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OPTN/SRTR 2021 Annual Data Report: Liver

OPTN/SRTR 2021 Annual Data Report: Liver

Allison J. Kwong1, Noelle H. Ebel2, W. Ray Kim1,3, John R. Lake3,4, Jodi M. Smith3,5, David P. Schladt3, Erin M. Schnellinger6, Dzhuliyana Handarova6, Samantha Weiss6, Matthew Cafarella6, Jon J. Snyder3,7,8, Ajay K. Israni3,7,8, Bertram L. Kasiske3,8

1Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA

2Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA

3Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN

4Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, MN

5Department of Pediatrics, University of Washington, Seattle, WA

6Organ Procurement and Transplantation Network, United Network for Organ Sharing, Richmond, VA

7Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN

8Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, MN

Abstract

In 2021, liver transplant volume continued to grow, with a record 9,234 transplants performed in the United States, 8,665 (93.8%) from deceased donors and 569 (6.2%) from living donors. There were 8,733 (94.6%) adult and 501 (5.4%) pediatric liver transplant recipients. An increase in the number of deceased donor livers corresponded to an increase in the overall transplant rate and shorter waiting times, although still 10.0% of livers that were recovered were not transplanted. Alcohol-associated liver disease was the leading indication for both waitlist registration and liver transplant in adults, outpacing nonalcoholic steatohepatitis, while biliary atresia remained the leading indication for children. Related to allocation policy changes implemented in 2019, the proportion of liver transplants performed for hepatocellular carcinoma has decreased. Among adult candidates listed for liver transplant in 2020, 37.7% received a deceased donor liver transplant within 3 months, 43.8% within 6 months, and 53.3% within 1 year. Pretransplant mortality improved for children following implementation of acuity circle–based distribution. Short-term graft and patient survival outcomes up to 1 year worsened for adult deceased and living donor liver transplant recipients, which is a reversal of previous trends and coincided with the onset of the COVID-19 pandemic in early 2020. Longer-term outcomes among adult deceased donor liver transplant recipients were unaffected, with overall posttransplant mortality rates of 13.3% at 3 years, 18.6% at 5 years, and 35.9% at 10 years. Pretransplant mortality improved for children following implementation of acuity circle–based distribution and prioritization of pediatric donors to pediatric recipients in 2020. Pediatric living donor recipients had superior graft and patient survival outcomes compared with deceased donor recipients at all time points.

Keywords: Liver transplant, allocation, distribution, waiting list

1 ADULT LIVER TRANSPLANTATION IN THE UNITED STATES

1.1 Waiting List

There were 11,771 adult candidates on the liver waiting list at the start of 2021, and 13,165 additional candidates were added during the calendar year, representing more new waitlist registrations than in any previous year (Figure LI 1, Table LI 4). Over the course of the year, 13,598 candidates were removed, leaving 11,338 candidates remaining on the liver transplant list on December 31, 2021.

Most adult candidates (48.0%) were 50-64 years of age, still representing the majority but a decrease from 63.9% in 2011. Those aged 65 years or older made up 27.4% of candidates, stable from the year prior but a substantial increase compared with 15.7% in 2011 (Figure LI 3). The sex and racial composition of the waiting list has remained relatively unchanged: 61.3% male, 38.7% female, 68.9% White, 6.8% Black, 18.0% Hispanic, and 4.7% Asian (Figures LI 4 and 5).

Alcohol-associated liver disease was the leading diagnosis among adult liver transplant candidates in 2021, representing 36.3% of waitlist registrations (Figure LI 6). This was followed by nonalcoholic steatohepatitis (19.3%) and other/unknown diagnoses (15.7%). The proportion of candidates with alcohol-associated liver disease and to a lesser extent nonalcoholic steatohepatitis has increased year-over-year, while the prevalence of hepatitis C virus (HCV) continued to decline, representing only 8.3% of diagnoses compared with 29.7% in 2011. The proportion of candidates with diagnoses of acute liver failure and cholestatic liver disease also declined in the past decade, representing only 1.9% and 7.8% of diagnoses, respectively, in 2021. Candidates with a primary diagnosis of hepatocellular carcinoma (HCC) made up 10.7% of new waitlist registrations.

