1 Introduction

This chapter reports data collected by the Organ Procurement and Transplantation Network (OPTN) to describe changes in deceased donor characteristics over the past decade and deceased organ donor metrics such as donation rate and rate of organs recovered for transplant but not transplanted (ie, nonuse). These metrics are currently produced by the Scientific Registry of Transplant Recipients (SRTR), and some are used for organ procurement organization (OPO) quality assessment by OPTN. Some data described in this chapter are also used by the Centers for Medicare & Medicaid Services (CMS) to develop its own quality assessment of OPOs. The chapter also describes the Centers for Disease Control and Prevention’s national data on deaths that will be used by CMS as part of its metrics to assess OPO quality. In 2019, the federal government ordered the revision of OPO quality metrics “to establish more transparent, reliable, and enforceable objective metrics for evaluating an OPO’s performance.”¹ This federal order also aims to reduce organ nonuse nationally. CMS has approved new metrics to assess OPO quality.² The new metrics to assess OPO quality became effective on August 1, 2022; their impact will be seen in the future.

2 Donors and Organs

In 2022, there were 14,905 deceased donors, a 7.5% increase from 13,863 in 2021. Over the past decade, the number of deceased donors has increased annually (from 8,126 in 2011) (Figure DD 1).

In 2022, there were 10,127 donation after brain death (DBD) and 4,778 donation after circulatory death (DCD) donors, which represent increases of 4.6% and 1.4%, respectively, compared with 2021. Since 2012, the numbers of both DBD and DCD donors have increased annually (Figure DD 2). There have also been similar annual increases in the numbers of organs authorized, organs recovered, and organs transplanted since 2012.

In 2022, there were 107,639 organs authorized for donation, a 7.9% increase from 99,708 in 2021, and this number has increased annually over the past decade. Likewise, the numbers of organs recovered and organs transplanted have increased annually since 2012. In 2022, there were 53,709 organs recovered, an increase of 9.4% from 49,091 in 2021.

In 2022, there were 37,334 organs used for transplant, an increase of 4.6% from 35,687 in 2021 (Figure DD 3). The characteristics of deceased organ donors in 2022 differ from those of donors in 2012. In 2022, there were more donors with the following characteristics: kidney donor profile index (KDPI) of 35%-85%, KDPI of greater than 85%, HIV positive, hepatitis C virus (HCV) positive, anoxia as cause of death, male, age 35 years and older, Latino ethnicity, White race, Other or unknown race, and DCD (Table DD 1).

3 Organs Recovered Per Donor

In 2022, there were 49,187 organs recovered for transplant, a 6.4% increase from 46,219 in 2021. The year 2022 saw 3.30 organs recovered per donor (ORPD) for all organs, a decrease of 1.0% from 2021. Over the past decade, this ORPD has ranged from 3.30 to 3.55. Given that each donor can potentially donate two kidneys, the organ-specific ORPD was highest for kidneys at 1.90 in 2022, stable since 2021. Over the past decade, the ORPD for kidneys has ranged from 1.80 to 1.90 (Figure DD 4).

The ORPD for liver was 0.66 in 2022, a decrease of 4.3% from 0.69 in 2021; the value in 2011 was 0.82. The ORPD for pancreas was 0.086 in 2022, a 4.3% decrease from 0.094 in 2021; the value was 0.18 in 2011 and has decreased annually over the past decade. The ORPD for intestine was 0.0058 in 2022, a decrease of 16.5% from 0.0069 in 2021; the value in 2011 was 0.016. Thus, ORPD values for liver, pancreas, and intestine have declined over the past decade (Figure DD 5).

In contrast, heart and lung did not have ORPD declines. The ORPD for heart was 0.28 in 2022, showing a slight increase from 2021. Over the past decade, the ORPD for heart has fluctuated between 0.28 and 0.32. The ORPD for lung was 0.36 in 2022, an increase of 0.4% from 2021. Over the past decade, the ORPD for lung has fluctuated from 0.37 to 0.45 (Figure DD 5).

In 2022, the ORPD for all organs varied by donation service area (DSA), ranging from 2.52 to 3.70 (Figure DD 6). The ORPD is an unadjusted number representing a mix of donor types, including young, old, DBD, and DCD, which explains some differences observed.

