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Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CAScientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN
Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MNDivision of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, MN
Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MNDepartment of Pediatrics, University of Washington, Seattle, WA
Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MNDepartment of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN
Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MNDepartment of Epidemiology and Community Health, University of Minnesota, Minneapolis, MNDepartment of Medicine, Hennepin Healthcare, Minneapolis, MN
Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MNDepartment of Medicine, Hennepin Healthcare, Minneapolis, MN
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.
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).
Figure LI 1New 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 2All 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.
Table LI 1Demographic 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.
Table LI 2Clinical 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.
Table LI 3Listing 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.
Table LI 4Liver 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.
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).
Figure LI 3Distribution 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.
Figure LI 4Distribution 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 5Distribution 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.
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.
Figure LI 6Distribution 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.
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).
Figure LI 7Distribution of adults waiting for liver transplant by first active lab MELD in the year. 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 8Distribution of adults waiting for liver transplant by BMI. 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 9Distribution of adults waiting for liver transplant by blood type. 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 10Distribution of adults waiting for liver transplant by prior transplant status. 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.
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).
Figure LI 11Adults willing to accept liver from HCV+ donor. Candidates waiting for transplant at any time in the given year. Candidates listed at more than one center are counted once per listing. Willingness to accept HCV+ organ at time of listing. HCV, hepatitus C virus.
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).
Figure LI 12Overall deceased donor liver transplant rates among adult waitlist candidates. Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately.
Figure LI 13Deceased donor liver transplant rates among adult waitlist candidates by age. Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately.
Figure LI 14Deceased donor liver transplant rates among adult waitlist candidates by race. Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately.
Figure LI 15Deceased donor liver transplant rates among adult waitlist candidates by blood type. Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately.
Figure LI 18Deceased donor liver transplant rates among adult waitlist candidates by metropolitan vs. non-metropolitan residence. Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately. Urban/rural determination is made using the RUCA (Rural-Urban Commuting Area) designation of the candidate’s permanent zip code.
Figure LI 17Deceased donor liver transplant rates among adult waitlist candidates by sex. Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately.
Figure LI 16Deceased donor liver transplant rates among adult waitlist candidates by HCC exception status. Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of wait time in a given year. Individual listings are counted separately.
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).
Figure LI 19Three-year outcomes for adults waiting for liver transplant, new listings in 2015-2017. Candidates listed at more than one center are counted once per listing. Removed from list includes all reasons except transplant and death. DD, deceased donor; LD, living donor.
Figure LI 20Median months to liver transplant for waitlisted adults. Observations censored on December 31, 2020; Kaplan-Meier competing risk methods used to estimate time to transplant. Analysis performed per listing. If an estimate is not plotted, 50% of the cohort listed in that year had not undergone transplant by the censoring date. Only the first transplant is counted.
Figure LI 21Percentage of adults who underwent deceased donor liver transplant within a given time period of listing. Candidates listed at more than one center are counted once per listing.
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.
Figure LI 22Percentage of adults who underwent deceased donor liver transplant within 3 years of listing, 2017, by DSA. Candidates listed at more than one center are counted once per listing.
Figure LI 23Percentage of adults who underwent deceased donor liver transplant within 3 years of listing, 2017, by state. Candidates listed at more than one center are counted once per listing. State is candidate’s home state.
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).
Figure LI 24Overall pretransplant mortality rates among adults waitlisted for liver transplant. Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately.
Figure LI 25Pretransplant mortality rates among adults waitlisted for liver transplant by age. Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately.
Figure LI 26Pretransplant mortality rates among adults waitlisted for liver transplant by race. Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately.
Figure LI 27Pretransplant mortality rates among adults waitlisted for liver transplant by sex. Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately.
Figure LI 28Pretransplant mortality rates among adults waitlisted for liver transplant by diagnosis. Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately. HCV, hepatitis C virus; ALD, alcoholic liver disease; Chol. disease, cholestatic disease.