The severity of liver disease, based on the last laboratory model for end-stage liver disease (MELD) score during the calendar year, continued to increase, with a greater proportion being listed with MELD score of 25-34 (15.7%), 35-39 (4.9%), and 40 or greater (4.9%) in 2021 compared with previous years (Figure LI 7). Obesity, defined as a body mass index (BMI) of 30 kg/m2 or greater, was observed in 41.1% of adult candidates; 17.3% had BMI of 35 kg/m2 or greater (Figure LI 8). Over the past decade, the proportion of candidates with a prior history of liver transplant declined from 4.0% to 3.1%, despite more transplants being performed overall (Figure LI 10). The distribution of blood types largely mirrored that in the general population: 47.7% O, 38.0% A, 11.3% B, and 3.0% AB (Figure LI 9).

1.2 Waitlist Outcomes

The overall deceased donor transplant rate among adult waitlist candidates continued to rise steadily, with an overall rate of 71.0 transplants per 100 patient-years (Figure LI 11). This increase occurred across all age groups, sexes, major racial and ethnic groups, blood types, and places of residence (metropolitan vs non-metropolitan) (Figures LI 12, 13, 14, 16, and 17). Still, men had higher transplant rates compared with women (73.8 vs 66.5 transplants per 100 patient-years). Candidates living in non-metropolitan areas, based on the rural-urban commuting area (RUCA) designation of their permanent zip code, had a higher transplant rate than those living in metropolitan areas. Candidates with blood type AB had the highest transplant rate (157.7 transplants per 100 patient-years), followed by type B (94.3 transplants per 100 patient-years), and then O and A (66.5 and 65.6 transplants per 100 patient-years, respectively) (Figure LI 14). Whereas candidates with HCC exception points historically had a much higher transplant rate than those without HCC, transplant rates for these two groups were essentially equal in 2021 (Figure LI 15). This observation occurred in the context of a policy change implemented in 2019, which set waitlist priority for HCC exception cases by the local median MELD at transplant minus 3 points.

Of the adults who were listed for liver transplant during 2016-2018, for whom at least 3 years of follow-up data were available, only 7.9% remained on the waiting list after 3 years (Figure LI 18). By the end of 3 years, 59.3% received a liver transplant (including 2.6% from a living donor), 9.3% died, and 23.5% were removed from the list for other reasons. Among candidates who were listed for liver transplant in 2020, 37.7% received a deceased donor liver transplant within 3 months, 43.8% within 6 months, and 53.3% within 1 year—all increases compared with previous years (Figure LI 19). By comparison, only 39.8% of candidates listed in 2011 received a deceased donor liver transplant within 1 year, 49.6% within 5 years, and 50.6% within 10 years.

In 2021, the pretransplant mortality rate was 13.1 deaths per 100 patient-years, compared with 15.5 deaths per 100 patient-years in 2011 (Figure LI 20). The pretransplant mortality rate was higher among women compared with men (14.1 vs 12.5 deaths per 100 patient-years), as well as older (65 years or older) compared with younger candidates, those with acute liver failure or nonalcoholic steatohepatitis compared with other diagnoses, and those living in non-metropolitan versus metropolitan areas (Figures LI 21, 23, 24, and 25). The pretransplant mortality rate has decreased over the past decade for candidates in all MELD groups (based on the first laboratory MELD score during the year) (Figure LI 26). The pretransplant mortality rate among patients waitlisted with an HCC exception remained lower than that observed in patients without HCC exceptions (10.9 vs 13.4 deaths per 100 patient-years) (Figure LI 27). Overall pretransplant mortality rates by donation service area (DSA) remain widely varied, ranging from 7.0 to 28.6 deaths per 100 patient-years (Figure LI 28).

