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CHAPTER I

Trends in Organ Donation and Transplantation in the United States, 1999-2008

Public-Use Slide Set public use slide set

In This Chapter

INTRODUCTION  [TOC]

This overview of solid organ transplantation in the United States is produced as part of the 2009 OPTN/SRTR Annual Report. The Scientific Registry of Transplant Recipients (SRTR) prepares the Annual Report in collaboration with the Organ Procurement and Transplantation Network (OPTN) under contract with the Health Resources and Services Administration (HRSA). The report was prepared by the Arbor Research Collaborative for Health, which, with the University of Michigan, is the contractor for the SRTR.

This report reviews many aspects of solid organ transplantation to provide a resource for patients, the transplant community, the public, and the federal government. It features 10 chapters showcasing specific topics in solid organ transplantation. Experts in the field of transplantation contributed to each chapter, offering a comprehensive look at the current state of transplantation and trends over the past decade.

The 2009 Annual Report reference tables may be accessed online at the SRTR and OPTN websites (www.ustransplant.org and optn.transplant.hrsa.gov), along with the 10 chapters presented here.

SUMMARY STATISTICS ON ORGAN TRANSPLANTATION IN THE UNITED STATES  [TOC]

At the close of 2007, 183,222 persons were recorded in available OPTN data as living with a functioning transplanted organ [Table 1.14]. This reflects an increase of 1.7 percent over 2006 and a 56.6 percent increase since 1999.

The total number of organs transplanted decreased from 27,586 in 2007 to 27,281 in 2008. This was an overall decrease of 305 organs transplanted (1.1 percent), including 91 (1.4 percent) fewer living donor transplants (Table I-1). The number of deceased donor kidney transplants increased by only 0.2 percent, while living donor kidney transplants dropped by 1.2 percent. A decrease of 1.1 percent was observed in deceased donor liver transplants in 2008. There was a corresponding 1.57 percent overall decrease in the number of organs recovered for transplant during this time period (Table I-2).

Table I-1. Change in Number of Transplanted Organs, 2007-2008

Transplanted Organs 2007 2008 Percent Change
Total 27,586 27,281 -1.1%
  Deceased donor 21,279 21,065 -1.0%
  Living donor 6,307 6,216 -1.4%
Kidney 16,120 16,067 -0.3%
  Deceased donor 10,082 10,101 0.2%
  Living donor 6,038 5,966 -1.2%
Pancreas 1,215 1,161 -4.4%
  PTA 108 122 13.0%
  PAK 259 214 -17.4%
  Kidney-pancreas 848 825 -2.7%
Liver 5,890 5,817 -1.2%
  Deceased donor 5,629 5,568 -1.1%
  Living donor 261 249 -4.6%
Intestine (deceased donor) 57 69 21.1%
Heart (deceased donor) 2,143 2,085 -2.7%
Lung 1,461 1,473 0.8%
  Deceased donor 1,458 1,473 1.0%
  Living donor 3 - n/a
Heart-lung 31 26 -16.1%

Table I-2. Change in Number of Recovered Organs, 2007-2008

Recovered Organs 2007 2008 Percent Change
Total 28405 27958 -1.57%
Kidney 14381 14274 -0.74%
Pancreas-all 1,932 1,830 -5.28%
Liver 7,025 6,832 -2.75%
Intestine 205 197 -3.90%
Heart 2,287 2,226 -2.67%
Lung 2,575 2,599 0.93%

Table I-3, which includes patients listed at both active and inactive status, shows the 1-year change in the number of patients on the waiting list for each organ. At the end of 2008, 100,597 people were registered on organ waiting lists (67,470 active, 33,120 inactive, and 7 of unknown status). This reflects a 3.8 percent increase over the number of people waiting for an organ at the end of 2007 [Table 1.4]. There were 25,465 patients listed as inactive status on the kidney waiting list at the end of 2008. The percentage of patients who were inactive on the kidney waiting list at the end of each year has increased from 10 percent in 2003 to 33 percent in 2008 [Table 5.1a and 5.1b]. This increase might be largely attributed to policy implemented in 2003, which allows accrual of waiting time during inactive status (http://optn.transplant.hrsa.gov/PoliciesandBylaws2/policies/pdfs/policy_7.pdf. See policy 3.5.11.1) (1).