4 Organs Transplanted Per Donor

In 2022, there were 39,833 organs transplanted, a 4.6% increase from 38,080 in 2021. In 2022, there were 2.67 organs transplanted per donor (OTPD) for all organs, a decrease of 2.9% from 2.75 in 2021. Organs divided into segments (liver, lung, pancreas, intestine) may account for more than one transplant; thus, this number will be higher than deceased donor organs used for transplant. This OTPD has generally been decreasing, from 3.07 in 2011. Given that each donor can potentially donate two kidneys, the organ-specific OTPD was highest for kidneys at 1.39 in 2022, a 2.8% decline from 1.43 in 2021. Over the past decade, the OTPD for kidneys has fluctuated between 1.39 and 1.50 (Figure DD 4). In 2022, from 14,411 donors, 10,130 left kidney transplants and 10,039 right kidney transplants were performed (Figure DD 21 and Figure DD 22). In 2022, from 494 donors, 298 en bloc kidney transplants were done (Figure DD 23).

The OTPD for liver was 0.59 in 2022, a decrease of 5.0% from 0.62 in 2021. Over the past decade, the OTPD for liver has typically decreased every year and was 0.74 in 2011 (Figure DD 8). In 2022, from the 14,905 total deceased organ donors, 8,847 livers were transplanted (Figure DD 25). The OTPD for pancreas was 0.062 in 2022, a 11.5% decrease from 0.070 in 2021. Over the past decade, the OTPD for pancreas has decreased annually and was 0.13 in 2011. In 2022, from the 14,905 donors, there were 922 pancreata transplanted and this includes five pancreata that were transplanted as islet cells (Figure DD 24). The OTPD for intestine was 0.0056 in 2022, a decrease of 19.5% from 0.0069 in 2021. Over the past decade, the OTPD for intestine has largely decreased year to year and was 0.015 in 2011. In 2022, from the 14,905 donors, there were 83 intestines transplanted (Figure DD 26). Thus, liver, pancreas, and intestine have seen a fairly steady decline in OTPD over the past decade (Figure DD 8).

The OTPD for heart was 0.28 in 2022, showing a slight increase from 2021. Since 2011, the OTPD for heart has fluctuated between 0.28 and 0.32. In 2022, from the 14,905 donors, there were 4,169 hearts transplanted (Figure DD 27). The OTPD for lung was 0.33 in 2022, showing a slight decrease from 2021. Over the past decade, the OTPD for lung has fluctuated between 0.33 and 0.42 (Figure DD 8). In 2022, from the 14,905 donors, there were 2,633 lung transplants done.

In 2022, the OTPD for all organs varied by DSA, ranging from 2.09 to 3.12 (Figure DD 9). The OTPD is an unadjusted number representing a mix of donor types, including young, old, DBD, and DCD, which explains some differences observed. The OTPD for all organs was 3.14 for DBD in 2022, a 1.2% decrease from 3.18 in 2021. This OTPD for DBD has varied from 3.14 to 3.34 over the past decade. The OTPD for all organs was 1.67 for DCD in 2022, a 4.6% decrease from 1.75 in 2021. The OTPD for DCD has decreased over the past decade and was 2.00 in 2011 (Figure DD 10). The percentage of DCD donors varies across DSAs on the mainland in the United States, ranging from 0% to 51.4% (Figure DD 19).

In 2022, the OTPD for kidneys was 1.44 for DBD donors and 1.30 for DCD donors. The OTPD for kidneys has been lower for DCD compared with DBD since 2021. In 2011 through 2020, the OTPD for kidneys for DCD was higher than that for DBD (Figure DD 11). In 2022, the OTPD for pancreas was 0.09 for DBD donors and 0.005 for DCD donors (Figure DD 12). In 2022, the OTPD for liver was 0.77 for DBD donors and 0.21 for DCD donors (Figure DD 13). No intestines were transplanted from DCD donors in 2022 or in the past decade (Figure DD 14). A few DCD hearts have been transplanted since 2019 (Figure DD 15). The OTPD for lung was 0.45 for DBD donors and 0.081 for DCD donors (Figure DD 16).

The OTPD for kidneys varied by KDPI in 2022, from 1.92 for KDPI of 20% or less to 0.56 for KDPI of greater than 85%. This trend was relatively stable over the past decade (Figure DD 17). The percentage of kidney donors with KDPI of greater than 85% also varied across DSAs, ranging from 2.4% to 14.4% (Figure DD 20).