Liver transplant was the most common reason for waitlist removal among adults, including 8,212 from a deceased donor and 492 from a living donor. The next most common reasons were death (1,134), being too sick for transplant (1,177), or condition improved with transplant no longer being needed (1,051) (Table LI 5). Deaths within 6 months after removal from the waiting list for reasons other than transplant or death decreased from 31.5% in 2011 to 15.1% in 2021; this outcome was highest among patients aged 65 years or older compared with other age groups (Figures LI 29 and 31).

1.3 Donation

The number of deceased liver donors continued to increase, reaching an all-time high of 9,540 in 2021, driven by growth in donors aged 30-39, 40-54, and 55 years or older (Figures LI 32 and 33). There were 683 pediatric donors younger than 18 years. This number has remained relatively stable in the past several years and represented 7.2% of deceased liver donors in 2021 (Figure LI 35). The sex and racial composition of donors has remained relatively unchanged: 62.3% male, 37.7% female, 62.7% White, 17.3% Black, 15.8% Hispanic, and 3.1% Asian (Figures LI 36 and 37). The number of livers with positive hepatitis C antibody has not increased as in previous years, but these livers do continue to make up a substantial proportion (9.1%) of deceased donor livers recovered in 2021 (Figures LI 34 and 38). Anoxia remains the most common cause of death among deceased liver donors (45.8%), followed by head trauma (26.6%) and cerebrovascular accident/stroke (25.7%) (Figure LI 47).

Overall, 10.0% of livers were recovered but not transplanted, an increase in the past 4 years, compared with 8.6% in 2018 (Figure LI 39). The trend may be explained at least in part by the increase in donation after circulatory death (DCD) livers (Table LI 8), which remained much less likely to be transplanted than donation after brain death (DBD) livers (29.4% vs 6.9%) (Figure LI 46). Livers from older donors (40 years or older) were also less likely to be transplanted (Figure LI 40). Livers with positive hepatitis C antibody or those at increased risk of disease transmission were not more likely to be unused (Figures LI 44 and 45).

Living donors were more likely to be women (56.3%) and White (77.8%) (Figures LI 50 and 51). Most donors were related to or directed to the recipient (Figure LI 48). In most cases, the right lobe of the liver was used (78.5%), an increasing trend over the past decade (Figure LI 52).

1.4 Transplants

In 2021, a record 9,234 liver transplants (adult and pediatric) were performed in the United States, of which 8,665 (93.8%) were from deceased donors and 569 (6.2%) were from living donors (Figures LI 54 and 55). The recipients were 61.7% male, 69.5% White, 16.7% Hispanic, 7.6% Black, and 4.4% Asian (Figures LI 57 and 58). The largest age group was adults aged 50-64 years, with a growing proportion of patients aged 35-49 years and no increase in the group aged 65 years or older in the past year (Figure LI 56).

Alcohol-associated liver disease was again the most common indication for liver transplant overall (ie, for adult and pediatric combined), making up 37.5% of transplants, followed by nonalcoholic steatohepatitis at 18.6% (Figure LI 59). Some proportion of recipients with other/unknown category, the third most common diagnosis (15.2%), may have also had liver disease due to nonalcoholic steatohepatitis. Liver transplants with a primary diagnosis of HCC declined to 10.9%, from 17.8% in 2011 and 16.1% in 2018. The prevalence of HCV also continued to decrease, representing only 4.7% of liver transplant recipients, compared with 22.6% in 2011.