Figure LI 29Pretransplant mortality rates among adults waitlisted for liver transplant by metropolitan vs. non-metropolitan residence. Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately. Urban/rural determination is made using the RUCA (Rural-Urban Commuting Area) designation of the candidate’s permanent zip code.
Figure LI 30Pretransplant mortality rates among adults waitlisted for liver transplant by first active lab MELD in the year. Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately. Medical urgency is determined at the later of listing date and January 1 of the year.
Figure LI 31Pretransplant mortality rates among adults waitlisted for liver by HCC exception status. Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately.
Figure LI 32Pretransplant mortality rates among adults waitlisted for liver transplant in 2020 by DSA. Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately.
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).
Table LI 5Removal 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.
Figure LI 33Deaths within six months after removal among adult liver waitlist candidates, overall. Denominator includes only candidates removed from the waiting list for reasons other than transplant or death while on the list.
Figure LI 34Deaths within six months after removal among adult liver waitlist candidates, by first active lab MELD in the year. Denominator includes only candidates removed from the waiting list for reasons other than transplant or death while on the list.
Figure LI 35Deaths within six months after removal among adult liver waitlist candidates, by age. Denominator includes only candidates removed from the waiting list for reasons other than transplant or death while on the list.
The number of deceased liver donors continue to increase, reaching an alltime 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).
Figure LI 36Overall deceased liver donor count. Count of deceased donors whose livers were recovered for transplant.
Figure LI 38Deceased liver donor count by HCV status. Count of deceased donors whose livers were recovered for transplant. Donor HCV status was based on an antibody test.
Figure LI 42Distribution of deceased liver donors by donor HCV status. Deceased donors whose livers were recovered for transplant. Donor HCV status was based on an antibody test.
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).
Figure LI 43Percent of pediatric donor livers allocated to adult recipients, by DSA of donor hospital, 2016-2020. Numerator: pediatric donor livers donors allocated to adult recipients. Denominator: total pediatric donor livers.
Figure LI 44Overall percent of livers recovered for transplant and not transplanted. Percentages of livers not transplanted out of all livers recovered for transplant.
Figure LI 45Percent of livers recovered for transplant and not transplanted by donor age. Percentages of livers not transplanted out of all livers recovered for transplant.
Figure LI 46Percent of livers recovered for transplant and not transplanted by donor sex. Percentages of livers not transplanted out of all livers recovered for transplant.
Figure LI 47Percent of livers recovered for transplant and not transplanted by donor race. Percentages of livers not transplanted out of all livers recovered for transplant.
Figure LI 48Percent of livers recovered for transplant and not transplanted by donor cause of death. Percentages of livers not transplanted out of all livers recovered for transplant. CVA, cerebrovascular accident.
Figure LI 49Percent of livers recovered for transplant and not transplanted by donor HCV status. Percentages of livers not transplanted out of all livers recovered for transplant. Donor HCV status was based on an antibody test.
Figure LI 50Percent of livers recovered for transplant and not transplanted, by donor risk of disease transmission. Percentages of livers not transplanted out of all livers recovered for transplant. ”Increased risk” is defined by criteria from the US Public Health Service Guidelines for increased risk for HIV, hepatitis B and hepatitis C transmission.
Figure LI 51Percent of livers recovered for transplant and not transplanted by DCD status. Percentages of livers not transplanted out of all livers recovered for transplant. DBD, donation after brain death; DCD, donation after circulatory death.
Figure LI 52Cause of death among deceased liver donors. Deceased donors with a liver recovered for the purposes of transplant. CVA, cerebrovascular accident.
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).
Figure LI 53Rehospitalization among living liver donors, 2015-2019. Cumulative hospital readmission. Thedischarge time point is recorded at the earliest of discharge or 6 weeks after donation. Domino liver donors excluded.
Figure LI 54Number of living liver transplants by donor relation. Numbers of living donor donations, excluding domino livers, as reported on the OPTN Living Donor Registration Form.
Table LI 7Living 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.
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%).
