAK with a deceased donor kidney are also excellent, with 1-, 5-, and 10-year all-cause kidney graft failure of 2.4%, 13.1%, and 38.1% (Figure PA 65). The 10-year death-censored kidney graft failure rate for SPK was 18.7% for the most recent cohort available for analysis (transplants in 2010 and 2011) (Figure PA 64). For PAK with a living donor kidney, the 10-year death-censored kidney graft failure rate was 16.0% (Figure PA 68). These low graft failure rates highlight the excellent quality of the deceased donors used in SPK and living-donor kidneys in PAK.

Rejection rates for PAK, PTA, and SPK have been consistently low for the past five years, with the incidence of acute rejection by one year in 2018-19 transplant recipients at 12.5% for PAK, 21.8% for PTA, and 10.6% for SPK (Figure PA 70). The relatively higher incidence of acute rejection in PTA has been consistent over the past several years and may in part reflect the use of protocol biopsies in this category of pancreas transplant recipients. Although the vast majority of pancreas transplants use induction with a T cell-depleting agent (Figure PA 53), it is interesting to note that the incidence of acute rejection among pancreas transplant recipients using IL2-receptor antibody induction in 2018-19 was low, at 15.1%, although higher than the 11.3% seen in pancreas transplant recipients undergoing T cell-depletion induction therapy (Figure PA 71).

The highest cumulative incidence of posttransplant lymphoproliferative disease disorder (PTLD) at five years was observed in Epstein-Barr virus (EBV)-negative PTA recipients (5.5%), compared with EBV-positive PTA recipients (Figure PA 73). The five-year cumulative incidence of PTLD in EBV-naive PAK and SPK recipients was lower, at 1.1% (Figure PA 72) and 2.8% (Figure PA 74), respectively. The higher incidence of PTLD observed in EBV-naive recipients of PTA may reflect more aggressive immunosuppression regimens used after PTA related to higher rejection rates in this cohort (Figure PA 70).

The long-term safety and efficacy of pancreas transplant is reflected in the steady increase in the number of recipients alive with a pancreas transplant to 19,458 (Figure PA 69). Patient mortality remained low for all categories of pancreas transplant recipients at one year, at 3.5%, 1.8%, and 2.6% for PAK, PTA (excluding recipients of multivisceral organs) and SPK, respectively, for transplants performed in 2018-19 (Figure PA 75). Long-term mortality rates continued to demonstrate a gradual decrease in all categories of pancreas transplants. Ten-year mortality rates among 2010-11 transplant recipients were 20.3%, 17.5%, and 20.9% for PAK, PTA, and SPK, respectively, likely reflecting cardiovascular comorbidities in the population (Figure PA 77). Five-year survival rates for PAK, PTA, and SPK were 88.6%, 94.6%%, and 92.7%, respectively (Figure PA 78). PTA recipients have the best patient survival of the three groups, presumably due to the lack of significant renal insufficiency in this group (Figure PA 78). Five-year survival rates for pancreas recipients were 92.7% and 91.6% for type 1 and type 2 diabetes, respectively (Figure PA 79). As more SPKs are performed for type 2 diabetes, it will be important to see if pancreas outcomes (using uniform definitions of graft success initiated in 2018) are comparable in both graft outcomes and survival. Finally, the comparable five-year patient survival among adult deceased donor pancreas transplant recipients in metropolitan (92.8% survival) versus non-metropolitan (91.6%) suggest that access to appropriate follow-up is not limited for recipients living in nonurban settings (Figure PA 80).