Among the 8,733 adult recipients, 94.4% received livers from deceased donors and 5.6% from living donors (Table LI 8). The recipients were 62.4% male, 70.6% White, 16.5% Hispanic, 6.9% Black, and 4.2% Asian (Table LI 6). For BMI, 21.0% had BMI 30-<35 kg/m2, and 15.3% had 35 kg/m2 or greater. Most liver transplants were covered by private insurance (51.8%), followed by Medicare (26.7%) and Medicaid (17.1%). In terms of place of residence, 83.5% of recipients lived in metropolitan areas, compared with 14.8% in non-metropolitan areas; 56.8% lived less than 50 miles from the transplant center, 17.8% within 50-<100 miles, 9.7% within 100-<150 miles, 7.5% within 150-<250 miles, and 7.1% 250 miles or farther.

Alcohol-associated liver disease was the diagnosis for 39.6% of adult liver transplants, compared with 17.5% in 2011 (Table LI 7). This was followed by nonalcoholic steatohepatitis (19.6%), other/unknown (13.8%) and HCC (11.5%). Cholestatic liver disease (8.0%), HCV (5.0%), and acute liver failure (2.5%) were less frequent. The percentage of transplanted recipients with HCC exception points decreased to 15.8% from 25.4% in 2011. The most common recipient blood type was O (45.5%), followed by A (36.4%), B (13.4%), and AB (4.7%).

Most liver transplant recipients waited fewer than 90 days (62.1%), with only 13.5% waiting longer than 1 year (Table LI 8). Overall, waiting times were shorter compared with 2011. The proportion of adults who received DCD livers increased from 4.6% in 2011 to 10.5% in 2021, while the proportion of those who received split livers decreased from 1.1% to 0.8%. The proportion of recipients with a history of previous transplant decreased from 5.7% in 2011 to 3.6% in 2021.

Induction therapy was used in 31.1% of adult liver transplants in 2021, and 71.8% of adult liver transplant recipients received steroid-containing immunosuppressive regimens (Figures LI 61 and 62).

There were 780 simultaneous liver-kidney transplants in 2021 (adult and pediatric), representing 8.4% of liver transplant recipients during the calendar year (Figure LI 60). This proportion has been stable over the past several years and decreased from a peak of 9.4% in 2016, just prior to the introduction of standardized medical eligibility criteria for simultaneous liver-kidney transplant in 2017.

1.5 Outcomes

Among adult liver transplants performed in 2020, the most recent year for which at least 1 full year of follow-up was available, graft failure occurred in 7.0% of deceased donor liver transplant recipients at 6 months and 9.2% at 1 year, an increase compared with the previous year and reversal of a previous trend of improving short-term outcomes (Figure LI 63). This observation coincided with the onset of the COVID-19 pandemic in early 2020 among other trends. Longer-term graft outcomes for recipients of deceased donor liver transplant in 2018, 2016, and 2011 were similar to previous years, with a graft failure frequency of 15.0% at 3 years for transplants in 2018, 20.7% at 5 years for transplants in 2016, and 38.5% at 10 years for transplants in 2011.

Overall survival for adult liver transplant recipients followed a similar pattern to graft failure (ie, a detectable increase in short-term mortality but similar longer-term survival), with 5.7% mortality at 6 months, 7.8% at 1 year, 13.3% at 3 years, 18.6% at 5 years, and 35.9% at 10 years (Figure LI 65).

Outcomes were similar, if not better, for adult living donor liver transplant recipients, with graft failure occurring in 6.1% at 6 months, 8.7% at 1 year, 14.2% at 3 years, 19.4% at 5 years, and 42.0% at 10 years (Figure LI 64). Graft outcomes, however, were inferior compared with previous years.

Five-year graft survival rates among deceased donor liver transplant recipients who underwent transplant during 2014-2016 exceeded 75% across all categories and surpassed 80% among those aged 35-49 years (81.6%), those with cholestatic liver disease (80.9%), and those with a MELD score of 15-24 at transplant (80.8%) (Figures LI 66, 67, and 68). The 5-year graft survival rate among recipients of DCD livers was 75.9%, compared with 79.2% for recipients of DBD livers (Figure LI 69). Five-year graft outcomes were equivalent between those with and without HCC exception points (Figure LI 70). Patient survival after deceased donor liver transplant largely mirrored that of graft survival, exceeding 80% except for those aged 65 years or older (77.4%) and those with acute liver failure (79.2%), HCC (79.4%), nonalcoholic steatohepatitis (79.7%), and a MELD score of 35-39 (79.6%) or 40 or greater (76.8%) (Figures LI 81, 82, and 83). Survival was similar between metropolitan and non-metropolitan residents (Figure LI 84).