Figure LI 60Overall liver transplants. All liver transplant recipients, including adult and pediatric, retransplant, and multi-organ recipients.
Figure LI 61Total liver transplants by donor type. All liver transplant recipients, including adult and pediatric, retransplant, and multi-organ recipients.
Table LI 8Demographic characteristics of adult liver transplant recipients, 2010 and 2020 (continued on next page). Liver transplant recipients, including retransplants. Distance is computed from recipient’s home zip code to the transplant center.
Table LI 9Clinical characteristics of adult liver transplant recipients, 2010 and 2020.Liver transplant recipients, including retransplants. HCC, hepatocellular carcinoma; HCV, hepatitis C virus.
Table LI 10Transplant characteristics of adult liver transplant recipients, 2010 and 2020. Liver transplant recipients, including retransplants. DBD, donation after brain death; DCD, donation after circulatory death.
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).
Figure LI 65Total liver transplants by diagnosis. All liver transplant recipients, including adult and pediatric, retransplant, and multi-organ recipients. HCV, hepatitis C virus; ALD, alcoholic liver disease; Chol. disease, cholestatic disease; HCC, hepatocellular carcinoma.
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).
Table LI 11Adult 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.
Table LI 12Adult 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.
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.
Figure LI 66Induction agent use in adult liver transplant recipients. Immunosuppression at transplant reported to the OPTN.
Figure LI 67Immunosuppression regimen use in adult liver transplant recipients. Immunosuppression regimen at transplant reported to the OPTN. Tac, tacrolimus. MMF, all mycophenolate agents.
Figure LI 68Median MELD scores for adult deceased donor liver transplant recipients by DSA, 2020.Deceased donor liver transplants. DSA of transplant center location. Status 1A and inactive status excluded; allocation MELD score used.
Figure LI 69Quartiles of median MELD at transplant across DSAs for adult deceased donor liver recipients.. Deceased donor liver transplants, excluding Status 1A. Annual quartiles of DSA-level median allocation MELD scores are given, using DSA where the transplant center is located.
Figure LI 70Percent of adult liver transplant recipients using exceptions in 2020, by DSA. Exceptions among those allocated by MELD. Denominator excludes status 1A recipients.
Figure LI 71Total HLA A, B, and DR mismatches among adult deceased donor liver-kidney transplant recipients, 2016-2020. Donor and recipient antigen matching is based on OPTN antigen values and split equivalences policy as of 2018. Limited to deceased donor liver-kidney transplants only.
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.
Figure LI 72Annual adult liver transplant center volumes by percentile. Annual volume data are limited to recipients aged 18 years or older.
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).
1.5 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, in14.7% at 3 years for transplants in 2017, in 20.7% at 5 years for transplants in2015, 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).
Figure LI 74Graft failure among adult deceased donor liver transplant recipients. All adult recipients of deceased donor livers, including multi-organ transplants.
Figure LI 75Graft failure among adult living donor liver transplant recipients. All adult recipients of living donor livers, including multi-organ transplants.
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 77Graft survival among adult deceased donor liver transplant recipients, 2013-2015, by age. Graft survival estimated using unadjusted Kaplan-Meier methods.
Figure LI 83Graft survival among adult deceased donor liver transplant recipients, 2013-2015, by metropolitan vs. non-metropolitan recipient residence. Graft survival estimated using unadjusted Kaplan-Meier methods.
Figure LI 84Graft survival among adult living donor liver transplant recipients, 2013-2015, by age. Graft survival estimated using unadjusted Kaplan-Meier methods.
Figure LI 85Graft survival among adult living donor liver transplant recipients, 2013-2015, by race. Graft survival estimated using unadjusted Kaplan-Meier methods.
Figure LI 87Graft survival among adult living donor liver transplant recipients, 2013-2015, by lab MELD. Graft survival estimated using unadjusted Kaplan-Meier methods.
Figure LI 88Graft survival among adult living donor liver transplant recipients, 2013-2015, by metropolitan vs. non-metropolitan recipient residence. Graft survival estimated using unadjusted Kaplan-Meier methods.