Table I-3. Patients on Waiting Lists at End of Year, 2007-2008

End of Year
Organs Total 2007 % Inactive Total 2008 % Inactive % Change in Total (2007-2008)
All organs
96,874
33%
100,597
33%
3.8%
Kidney
71,601
32%
76,089
33%
6.3%
PTA
581
59%
581
64%
0.0%
PAK
919
75%
856
74%
-6.9%
Kidney-pancreas
2,235
40%
2,234
45%
0.0%
Liver
16,365
25%
15,807
23%
-3.4%
Intestine
220
24%
212
31%
-3.6%
Heart
2,637
47%
2,711
38%
2.8%
Lung
2,211
55%
2,016
46%
-8.8%
Heart-lung
105
68%
91
64%
-13.3%

The kidney waiting list grew 6.3 percent, while the liver waiting list decreased 3.4 percent, and the lung waiting list decreased 8.8 percent. The size of the waiting list is influenced by many factors, including listing practices, donation rates, death rates, and allocation policy. consists of recipients transplanted in 2006-2007, while the "5-year survival" cohort is based on recipients transplanted in 2002-2005. These are the most recent cohorts for which adequate follow-up data are available. One-year patient survival was above 90 percent for transplants involving deceased and living donor kidney alone, kidney-heart, kidney-pancreas, pancreas after kidney (PAK), and pancreas transplants alone (PTA). One-year patient survival following kidney-liver transplant was lower (87.4 percent). Patient survival was lowest for liver-intestine transplants (63.3 percent), plausibly due to the greater burden of disease for patients receiving the multi-organ transplant.

Table I-4. Unadjusted 1- and 5-Year Patient Survival by Organ

Organ Transplanted 1-Year Survival (Txp 2006-2007) 5-Year Survival (Txp 2002-2007)
Kidney
  Deceased donor 95.6% 81.9%
  Living donor 98.5% 91.0%
Pancreas alone 97.8% 88.7%
Pancreas after kidney 97.0% 84.5%
Kidney-pancreas 95.7% 87.2%
Liver
  Deceased donor 88.4% 73.8%
  Living donor 91.0% 79.0%
Intestine 89.3% 57.9%
Heart 88.3% 74.9%
Lung 83.3% 54.4%
Heart-lung 80.6% 44.9%
Kidney-liver 87.4% 71.4%
Kidney-heart 95.8% 77.6%
Liver-intestine 63.3% 58.0%

Table I-5 shows graft survival by organ at 1 and 5 years after transplantation. Graft survival was calculated using the same cohorts as patient survival (Table I-4). Over 90 percent of kidneys transplanted alone or in combination with other organs were functioning 1 year after transplantation, except for those used in kidney-liver and kidney-heart transplants, of which 83 percent and 88 percent were still functioning after 1 year, respectively. Some patients survived organ failure by receiving a subsequent transplant or alternative therapy such as dialysis or resumption of insulin, resulting in lower graft survival rates than corresponding patient survival rates.

Table I-5. Unadjusted 1- and 5-Year Graft Survival by Organ

Organ Transplanted 1-Year Survival (Txp 2006-2007) 5-Year Survival (Txp 2002-2007)
Kidney
  Deceased donor 91.0% 69.3%
  Living donor 96.3% 81.4%
Pancreas alone 75.5% 51.5%
Pancreas after kidney 80.0% 53.4%
Kidney-pancreas (kidney) 92.5% 78.6%
Kidney-pancreas (pancreas) 84.8% 73.4%
Liver
  Deceased donor 84.3% 68.4%
  Living donor 86.0% 72.9%
Intestine 78.9% 39.6%
Heart 87.9% 73.7%
Lung 81.6% 51.5%
Heart-lung 80.5% 43.1%
Kidney-liver (kidney) 83.0% 64.4%
Kidney-liver (liver) 83.7% 66.0%
Kidney-heart (heart) 92.6% 76.0%
Kidney-heart (kidney) 88.2% 72.0%
Liver-intestine (intestine) 58.7% 53.0%
Liver-intestine (liver) 58.7% 53.4%