Five-year graft survival among living donor liver transplant recipients was higher among patients with a MELD score 14 or lower (81.5%), compared with MELD 15-24 (79.9%) and 25-34 (69.0%) (Figure LI 76). In terms of patient survival, however, 5-year outcomes were similar between those with a MELD score 14 or lower and those with a MELD score 15-24 (85.6% vs 85.1%) and lower for those with a MELD score 25-34 (75.9%) (Figure LI 88). Five-year graft and patient survival were highest for living donor recipients with cholestatic liver disease and nonalcoholic steatohepatitis, and lowest for those with HCC (Figures LI 75 and 86).

2 PEDIATRIC LIVER TRANSPLANTATION IN THE UNITED STATES

2.1 Summary

In 2021, 36 children died on the waiting list or were removed for being too sick to undergo transplant. While living donor recipients have better long-term graft and patient survival compared with deceased donor recipients, the proportion of children undergoing living donor transplant (15.4%) has not changed significantly in the past decade, nor has the use of split liver grafts (16.6%). With 83.4% of pediatric liver transplants using whole or partial liver grafts, candidates younger than 1 year continued to have the highest pretransplant mortality rates, which has also not changed over the past decade. Pediatric liver transplant candidates were prioritized for pediatric donors as part of the acuity circles policy implemented in February 2020. This policy allowed offers to be prioritized for children nationally before being offered to adults within a 500–nautical mile acuity circle. Since this policy change, pediatric waitlist mortality in 2020 and 2021 decreased to its lowest rate since 2011. (Simultaneously, in 2020 and 2021, adult waitlist pretransplant mortality rates remained stable despite this policy change.) While long-term patient survival continues to improve, 12% of pediatric liver transplant recipients who underwent transplant in 2011 did not survive to 2021. In 2021, the pretransplant mortality rate for Black children improved to its lowest value since 2014, although this metric does not capture the barriers to transplant evaluation and listing for non-White children. In addition, use of exception narratives, access to living donor transplant, and graft and patient survival data were not further stratified by race. Addressing racial disparities in pediatric liver transplantation is critical to ensuring equitable access and outcomes for all children requiring liver transplant.

2.2 Waiting List

In 2021, 666 new registrants were added to the pediatric liver transplant waiting list (Figure LI 90, Table LI 12). Registrants aged 1-5 years (32.9%) and 12-17 years (22%) in the year 2021 made up the largest age groups, followed by younger than 1 year (19%), 6-11 years (18.1%), and 18 years or older (8.1%) (Figure LI 92). In terms of race and ethnicity, White registrants continued to make up the largest group on the waiting list in 2021 (48.3%), followed by Hispanic (24.5%), Black (17.1%), and Asian registrants (6.5%) (Figure LI 92). For pediatric liver waitlist registrants, from 2011 to 2021, age, sex, race, diagnosis, and geographic distributions did not change substantially (Tables LI 9 and 10). Waiting time has improved in the past decade. In 2021, 29.2% of candidates waited fewer than 90 days, 24.4% waited 3-12 months, 12.7% waited 1-2 years, and 33.7% waited 2 or more years until transplant (Table LI 11).