5 Organs Recovered for Transplant but Not Transplanted

In 2022, there were 9,354 organs recovered for transplant but not transplanted (ie, nonuse), a 14.9% increase from 8,139 in 2021. These unused organs represented 19.0% of all organs recovered combined in 2022, an increase from 17.6% in 2021. The percentage of nonuse has increased annually since 2018. In 2022, the nonuse percentage varied by organs. Pancreas had the highest percentage of nonuse in 2022 at 28.6%, followed by kidneys, liver, lung, intestine, and heart in sequential order with 26.7%, 9.8%, 9.0%, 4.6%, and 1.3%, respectively (Figure DD 18); by their number values, 366 pancreata, 3,563 left kidneys, 3,673 right kidneys, 156 en bloc kidneys, 965 livers, 219 lungs, 4 intestines, and 54 hearts were not used. Given the high nonuse rates of kidney and pancreas, the OPTN Board of Directors has asked the Kidney and Pancreas Committees to focus on increasing the efficiency in use of such organs prior to changing their allocation systems.

6 Change in Characteristics of Donors Over the Past Decade

In 2022, 20.9% of donors had a KDPI of greater than 85%, an increase from 17.9% in 2012. In contrast, in 2022, there was a decline in percentage of donors with a KDPI of less than 20% compared with 2012. In 2022, the use of HIV-positive and HCV-positive donors increased compared with 2012. Given the increase in deceased donors over the past decade, there is controversy regarding an explanation (Table DD 1). Some have argued that deaths from the opioid epidemic have fueled this increase in donors. In 2022, 16.7% of donors died from drug intoxication, an increase from 5.4% in 2012. However, in 2022, 20.5% of donors died from cardiovascular causes, an increase from 15.7% in 2012. This stagnation in improvement of deaths from cardiovascular causes has been well described in the medical literature. In contrast, there was an increase in deaths from gunshot wound, blunt injury, and stroke in 2022 compared with 2012, but they all represent a lower percent of the total deaths. Others have argued that the improvement in performance of OPOs is responsible for the increase in deceased donors. The unadjusted analysis presented herein is unlikely to resolve the issue.

For circumstances of death, in 2022, 19.3% of the donors died from non–motor vehicle accidents (non-MVAs), an increase from 9.9% in 2012. Natural causes was the category with the largest percentages in both years, at 47.6% and 45.0% of deaths in 2022 and 2012, respectively. In 2022, anoxia was the cause of death in 48.0% of donors, an increase from 29.9% in 2012. All other causes of death decreased in relative percentage in 2022 from 2012. The increases in deaths related to non-MVAs and anoxia are consistent with increases in deaths from opioid overdose (Table DD 2).

7 New Metrics From the Centers for Medicare & Medicaid Services

The CMS has finalized and published new metrics in December 2021 for the OPO public performance report cards. These new metrics were used in 2022. The new metrics determine the CMS potential donors, which is the denominator for both the donation rate and transplant rate metrics. In Figure DD 29, the CMS potential donors were identified using data obtained from the National Center for Health Statistics Detailed Multiple Cause of Death (MCOD) file as provided by the Centers for Disease Control and Prevention. The potential donor deaths were identified using the codes from the International Classification of Diseases, Tenth Revision, for ischemic heart disease (120-125), cerebrovascular disease (160-169), and external causes of morbidity and mortality, which includes blunt trauma, gunshot wound, suicide, drowning, and asphyxiation (V-1-Y89). The definition of potential donors is based on the cause of death, age younger than 75 years, and the location of death being consistent with organ donation, mainly inpatient deaths. The numerator is the number of donors for the donation rate metric and is defined as the number of deceased individuals from whom at least one organ, such as heart, liver, lung, kidney, pancreas, or intestine, was transplanted. The number of donors also includes donors with pancreata or islet cells that were either recovered for research or recovered for transplant but submitted for research. In 2021, the donation rate metric varied across DSAs from 6.9 to 19.2 (Figure DD 29 and Table DD 3).

The transplant rate metric, the second CMS metric, uses the number of organs transplanted from deceased donors as shown in Figure DD 30. In 2021, the CMS transplant rate varied across DSAs from 15.0 to 57.5. The CMS transplant rate was lowest for the Hawaii DSA, and the metric for this DSA only includes transplanted kidneys in its numerator. For the US mainland, the lowest transplant rate metric was 20.8 (Figure DD 30 and Table DD 3).

This numerator for the transplant metric also includes pancreata and islet cells that were either recovered for research or recovered for transplant but submitted for research. In 2022, there were 2,737 pancreata either recovered for research or recovered for transplant but submitted for research, a 134% increase from 1,165 in 2021 (Figure DD 31). In 2022, there were 254 donors who had only a pancreas recovered for research or recovered for transplant but submitted for research, a 230% increase from 107 in 2021.