Figure LI 89Recipients alive with a functioning liver graft on June 30 of the year, by age at transplant. Recipients are assumed to be alive with function unless a death or graft failure is recorded. A recipient may experience a graft failure and be removed from the cohort, undergo retransplant, and reenter the cohort.
Figure LI 90Incidence of acute rejection by 1 year posttransplant among adult liver transplant recipients by age, 2018-2019. Only the first reported rejection event is counted. Cumulative incidence is estimated using the Kaplan-Meier method.
Figure LI 91Incidence of acute rejection by 1 year posttransplant among adult liver transplant recipients by induction agent, 2018-2019. Only the first reported rejection event is counted. Cumulative incidence is estimated using the Kaplan-Meier method. IL2-RA, interleukin-2 receptor agonist; TCD, T-cell depleting.
Figure LI 92Incidence of PTLD among adult liver transplant recipients by recipient EBV status at transplant, 2014-2018. Cumulative incidence is estimated using the Kaplan-Meier method. PTLD is identified as a reported complication or cause of death on the OPTN Transplant Recipient Follow-up Form or the Posttransplant Malignancy Form as polymorphic PTLD, monomorphic PTLD, or Hodgkin’s disease. Only the earliest date of PTLD diagnosis is considered. EBV, Epstein-Barr virus; PTLD, posttransplant lymphoproliferative disorder.
Figure LI 95Patient survival among adult deceased donor liver transplant recipients, 2013-2015, by medical urgency. Patient survival estimated using unadjusted Kaplan-Meier methods.
Figure LI 96Patient survival among adult deceased donor liver transplant recipients, 2013-2015, by metropolitan vs. non-metropolitan recipient residence. Patient survival estimated using unadjusted Kaplan-Meier methods.
Figure LI 97Patient survival among adult living donor liver transplant recipients, 2013-2015, by age. Patient survival estimated using unadjusted Kaplan-Meier methods.
Figure LI 99Patient survival among adult living donor liver transplant recipients, 2013-2015, by race. Patient survival estimated using unadjusted Kaplan-Meier methods.
Figure LI 100Patient survival among adult living donor liver transplant recipients, 2013-2015, by MELD score. Patient survival estimated using unadjusted Kaplan-Meier methods.
Figure LI 101Patient survival among adult living donor liver transplant recipients, 2013-2015, by metropolitan vs. non-metropolitan recipient residence. Patient survival estimated using unadjusted Kaplan-Meier methods.
(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).
2. Pediatric Transplant
2.1 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 longterm 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.
2.2 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).
Figure LI 102New pediatric 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. Candidates listed at more than one center are counted once per listing. Active and inactive patients are included.
Figure LI 103All pediatric candidates on the liver transplant waiting list. Pediatric candidates listed at any time during the year. Candidates listed at more than one center are counted once per listing.
Figure LI 104Distribution of pediatric candidates 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.
Figure LI 105Distribution of pediatric candidates waiting for liver transplant by race. Candidates waiting for transplant any time in the given year. Candidates listed at more than one center are counted once per listing. Active and inactive candidates are included.
Figure LI 106Distribution of pediatric candidates waiting for liver transplant by sex. Candidates waiting for transplant 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 107. Three-year outcomes for newly listed pediatric candidates waiting for liver transplant, 2015-2017. Pediatric candidates who joined the waitlist in 2016. Candidates listed at more than one center are counted once per listing. DD, deceased donor; LD, living donor.
Figure LI 107Three-year outcomes for newly listed pediatric candidates waiting for liver transplant, 2015-2017. Pediatric candidates who joined the waitlist in 2016. Candidates listed at more than one center are counted once per listing. DD, deceased donor; LD, living donor.
Figure LI 108Overall deceased donor liver transplant rates among pediatric waitlist candidates. Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of waiting in a given year. Individual listings are counted separately.
Figure LI 109Deceased donor liver transplant rates among pediatric waitlist candidates by age. Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of waiting in a given year. Individual listings are counted separately.