Pretransplant mortality remained steady at a rate of 5.6 deaths per 100 patient-years in 2021, with the highest mortality rate remaining for candidates younger than 1 year at a rate of 21.7 deaths per 100 patient-years (Figures LI 100 and 101). In 2021, more registrants died on the waiting list (n=20, 3.0%) compared with 2020 (n=17, 2.5%), 12.7% were removed because their condition improved, and 2.4% were considered too sick for transplant. In total in 2021, 36 children died on the waiting list or were removed for being too sick for transplant (Table LI 13). Pretransplant mortality rates were highest in Hispanic registrants (Figure LI 102).

2.3 Transplants

In 2021, 501 pediatric liver transplants were performed in the United States compared with 502 in 2020 and 551 in 2019. The number of annual liver transplants in 2020 and 2021 remained the lowest of the past decade (Figure LI 104), perhaps partially attributable to the COVID-19 pandemic. The overall number of pediatric transplants increased for 1- to 5-year-olds and decreased for 12- to 17-year-olds, reversing the previous year’s trend (Figure LI 106). Recipient demographic information, including age at the time of transplant, race or ethnicity, insurance type, and geography, has remained similar over the past decade (Table LI 14). Biliary atresia remains the leading indication for transplant (40.9%) followed by other/unknown diagnosis (22%), metabolic (13%), acute liver failure (10.8%), other cholestatic condition (7%), and hepatoblastoma (6.4%), which remains relatively unchanged over the past decade (Table LI 15). In 2021, no patients received a DCD graft (Table LI 16).

Over the past decade, there has been no significant change in living donor transplants, which accounted for 15.4% of total transplants in 2021 (Figure LI 105). There has additionally been no increase in the use of technical variant grafts over the past decade, and in 2021 61.1% were whole liver, 22.4% were partial liver, and 16.6% were split liver transplants (Figure LI 107, Table LI 16). The plurality of recipients (42%) underwent transplant at a MELD/PELD score of 25 or greater, of which 9.6% underwent transplant at a MELD/PELD score of 40 or greater. The number of recipients who underwent transplant at status 1B (16.8%) or 1A (14.2%) has not changed significantly over the past decade (Table LI 15).

In 2021, 62.3% of pediatric liver transplant recipients received no induction therapy (Figure LI 108). The most common initial immunosuppression regimens were tacrolimus and steroids (39.9%) followed by tacrolimus, mycophenolate agent, and steroids (34.7%) (Figure LI 109).

2.4 Outcomes

Within 1 year of transplant, 19%-24% of transplant recipients had at least one episode of rejection, with the highest incidence in recipients younger than 1 year (Figure LI 116). By 5 years posttransplant, 3.7% of recipients developed posttransplant lymphoproliferative disorder (Figure LI 117).

Graft failure occurred in 5.9% of deceased donor recipients at 6 months, 6.9% at 1 year, 11.4% at 3 years, 15.3% at 5 years, and 21.0% at 10 years from transplant (Figure LI 110). Fewer living donor recipients developed graft failure, occurring in 3.0% at 6 months, 6.1% at 1 year, 9.7% at 3 years, 8.1% at 5 years, and 10.2% at 10 years from transplant (Figure LI 111), compared with deceased donor recipients. Five-year graft survival was highest for deceased donor recipients who were aged 6-11 years at the time of transplant (91.7%) followed by 12-17 years (85.0%), younger than 1 year (83.9%), and 1-5 years (82.3%) (Figure LI 112). By diagnosis, 5-year graft survival was highest for deceased donor recipients with metabolic conditions (90.6%), followed by biliary atresia (89.3%), acute liver failure (82.4%), other/unknown (80.2%), hepatoblastoma (78.2%), and other cholestatic conditions (77.6%) (Figure LI 113). Deceased donor recipients who underwent transplant at a MELD/PELD score of 35-39 had the lowest 5-year graft survival at 70.3% (Figure LI 114). At all time points, living donor recipients had better graft survival compared with deceased donor recipients, with a 5-year graft survival of 91.2% compared with 84.8%, respectively (Figure LI 115).