Figure List

Waiting list

Figure PA 1. New adult candidates added to the pancreas transplant waiting list
Figure PA 2. All adult candidates on the pancreas transplant waiting list
Figure PA 3. Distribution of adults waiting for pancreas transplant by age
Figure PA 4. Distribution of adults waiting for pancreas transplant by sex
Figure PA 5. Distribution of adults waiting for pancreas transplant by race
Figure PA 6. Distribution of adults waiting for pancreas transplant by diagnosis
Figure PA 7. Distribution of adults waiting for pancreas transplant by waiting time
Figure PA 8. Distribution of adults waiting for pancreas transplant by BMI
Figure PA 9. Distribution of adults waiting for pancreas transplant by blood type
Figure PA 10. Distribution of adults waiting for pancreas transplant by intended transplant type
Figure PA 11. Distribution of adults waiting for pancreas transplant by prior transplant status
Figure PA 12. Overall deceased donor pancreas transplant rates among adult waitlist candidates
Figure PA 13. Deceased donor pancreas transplant rates among adult waitlist candidates by diagnosis
Figure PA 14. Deceased donor pancreas transplant rates among adult waitlist candidates by blood type
Figure PA 15. Deceased donor pancreas transplant rates among adult waitlist candidates by intended transplant type
Figure PA 16. Three-year outcomes for adults waiting for pancreas after kidney transplant, new listings in 2015-2017
Figure PA 17. Three-year outcomes for adults waiting for pancreas transplant alone, new listings in 2015-2017
Figure PA 18. Three-year outcomes for adults waiting for simultaneous kidney-pancreas transplant, new listings in 2015-2017
Figure PA 19. Median months to pancreas transplant for waitlisted adults
Figure PA 20. Percentage of adults listed in 2018 who underwent pancreas after kidney transplant within 2 years, by DSA
Figure PA 21. Percentage of adults listed in 2018 who underwent pancreas transplant alone within 2 years, by DSA
Figure PA 22. Percentage of adults listed in 2018 who underwent simultaneous kidney-pancreas transplant within 2 years, by DSA
Figure PA 23. Overall pretransplant mortality rates among adults waitlisted for pancreas transplant
Figure PA 24. Pretransplant mortality rates among adults waitlisted for pancreas transplant by age
Figure PA 25. Pretransplant mortality rates among adults waitlisted for pancreas transplant by race
Figure PA 26. Pretransplant mortality rates among adults waitlisted for pancreas transplant by sex
Figure PA 27. Pretransplant mortality rates among adults waitlisted for pancreas transplant by intended transplant type
Figure PA 28. Pretransplant mortality rates among adults waitlisted for pancreas transplant in 2020 by DSA
Figure PA 29. Deaths within six months after removal among adult pancreas waitlist candidates, overall
Figure PA 30. Deaths within six months after removal among adult pancreas waitlist candidates, by age
Figure PA 31. Deaths within six months after removal among adult pancreas waitlist candidates, by intended transplant type

Deceased donation

Figure PA 32. Overall deceased pancreas donor count
Figure PA 33. Deceased pancreas donor count by age
Figure PA 34. Distribution of deceased pancreas donors by age
Figure PA 35. Distribution of deceased pancreas donors by sex
Figure PA 36. Distribution of deceased pancreas donors by race
Figure PA 37. Distribution of deceased pancreas donors by donor BMI
Figure PA 38. Cause of death among deceased pancreas donors
Figure PA 39. Overall rates of pancreata recovered for transplant and not transplanted
Figure PA 40. Rates of pancreata recovered for transplant and not transplanted by donor age
Figure PA 41. Rates of pancreata recovered for transplant and not transplanted by donor sex
Figure PA 42. Rates of pancreata recovered for transplant and not transplanted by donor race
Figure PA 43. Rates of pancreata recovered for transplant and not transplanted by donor BMI
Figure PA 44. Rates of pancreata recovered for transplant and not transplanted, by donor risk of disease transmission
Figure PA 45. Donor-specific components of the pancreas donor risk index
Figure PA 46. Average pancreas donor risk index

Transplant

Figure PA 47. Overall pancreas transplants
Figure PA 48. Total pancreas transplants by pancreas transplant type
Figure PA 49. Total pancreas transplants by age
Figure PA 50. Total pancreas transplants by sex
Figure PA 51. Total pancreas transplants by race
Figure PA 52. Total pancreas transplants by diagnosis
Figure PA 53. Induction agent use in adult pancreas transplant recipients
Figure PA 54. Immunosuppression regimen use in adult pancreas transplant recipients
Figure PA 55. C/PRA in adult recipients of pancreas after kidney transplant.
Figure PA 56. C/PRA in adult recipients of pancreas transplant alone.
Figure PA 57. C/PRA in adult recipients of simultaneous kidney-pancreas transplant
Figure PA 58. Total HLA A, B, and DR mismatches among adult pancreas transplant recipients, 2016-2020
Figure PA 59. Annual adult pancreas transplant center volumes by percentile
Figure PA 60. Distribution of adult pancreas transplants by annual center volume