Figure LI 110Deceased donor liver transplant rates among pediatric waitlist candidates by race. Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of waiting in a given year. Individual listings are counted separately.
Figure LI 111Deceased donor liver transplant rates among pediatric waitlist candidates by allocation MELD/PELD. Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of waiting in a given year. Individual listings are counted separately. Medical urgency group is determined at the later of listing date and January 1 of the given year. Pediatric candidates aged 12 to 17 years can be assigned MELD or PELD scores.
Figure LI 112Deceased donor liver transplant rates among pediatric waitlist candidates by Status 1A or 1B. Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of waiting in a given year. Individual listings are counted separately. Medical urgency group is determined at the later of listing date and January 1 of the given year.
Figure LI 113Deceased donor liver transplant rates among pediatric waitlist candidates by metropolitan vs. non-metropolitan residence. Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of waiting in a given year. Individual listings are counted separately.
Table LI 13Demographic 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.
Table LI 14Clinical 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.
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).
Table LI 15Listing 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.
Table LI 16Liver 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.
Table LI 17Removal 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.
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 ( Figure LI s 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).
Figure LI 114Overall pretransplant mortality rates among pediatric candidates waitlisted for liver. Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately.
Figure LI 115Pretransplant mortality rates among pediatric candidates waitlisted for liver transplant by age. Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately.
Figure LI 116Pretransplant mortality rates among pediatric candidates waitlisted for liver transplant by race. Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately.
Figure LI 117Pretransplant mortality rates among pediatric candidates waitlisted for liver transplant by metropolitan vs. non-metropolitan residence. Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Waiting time is censored at transplant, death, transfer to another program, removal because of improved condition, or end of cohort. Individual listings are counted separately. Urban/rural determination is made using the RUCA (Rural-Urban Commuting Area) designation of the candidate’s permanent zip code.
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).
Figure LI 118Overall pediatric liver transplants. All pediatric liver transplant recipients, including retransplant, and multi-organ recipients.
Figure LI 120Pediatric liver transplants by recipient age. All pediatric liver transplant recipients, including retransplant, and multi-organ recipients.
Figure LI 121Pediatric liver transplants from living donors by relation. Relationship of living donor to recipient is as indicated on the OPTN Living Donor Registration Form.
Figure LI 122Percent of pediatric liver transplants from living donors by recipient age. All pediatric living liver transplant recipients, including retransplant, and multi-organ recipients.
Figure LI 123Number of centers performing pediatric and adult liver transplants by center’s age mix. Adult centers transplanted only recipients aged 18 years or older. Functionally adult centers transplanted 80% adults or more, and the remainder were children aged 15-17 years. Mixed included adults and children of any age groups. Pediatric center transplanted recipients aged 0-17 years, and a small number of adults up to age 21 years.
Table LI 18Demographic 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.
Table LI 19Clinical 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.
Table LI 20Transplant characteristics of pediatric liver transplant recipients, 2008-2010 and 2018-2020 (continued on next page).Pediatric liver transplant recipients, including retransplants. DBD, donation after brain death; DCD, donation after circulatory death
Table LI 21Pediatric 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.
Table LI 22Pediatric 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.
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).
Figure LI 126Percent of pediatric and adult liver transplant recipients allocated by exception. Exceptions among those allocated by MELD/PELD. Denominator excludes status 1A and 1B recipients.
Figure LI 127Percent of pediatric liver transplant recipients using exceptions, 2018-2020, by DSA. Exceptions among those allocated by MELD/PELD. Denominator excludes status 1A and 1B recipients.
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).
Figure LI 128Induction agent use in pediatric liver transplant recipients. Immunosuppression at transplant reported to the OPTN.
Figure LI 129Immunosuppression regimen use in pediatric liver transplant recipients. Immunosuppression regimen at transplant reported to the OPTN. Tac, tacrolimus. MMF, all mycophenolate agents.