Recipient mortality remains notable with death occurring in 5.2% of deceased and living donor recipients at 6 months, 6.4% at 1 year, 6.9% at 3 years, 10.1% at 5 years, and 11.9% at 10 years from transplant. Since 2018, deaths at 6 months and 1 year posttransplant are now increasing (Figure LI 118). Five-year patient survival was highest for recipients who were aged 6-11 years at the time of transplant (92.8%), followed by younger than 1 year (91.4%), 12-17 years (88.8%), and 1-5 years (87.8%), for deceased donor recipients (Figure LI 120). By diagnosis, 5-year patient survival was highest for deceased donor recipients with biliary atresia (94.8%), followed by metabolic conditions (94.1%), acute liver failure (89.4%), other/unknown (85.5%), hepatoblastoma (82.3%), and other cholestatic (80.6%) (Figure LI 121). At all time points, living donor recipients had better patient survival compared with deceased donor recipients, with a 5-year patient survival of 95.3% compared with 89.7%, respectively (Figure LI 122).




This publication was produced for the U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), by Hennepin Healthcare Research Institute (HHRI) and the United Network for Organ Sharing (UNOS) under contracts HHSH75R60220C00011 and HHSH250201900001C, respectively.

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Suggested Citations:
Full citation: Organ Procurement and Transplantation Network (OPTN) and Scientific Registry of Transplant Recipients (SRTR). OPTN/SRTR 2021 Annual Data Report. U.S. Department of Health and Human Services, Health Resources and Services Administration; 2023. Accessed [insert date]. http://srtr.transplant.hrsa.gov/annual_reports/Default.aspx
Abbreviated citation: OPTN/SRTR 2021 Annual Data Report. HHS/HRSA; 2023. Accessed [insert date]. http://srtr.transplant.hrsa.gov/annual_reports/Default.aspx

Publications based on data in this report or supplied on request must include a citation and the following statement: The data and analyses reported in the OPTN/SRTR 2021 Annual Data Report have been supplied by the United Network for Organ Sharing and Hennepin Healthcare Research Institute under contract with HHS/HRSA. The authors alone are responsible for reporting and interpreting these data; the views expressed herein are those of the authors and not necessarily those of the U.S. government.

This report is available at https://srtr.transplant.hrsa.gov. Individual chapters may be downloaded.

List of Figures

List of Tables




**New adult candidates added to the liver transplant waiting list.** A new candidate is one who first joined the list during the given year, without having been listed in a previous year. Previously listed candidates who underwent transplant and subsequently relisted are considered new. Active and inactive patients are included.

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




**All adult candidates on the liver transplant waiting list.** Adult candidates on the list at any time during the year. Candidates listed at more than one center are counted once per listing.

Figure LI 2: All adult candidates on the liver transplant waiting list. Adult candidates on the list at any time during the year. Candidates listed at more than one center are counted once per listing.




**Distribution of adults waiting for liver transplant by age.** Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive candidates are included. Age is determined at the earliest of transplant, death, removal, or December 31 of the year.

Figure LI 3: Distribution of adults waiting for liver transplant by age. Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive candidates are included. Age is determined at the earliest of transplant, death, removal, or December 31 of the year.




**Distribution of adults waiting for liver transplant by sex.** Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive patients are included.

Figure LI 4: Distribution of adults waiting for liver transplant by sex. Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive patients are included.




**Distribution of adults waiting for liver transplant by race.** Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive patients are included.

Figure LI 5: Distribution of adults waiting for liver transplant by race. Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive patients are included.




**Distribution of adults waiting for liver transplant by diagnosis.** Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive patients are included. HCC, hepatocellular carcinoma; HCV, hepatitis C virus; NASH, nonalcoholic steatohepatitis.

Figure LI 6: Distribution of adults waiting for liver transplant by diagnosis. Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive patients are included. HCC, hepatocellular carcinoma; HCV, hepatitis C virus; NASH, nonalcoholic steatohepatitis.