Table I-6 shows that posttransplant patient and graft survival outcomes have improved over the past decade for almost every organ [Table 1.11b and 1.12b]. Unadjusted 1-year graft survival for deceased donor kidney recipients improved from 88.8 percent to 91.4 percent. Graft survival after living donor kidney transplant improved 2 percent. Unadjusted 1-year graft survival for deceased donor and living donor liver recipients improved 6 percent and 16 percent respectively. One-year graft survival after intestine (alone) transplant increased markedly from 50 percent in 1998 to 75 percent in 2007. The greatest improvement was seen in heart-lung recipients, for whom 1-year unadjusted graft survival increased from 54 percent in 1998 to 90 percent in 2007. While only PTA transplants showed lower graft survival in 2007 than in 1998, the graft survival estimates are based on small numbers of transplants and are not statistically significantly different from each other (p = 0.83). The statistical significance of each comparison of 1998 survival with 2007 survival is shown in Table I-6 by organ type.

Table I-6. Unadjusted 1-year Graft and Patient Survival by Organ (1998 and 2007)

Graft Survival
Year of Transplant      
  1998 2007 % Change P-Value
Kidney: deceased donor graft survival 89% 91% 3% <0.0001
Kidney: living donor graft survival 95% 97% 2% <0.0001
Pancreas transplant alone 78% 76% -1% 0.8341
Pancreas after kidney 72% 82% 10% 0.0302
Kidney-pancreas: kidney 91% 93% 2% 0.1355
Kidney-pancreas: pancreas 83% 86% 4% 0.0392
Liver: deceased donor graft survival 80% 86% 6% <0.0001
Liver: living donor graft survival 70% 87% 16% 0.0022
Intestine 50% 75% 25% 0.0004
Heart 85% 88% 3% 0.0006
Lung 75% 80% 5% 0.0115
Heart-lung 54% 90% 36% 0.0001
Patient Survival        
Year of Transplant      
  1998 2007 % Change P-Value
Kidney: deceased donor patient survival 95% 96% 1% 0.0055
Kidney: living donor patient survival 98% 99% 1% 0.0015
Pancreas transplant alone 98% 98% 0% 0.9320
Pancreas after kidney 94% 97% 3% 0.2472
Kidney-pancreas 94% 97% 3% 0.0093
Liver: deceased donor patient survival 86% 89% 3% <0.0001
Liver: living donor patient survival 80% 91% 11% 0.0173
Intestine 67% 78% 11% 0.0995
Heart 86% 89% 3% 0.0006
Lung 77% 82% 6% 0.0016
Heart-lung 57% 90% 34% 0.0003

Trends in patient survival over the past decade have mirrored those in graft survival, with notable improvements in survival for recipients of every organ type except PTA, PAK, and intestine. Trends in patient and graft survival are explored in detail in each of the organ-specific chapters in this 2009 Annual Report.

TRANSPLANTATION AT A GLANCE  [TOC]

The figure sets accompanying this chapter (Figures I-1, I-2, I-3, I-4, I-5, I-6, I-7, and I-8) provide overviews of the state of transplantation for eight organ groups: kidney, PTA, PAK, liver, intestine, heart, lung, and simultaneous pancreas-kidney (SPK) transplantation, which is the most common multi-organ procedure. Because of the small numbers of other multi-organ procedures (e.g., heart-lung transplants), they are excluded from the counts presented here.


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Number of Transplants and Size of Active Waiting List  [TOC]

These figures show the size of the active waiting list and the number of transplants performed for each of the past 10 years. The size of the waiting list is best described as a snapshot capturing the number of candidates active on the waiting list on December 31. It does not count those patients who were transplanted, listed, or removed during the preceding 12 months. The number of transplants includes all transplants performed over the year.

Because of these different methods of counting, for some organs (e.g., lung), the number of transplants performed during a certain year may exceed the number of people awaiting a transplant on the last day of the same year. The narrowing gap between waiting list size and number of transplants can be explained, in some cases, by changes in allocation policy and wait-listing practices.

Unadjusted Patient and Graft Survival  [TOC]

These summary figures show survival of transplant recipients (patient survival) and continued function of the transplanted organ (graft survival) at 3 months, 1 year, 5 years, and 10 years following transplantation. These results are based on analysis of the most recent cohorts, with sufficient follow-up time for data collection and ascertainment of events.