Outcomes

Figure PA 61. Pancreas graft failure within the first 90 days posttransplant among adult pancreas transplant recipients
Figure PA 62. Pancreas graft failure within the first year posttransplant among adult pancreas transplant recipients
Figure PA 63. Kidney graft failure among adult SPK transplant recipients
Figure PA 64. Death censored kidney graft failure among adult SPK transplant recipients
Figure PA 65. Kidney graft failure among adult PAK transplant recipients with a deceased donor kidney (from time of pancreas transplant)
Figure PA 66. Death-censored kidney graft failure among adult PAK transplant recipients with a deceased donor kidney (from time of pancreas transplant)
Figure PA 67. Kidney graft failure among adult PAK transplant recipients with a living donor kidney (from time of pancreas transplant)
Figure PA 68. Death-censored kidney graft failure among adult PAK transplant recipients with a living donor kidney (from time of pancreas transplant)
Figure PA 69. Recipients alive after pancreas transplant on June 30 of the year, by age at transplant
Figure PA 70. Incidence of acute rejection by 1 year posttransplant among adult pancreas transplant recipients by transplant type, 2018-2019
Figure PA 71. Incidence of acute rejection by 1 year posttransplant among adult pancreas transplant recipients by induction agent, 2018-2019
Figure PA 72. Incidence of PTLD among adult recipients of pancreas after kidney transplant by recipient EBV status at transplant, 2008-2018
Figure PA 73. Incidence of PTLD among adult recipients of pancreas transplant alone by recipient EBV status at transplant, 2008-2018
Figure PA 74. Incidence of PTLD among adult recipients of simultaneous kidney-pancreas transplant by recipient EBV status at transplant, 2008-2018
Figure PA 75. Patient death at one year among adult pancreas transplant recipients
Figure PA 76. Patient death at five years among adult pancreas transplant recipients
Figure PA 77. Patient death at ten years among adult pancreas transplant recipients
Figure PA 78. Patient survival among adult deceased donor pancreas transplant recipients, 2013-2015, by transplant type
Figure PA 79. Patient survival among adult deceased donor pancreas transplant recipients, 2013-2015, by diagnosis
Figure PA 80. Patient survival among adult deceased donor pancreas transplant recipients, 2013-2015, by metropolitan vs. non-metropolitan recipient residence

Table List

Waiting list

Table PA 1. Demographic characteristics of adults on the pancreas transplant waiting list on December 31, 2020
Table PA 2. Clinical characteristics of adults on the pancreas transplant waiting list on December 31, 2020
Table PA 3. Listing characteristics of adults on the pancreas transplant waiting list on December 31, 2020
Table PA 4. Transplant waitlist activity among adults waiting for a pancreas after kidney transplant
Table PA 5. Transplant waitlist activity among adults waiting for a pancreas transplant alone
Table PA 6. Transplant waitlist activity among adults waiting for a simultaneous kidney pancreas transplant
Table PA 7. Removal reason among adults waiting for pancreas after kidney transplant
Table PA 8. Removal reason among adults waiting for pancreas transplant alone
Table PA 9. Removal reason among adults waiting for simultaneous kidney-pancreas transplant

Transplant

Table PA 10. Demographic characteristics of adult pancreas transplant recipients, 2020
Table PA 11. Clinical characteristics of adult pancreas transplant recipients, 2020
Table PA 12. Transplant characteristics of adult pancreas transplant recipients, 2020
Table PA 13. Adult pancreas donor-recipient serology matching, 2018-2020

Table PA 1. Demographic characteristics of adults on the pancreas transplant waiting list on December 31, 2020
Candidates waiting for transplant on December 31, 2020, regardless of first listing date. Distance is computed from candidate's home zip code to the transplant center. PAK, pancreas after kidney; PTA, pancreas transplant alone; SPK, simultaneous kidney pancreas transplant.

