CHAPTER I

Trends in Organ Donation and Transplantation in the United States, 1996-2005

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INTRODUCTION

This chapter provides a brief overview of solid organ transplantation in the United States, and is produced as part of the 2006 OPTN/SRTR Annual Report. The Annual Report is prepared by the Scientific Registry of Transplant Recipients (SRTR) in collaboration with the Organ Procurement and Transplantation Network (OPTN) under contract with the Health Resources and Services Administration (HRSA). The report gathers a large amount of information on many aspects of solid organ transplantation in one publication, making it a valuable resource for patients, the transplant community, the public, and the Federal Government.

The text section of this report includes nine chapters devoted to specific topics in solid organ transplantation. Each chapter was written by a group of experts in the field of transplantation and provides a comprehensive look at the current state of transplantation and trends over the past decade. The text and figures in these chapters are based on recent SRTR analyses and the extensive reference tables of the 2006 Annual Report, which were prepared by the Arbor Research Collaborative for Health (formerly known as the University Renal Research and Education Association, or URREA), which with the University of Michigan has been the contractor for the SRTR since October 2000. These nine chapters and reference tables are included in the Annual Report and are available online, at the websites of the SRTR and OPTN www.ustransplant.org and www.optn.org. All nine chapters of this report have undergone peer-review and are being published separately as stand-alone articles in the 2006 SRTR Report on the State of Transplantation, a special issue of the American Journal of Transplantation.

In This Chapter Summary Statistics On Organ Transplantation In The United States Transplantation At A Glance     Number of Transplants and Size of Active Waiting List     Age Distribution of Recipients and Active Waiting List     Unadjusted Patient and Graft Survival Chapters In The 2006 OPTN/SRTR Annual Report References

SUMMARY STATISTICS ON ORGAN TRANSPLANTATION IN THE UNITED STATES

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As of the end of 2004 there were 153,245 persons living with a functioning organ transplant in the United States [Table 1.14]. This number reflects an increase by about 1.8% over the prior year and a 1.7-fold increase since 1996.

The total number of organs transplanted annually increased from 26,541 in 2004 to 27,527 in 2005, an increase of 986 (4%) [Table 1.7]. The transplanted organs with the highest percentage increases were intestine (31%) and lung (20%), as shown in Table I-1. These organs came from 14,488 organ donors in 2005, 335 more donors than in 2004 (2%) [Table 1.1]. The increase in the total number of donors resulted from a substantial increase of 443 (6%) deceased donors and a slight decrease of 108 (2%) living donors. This is the first time in the past decade that a decrease in the number of living donors was observed from one year to the next. A deceased donor usually provides several organs to benefit multiple patients with organ failure. The organ donation and transplantation collaborative initiatives of the Division of Transplantation at HRSA have successfully focused on increasing the number of deceased donors and on the number of organs per donor by working with professionals at organ procurement organizations, donor hospitals and transplant centers (1).

Table I-1. Growth in Number of Transplanted and Recovered Organs, 2004-2005

Organs Transplanted				Organs Recovered from Deceased Donors
Transplanted Organs	2004	2005	Percent Change	Recovered Organs	2004	2005	Percent Change
Total	26,541	27,527	3.7%	All DD organs	25,221	26,910	6.7%
Deceased donor	19,551	20,635	5.5%
Living donor	6,990	6,892	-1.4%
Kidney	15,674	16,072	2.5%	Kidney	12,570	13,313	5.9%
Deceased donor	9,027	9,509	5.3%
Living donor	6,647	6,563	-1.3%
Pancreas				Pancreas (all)	2,010	2,034	1.2%
PTA	130	129	-0.8%
PAK	419	343	-18.1%
Kidney-pancreas	880	896	1.8%
Liver	5,779	6,000	3.8%	Liver	6,404	6,784	5.9%
Deceased donor	5,457	5,679	4.1%
Living donor	322	321	-0.3%
Intestine	52	68	30.8%	Intestine	168	185	10.1%
Heart	1,961	2,063	5.2%	Heart	2,096	2,220	5.9%
Lung	1,168	1,405	20.3%	Lung	1,973	2,374	20.3%
Deceased donor	1,153	1,404	21.8%
Living donor	15	1	-93.3%
Heart-lung	37	32	-13.5%	Heart-lung	NA	NA	NA

Source: 2006 OPTN/SRTR Annual Report, Tables 1.2, and 1.7.