THE CHAPTERS IN THE 2009 OPTN/SRTR ANNUAL REPORT  [TOC]

This report first presents "Organ Donation and Utilization in the United States, 1999-2008" (2). Five organ-specific chapters then follow: "Kidney and Pancreas Transplantation in the United States, 1999-2008: The Changing Face of Living Donation" (3), "Liver Transplantation in the United States, 1999-2008" (4), "Intestine and Multi-Visceral Transplantation in the United States, 1999-2008" (5), "Heart Transplantation in the United States, 1999-2008" (6), and "Lung Transplantation in the United States, 1999-2008" (7). Each chapter provides detailed updates regarding donation, waiting time, allocation, posttransplant outcomes, and the demographics of candidates and recipients. These chapters are intended to supplement the reporting of 10-year trends, with coverage of recent changes in allocation policy, clinical practice, and other areas relevant to the transplantation of different organ types.

This year's report concludes with three special-focus chapters that closely examine issues of recent interest to the transplant community. "Geographic Variation in End-Stage Renal Disease Incidence and Access to Kidney Transplantation" (8) investigates differences in organ donation rates and how the density of end-stage renal disease (ESRD) in the general population affects access to the kidney transplant waiting list and successful kidney transplantation. "DonorNet and the Effects on Organ Donation" (9) discusses the impact of DonorNet on organ utilization, focusing on ischemia time of transplanted organs and graft outcomes. "Transplant Outcomes Among Minorities Between 1999 and 2008: Determinants of Kidney Allograft Survival" (10) assesses trends in minority access to care and outcomes for kidney and heart transplantation by race/ethnicity category, and examines specific determinants of kidney transplant outcomes. Each chapter includes special analyses conducted by the SRTR, addressing topics that are both timely and pertinent because of their implications for policy and clinical practice.

REFERENCES  [TOC]

1. Leichtman A, Cohen D, Keith D, O'Connor K, Goldstein M, McBride V. Kidney and pancreas transplantation in the United States, 1997-2006: the HRSA breakthrough collaboratives and the 58 DSA challenge. Am J Transplant 2008; 8 (4 Pt 2): 946-957.

2. Klein AS, Messersmith EE, Ratner LE, Kochik R, Baliga PK, Ojo AO. Organ donation and utilization in the United States, 1999-2008. Am J Transplant 2010; 10(4 Pt 2):973-986.

3. Axelrod DA, McCullough KP, Brewer ED, Becker B, Segev DL, Rao P. Kidney and pancreas transplantation in the United States, 1999-2008: the changing face of living donation. Am J Transplant 2010; 10(4 Pt 2):987-1002.

4. Thuluvath PJ, Guidinger MK, Fung JJ, Johnson LB, Rayhill SC, Pelletier SJ. Liver transplantation in the United States, 1999-2008. Am J Transplant 2010; 10(4 Pt 2):1003-1019.

5. Mazariegos G, Steffick D, Farmer D, Grant D, Horslen S, Langnas A et al. Intestine and multi-visceral transplantation in the United States, 1999-2008. Am J Transplant 2010; 10(4 Pt 2):1020-1034.

6. Johnson MR, Meyer KH, Haft J, Kinder D, Webber SA, Dyke DB. Heart transplantation in the United States, 1999-2008. Am J Transplant 2010; 10(4 Pt 2):1035-1046.

7. Yusen R, Shearon T, Qian Y, Barr M, Kotloff R, Dyke DB et al. Lung transplantation in the United States, 1999-2008. Am J Transplant 2010; 10(4 Pt 2):1047-1068.

8. Mathur AK, Ashby VB, Sands R, Wolfe R. Geographic variation in end-stage renal disease incidence and access to kidney transplantation. Am J Transplant 2010; 10(4 Pt 2):1069-1080.

9. Gerber DA, Arrington CJ, Taranto SE, Baker T, Sung RS. DonorNet and the effects on organ donation. Am J Transplant 2010; 10(4 Pt 2):1081-1089.

10. Fan PY, Norman SP, Boulware LE, Randall HB, Young C, Kao A et al. Transplant outcomes among minorities between 1999 and 2008: determinants of kidney allograft survival. Am J Transplant 2010; 10(4 Pt 2):1090-1107.



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