Figure LI 130Total HLA A, B, and DR mismatches among pediatric deceased donor liver-kidney transplant recipients, 2015-2019. Donor and recipient antigen matching is based on OPTN antigen values and split equivalences policy as of 2018.
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).
Figure LI 131Graft failure among pediatric deceased donor liver transplant recipients. All pediatric recipients of deceased donor livers, including multi-organ transplants. Estimates are unadjusted, computed using Kaplan-Meier methods. Recipients are followed to the earliest of retransplant; death; or 6 months, 1, 3, 5, or 10 years posttransplant. All-cause graft failure (GF) is defined as any of the prior outcomes prior to 6 months, 1, 3, 5, or 10 years, respectively.
Figure LI 132Graft failure among pediatric living donor liver transplant recipients. All pediatric recipients of living donor livers, including multi-organ transplants. Estimates are unadjusted, computed using Kaplan-Meier methods. Recipients are followed to the earliest of retransplant; death; or 6 months, 1, 3, 5, or 10 years posttransplant. All-cause graft failure (GF) is defined as any of the prior outcomes prior to 6 months, 1, 3, 5, or 10 years, respectively.
Figure LI 135Graft survival among pediatric deceased donor liver transplant recipients, 2013-2015, by lab MELD/PELD score. Graft survival estimated using unadjusted Kaplan-Meier methods. Pediatric candidates aged 12 to 17 years can be assigned MELD or PELD scores.
Figure LI 136Graft survival among pediatric liver transplant recipients, 2013-2015, by donor type. Recipient survival estimated using unadjusted Kaplan-Meier methods.
Figure LI 137Incidence of acute rejection by 1 year posttransplant among pediatric liver transplant recipients by age, 2018-2019. Only the first reported rejection event is counted. Cumulative incidence is estimated using the Kaplan-Meier method.
Figure LI 138Incidence of PTLD among pediatric liver transplant recipients by recipient EBV status at transplant, 2008-2018. Cumulative incidence is estimated using the Kaplan-Meier method. PTLD is identified as a reported complication or cause of death on the OPTN Transplant Recipient Follow-up Form or on the Posttransplant Malignancy Form as polymorphic PTLD, monomorphic PTLD, or Hodgkin’s disease. Only the earliest date of PTLD diagnosis is considered. EBV, Epstein-Barr virus.
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/un-known (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 LI 139Patient death among pediatric liver transplant recipients. All pediatric recipients of deceased donor livers, including multi-organ transplants. Estimates are unadjusted, computed using unadjusted Kaplan-Meier methods.
Figure LI 143Patient survival among pediatric liver transplant recipients, 2013-2015, by donor type. Recipient survival estimated using unadjusted Kaplan-Meier methods.
The publication was produced for the U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), by the Hennepin Healthcare Research Institute (HHRI) and by the United Network for Organ Sharing (UNOS) under contracts HHSH75R60220C00011, and HHSH25020190001C, respectively.
This publication lists non-federal resources in order to provide additional information to consumers. The views and content in these resources have not been formally approved by HHS or HRSA. Neither HHS nor HRSA endorses the products or services of the listed resources.
OPTN/SRTR 2020 Annual Data Report is not copyrighted. Readers are free to duplicate and use all or part of the information contained in this publication. Data are not copyrighted and may be used without permission if appropriate citation information is provided.
Pursuant to 42 U.S.C. §1320b-10, this publication may not be reproduced, reprinted, or redistributed for a fee without specific written authorization from HHS.
Suggested Citations Full citation: Organ Procurement and Transplantation Network (OPTN) and Scientific Registry of Transplant Recipients (SRTR).
OPTN/SRTR 2020 Annual Data Report. Rockville, MD: Department of Health and Human Services, Health Resources and Services Administration; 2022. Abbreviated citation: OPTN/SRTR 2020 Annual Data Report. HHS/HRSA.
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 2020 Annual Data Report of the U.S. Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients have been supplied by the United Network for Organ Sharing and the 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 srtr.transplant.hrsa.gov. Individual chapters, as
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