Characteristic	PAK, N	PAK, Pct	PTA, N	PTA, Pct	SPK, N	SPK, Pct
Age: 18-34 years	27	9.2%	87	24.0%	349	20.3%
Age: 35-49 years	164	56.2%	178	49.0%	872	50.6%
Age: 50-60 years	87	29.8%	76	20.9%	437	25.4%
Age: > 60 years	14	4.8%	22	6.1%	64	3.7%
Sex: Female	138	47.3%	214	59.0%	788	45.8%
Sex: Male	154	52.7%	149	41.0%	934	54.2%
Race/ethnicity: White	161	55.1%	286	78.8%	862	50.1%
Race/ethnicity: Black	78	26.7%	31	8.5%	501	29.1%
Race/ethnicity: Hispanic	44	15.1%	35	9.6%	250	14.5%
Race/ethnicity: Asian	7	2.4%	7	1.9%	74	4.3%
Race/ethnicity: Other/unknown	2	0.7%	4	1.1%	35	2.0%
Geography: Metropolitan	248	84.9%	275	75.8%	1446	84.0%
Geography: Non-metro	44	15.1%	88	24.2%	276	16.0%
Distance: < 50 miles	191	65.4%	162	44.6%	1044	60.6%
Distance: 50-<100 miles	51	17.5%	72	19.8%	351	20.4%
Distance: 100-<150 miles	26	8.9%	35	9.6%	141	8.2%
Distance: 150-<250 miles	12	4.1%	32	8.8%	109	6.3%
Distance: ≥ 250 miles	11	3.8%	56	15.4%	71	4.1%
Distance: Unknown	1	0.3%	6	1.7%	6	0.3%
BMI: < 18.5 kg/m2	3	1.0%	21	5.8%	22	1.3%
BMI: 18.5-< 25 kg/m2	111	38.0%	144	39.7%	588	34.1%
BMI: 25-< 28 kg/m2	70	24.0%	91	25.1%	411	23.9%
BMI: 28-< 30 kg/m2	37	12.7%	31	8.5%	288	16.7%
BMI: 30-< 35 kg/m2	58	19.9%	64	17.6%	340	19.7%
BMI: ≥ 35 kg/m2	11	3.8%	12	3.3%	73	4.2%
BMI: Unknown	2	0.7%	0	0.0%	0	0.0%
All candidates	292	100.0%	363	100.0%	1722	100.0%

Table PA 2. Clinical characteristics of adults on the pancreas transplant waiting list on December 31, 2020
Candidates waiting for transplant on December 31, 2020, regardless of first listing date. PAK, pancreas after kidney; PTA, pancreas transplant alone; SPK, simultaneous kidney pancreas transplant.

Characteristic	PAK, N	PAK, Pct	PTA, N	PTA, Pct	SPK, N	SPK, Pct
Diagnosis: Diabetes type 1	233	79.8%	281	77.4%	1242	72.1%
Diagnosis: Diabetes type 2	53	18.2%	16	4.4%	399	23.2%
Diagnosis: Other	6	2.1%	66	18.2%	81	4.7%
Blood type: A	104	35.6%	158	43.5%	514	29.8%
Blood type: B	31	10.6%	35	9.6%	339	19.7%
Blood type: AB	16	5.5%	10	2.8%	45	2.6%
Blood type: O	141	48.3%	160	44.1%	824	47.9%
CPRA: < 1%	145	49.7%	239	65.8%	1026	59.6%
CPRA: 1-< 20%	26	8.9%	14	3.9%	170	9.9%
CPRA: 20-< 80%	55	18.8%	48	13.2%	295	17.1%
CPRA: 80-< 98%	27	9.2%	27	7.4%	105	6.1%
CPRA: 98-100%	35	12.0%	35	9.6%	126	7.3%
CPRA: Unknown	4	1.4%	0	0.0%	0	0.0%
All candidates	292	100.0%	363	100.0%	1722	100.0%

Table PA 3. Listing characteristics of adults on the pancreas transplant waiting list on December 31, 2020
Candidates waiting for transplant on December 31, 2020, regardless of first listing date. PAK, pancreas after kidney; PTA, pancreas transplant alone; SPK, simultaneous kidney pancreas transplant.

Characteristic	PAK, N	PAK, Pct	PTA, N	PTA, Pct	SPK, N	SPK, Pct
Transplant history: First	215	73.6%	323	89.0%	1669	96.9%
Transplant history: Retransplant	77	26.4%	40	11.0%	53	3.1%
Wait time: < 1 year	79	27.1%	118	32.5%	814	47.3%
Wait time: 1-< 2 years	73	25.0%	75	20.7%	446	25.9%
Wait time: 2-< 3 years	32	11.0%	59	16.3%	185	10.7%
Wait time: 3-< 4 years	27	9.2%	38	10.5%	104	6.0%
Wait time: 4-< 5 years	22	7.5%	18	5.0%	63	3.7%
Wait time: ≥ 5 years	59	20.2%	55	15.2%	110	6.4%
All candidates	292	100.0%	363	100.0%	1722	100.0%

Table PA 4. Transplant waitlist activity among adults waiting for a pancreas after kidney transplant
Candidates listed at more than one center are counted one 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	333	286	300
Patients added during year	103	124	103
Patients removed during year	150	110	110
Patients at end of year	286	300	293

Table PA 5. Transplant waitlist activity among adults waiting for a pancreas transplant alone
Candidates listed at more than one center are counted one 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	375	378	332
Patients added during year	212	168	175
Patients removed during year	209	213	144
Patients at end of year	378	333	363

Table PA 6. Transplant waitlist activity among adults waiting for a simultaneous kidney pancreas transplant
Candidates listed at more than one center are counted one 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	1722	1656	1735
Patients added during year	1292	1479	1308
Patients removed during year	1356	1396	1322
Patients at end of year	1658	1739	1721

Table PA 7. Removal reason among adults waiting for pancreas after kidney transplant
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	48	33	35
Living donor kidney transplant	0	0	0
Patient died	5	3	8
Patient refused transplant	9	9	3
Improved, transplant not needed	1	1	0
Too sick for transplant	15	15	10
Changed to kidney-pancreas list	5	2	1
Other	67	47	53

Table PA 8. Removal reason among adults waiting for pancreas transplant alone
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	110	90	77
Living donor kidney transplant	0	0	0
Patient died	4	9	12
Patient refused transplant	4	8	2
Improved, transplant not needed	5	7	2
Too sick for transplant	13	21	10
Changed to kidney-pancreas list	8	5	8
Other	65	73	33

Table PA 9. Removal reason among adults waiting for simultaneous kidney-pancreas transplant
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	859	908	855
Living donor kidney transplant	70	60	49
Patient died	107	84	109
Patient refused transplant	9	6	3
Improved, transplant not needed	7	9	3
Too sick for transplant	76	88	71
Changed to kidney-pancreas list	0	0	0
Other	228	241	232

Table PA 10. Demographic characteristics of adult pancreas transplant recipients, 2020
Pancreas transplant recipients, including retransplants. Distance is computed from recipient's home zip code to the transplant center. PAK, pancreas after kidney; PTA, pancreas transplant alone; SPK, simultaneous kidney pancreas transplant.

Characteristic	PAK, N	PAK, Pct	PTA, N	PTA, Pct	SPK, N	SPK, Pct	All, N	All, Pct
Age: 18-34 years	10	20.8%	18	26.1%	198	24.1%	226	24.1%
Age: 35-49 years	27	56.2%	24	34.8%	426	51.8%	477	50.8%
Age: 50-60 years	9	18.8%	19	27.5%	176	21.4%	204	21.7%
Age: > 60 years	2	4.2%	8	11.6%	22	2.7%	32	3.4%
Sex: Female	19	39.6%	40	58.0%	336	40.9%	395	42.1%
Sex: Male	29	60.4%	29	42.0%	486	59.1%	544	57.9%
Race/ethnicity: White	28	58.3%	59	85.5%	400	48.7%	487	51.9%
Race/ethnicity: Black	6	12.5%	6	8.7%	245	29.8%	257	27.4%
Race/ethnicity: Hispanic	14	29.2%	3	4.3%	132	16.1%	149	15.9%
Race/ethnicity: Asian	0	0.0%	1	1.4%	36	4.4%	37	3.9%
Race/ethnicity: Other/unknown	0	0.0%	0	0.0%	9	1.1%	9	1.0%
BMI: < 18.5 kg/m2	0	0.0%	2	2.9%	14	1.7%	16	1.7%
BMI: 18.5-< 25 kg/m2	19	39.6%	25	36.2%	346	42.1%	390	41.5%
BMI: 25-< 28 kg/m2	18	37.5%	23	33.3%	213	25.9%	254	27.1%
BMI: 28-< 30 kg/m2	3	6.2%	8	11.6%	123	15.0%	134	14.3%
BMI: 30-< 35 kg/m2	4	8.3%	8	11.6%	113	13.7%	125	13.3%
BMI: ≥ 35 kg/m2	4	8.3%	3	4.3%	13	1.6%	20	2.1%
Insurance: Private	20	41.7%	49	71.0%	323	39.3%	392	41.7%
Insurance: Medicare	26	54.2%	10	14.5%	386	47.0%	422	44.9%
Insurance: Other government	2	4.2%	7	10.1%	93	11.3%	102	10.9%
Insurance: Unknown	0	0.0%	3	4.3%	20	2.4%	23	2.4%
Geography: Metropolitan	44	91.7%	49	71.0%	684	83.2%	777	82.7%
Geography: Non-metro	4	8.3%	20	29.0%	138	16.8%	162	17.3%
Distance: < 50 miles	33	68.8%	21	30.4%	502	61.1%	556	59.2%
Distance: 50-<100 miles	10	20.8%	18	26.1%	145	17.6%	173	18.4%
Distance: 100-<150 miles	3	6.2%	9	13.0%	71	8.6%	83	8.8%
Distance: 150-<250 miles	1	2.1%	7	10.1%	46	5.6%	54	5.8%
Distance: ≥ 250 miles	1	2.1%	11	15.9%	37	4.5%	49	5.2%
Distance: Unknown	0	0.0%	3	4.3%	21	2.6%	24	2.6%
All recipients	48	100.0%	69	100.0%	822	100.0%	939	100.0%

Table PA 11. Clinical characteristics of adult pancreas transplant recipients, 2020
Pancreas transplant recipients, including retransplants. PAK, pancreas after kidney; PTA, pancreas transplant alone; SPK, simultaneous kidney pancreas transplant.

Characteristic	PAK, N	PAK, Pct	PTA, N	PTA, Pct	SPK, N	SPK, Pct	All, N	All, Pct
Diagnosis: Diabetes type 1	40	83.3%	42	60.9%	591	71.9%	673	71.7%
Diagnosis: Diabetes type 2	7	14.6%	2	2.9%	189	23.0%	198	21.1%
Diagnosis: Other	1	2.1%	25	36.2%	42	5.1%	68	7.2%
Blood type: A	15	31.2%	27	39.1%	286	34.8%	328	34.9%
Blood type: B	5	10.4%	12	17.4%	103	12.5%	120	12.8%
Blood type: AB	2	4.2%	2	2.9%	29	3.5%	33	3.5%
Blood type: O	26	54.2%	28	40.6%	404	49.1%	458	48.8%
All recipients	48	100.0%	69	100.0%	822	100.0%	939	100.0%

Table PA 12. Transplant characteristics of adult pancreas transplant recipients, 2020
Pancreas transplant recipients, including retransplants. PAK, pancreas after kidney; PTA, pancreas transplant alone; SPK, simultaneous kidney pancreas transplant.

Characteristic	PAK, N	PAK, Pct	PTA, N	PTA, Pct	SPK, N	SPK, Pct	All, N	All, Pct
Wait time: < 31 days	8	16.7%	9	13.0%	143	17.4%	160	17.0%
Wait time: 31-60 days	0	0.0%	6	8.7%	76	9.2%	82	8.7%
Wait time: 61-90 days	2	4.2%	8	11.6%	73	8.9%	83	8.8%
Wait time: 3-< 6 months	9	18.8%	8	11.6%	120	14.6%	137	14.6%
Wait time: 6-< 12 months	10	20.8%	18	26.1%	188	22.9%	216	23.0%
Wait time: 1-< 2 years	13	27.1%	10	14.5%	134	16.3%	157	16.7%
Wait time: 2-< 3 years	5	10.4%	3	4.3%	50	6.1%	58	6.2%
Wait time: ≥ 3 years	1	2.1%	7	10.1%	38	4.6%	46	4.9%
Transplant history: First	37	77.1%	58	84.1%	814	99.0%	909	96.8%
Transplant history: Retransplant	11	22.9%	11	15.9%	8	1.0%	30	3.2%
Tx type: Kidney-pancreas	0	0.0%	0	0.0%	819	99.6%	819	87.2%
Tx type: Pancreas only	48	100.0%	45	65.2%	0	0.0%	93	9.9%
Tx type: Other	0	0.0%	24	34.8%	3	0.4%	27	2.9%
All recipients	48	100.0%	69	100.0%	822	100.0%	939	100.0%

Table PA 13. Adult pancreas 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-	19.2%	1.9%	97.4%	94.2%	94.7%
D-	R+	21.3%	11.6%	1.2%	1.9%	2.0%
D-	R unk	0.4%	0.5%	1.3%	1.8%	1.8%
D+	R-	25.5%	6.4%	0.1%	1.9%	1.3%
D+	R+	32.4%	76.5%	0.0%	0.2%	0.1%
D+	R unk	0.5%	3.0%	0.0%	0.1%	0.0%
D unk	R-	0.2%	0.0%	0.0%	0.0%	0.0%
D unk	R+	0.2%	0.1%	0.0%	0.0%	0.0%
D unk	R unk	0.0%	0.0%	0.0%	0.0%	0.0%