Overall there were approximately 90,000 people registered on organ waiting lists at the end of 2005 (63,814 actively waiting and 26,053 with an "inactive" status), a 5% increase over the number of people waiting for an organ at the end of 2004 [Table 1.4]. The overall percentage of wait-listed patients with inactive status rose from 14% in 1996 to 29% in 2005; percentages vary considerably by organ. The largest increase was in the number of people on the kidney transplant waiting list, increasing by 8% from 57,389 in 2004 to 62,294 in 2005, a net addition of 4,905 candidates (Table I-2). This large waiting list is in part due to the cumulative effect of the imbalance between supply of organs and demand (need) for organs over past years. The net change in the total number of candidates on the waiting list at year-end from one year to the next provides an indication of the balance between supply and demand during that year. A net growth indicates that the waiting time on average increases, whereas a decline in the number of patients on the waiting list projects a shortening of average waiting times. Figure I-1 shows that for 2004 to 2005, the organ supply fell short of the increasing need not only for kidneys but also to a lesser degree for livers (by 1%, or 117 livers) and pancreata. By contrast, there is good news for other organs, particularly for lungs and hearts, for which organs both the supply and demand increased and the size of the waiting list decreased. From 2004 to 2005, the size of the heart, lung, and heart-lung waiting lists dropped by 8%, 18%, and 18%, respectively [Table 1.3]. The dramatic changes for lungs can be largely attributed to a new deceased donor lung allocation policy that was implemented in May 2005. The allocation policy was changed from a system based on waiting times to one based on net survival benefit from transplantation and medical urgency (waiting list mortality risk) (2).

Table I-2. Waiting List Candidates (Active and Inactive Combined), 2004-2005

Source: 2006 OPTN/SRTR Annual Report, Table 1.3. PTA: Pancreas transplant alone. PAK: Pancreas after kidney

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Continuing a trend extending back more than 10 years, the transplant candidate population is increasingly older (Figure I-2) [Table 1.4]. In 1996, 7% of the overall waiting list candidates were 65 or older; in 2005, that percentage was 13%. The proportion of candidates age 50-64 rose as well, from 34% in 1996 to 44% in 2005. The percentages of candidates in every age group below 50 years, including pediatric candidates (under 18 years), have dropped over the decade.

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Key outcomes after transplantation include 1) survival of transplant recipients, and 2) the function of transplanted grafts. Table I-3 displays one- and five-year unadjusted patient survival for all transplant recipients by organ, using the most recent cohort for which adequate follow-up exists. The cohort used to compute one-year survival consists of recipients transplanted in 2003-2004, while the cohort for five-year survival is based on recipients transplanted in 1999-2004. One-year patient survival rates were highest for kidney and pancreas recipients, ranging from about 95% to 98%; corresponding survival for liver, intestine, and heart recipients was approximately 87% to 91%, about 85% for lung, and lowest for the small number of heart-lung recipients with approximately 67% surviving at one-year [Table 1.13].

Table I-3. Unadjusted One- and Five-Year Patient Survival by Organ

Organ Transplanted	1-Year Survival	5-Year Survival
Kidney
Deceased donor	94.7%	80.7%
Living donor	98.0%	90.4%
Pancreas alone	94.9%	90.2%
Pancreas after kidney	95.5%	83.6%
Kidney-pancreas	95.1%	85.8%
Liver
Deceased donor	86.9%	73.4%
Living donor	91.2%	76.8%
Intestine	87.5%	50.2%
Heart	88.1%	73.7%
Lung	84.9%	51.6%
Heart-lung	66.7%	43.6%

Source: 2006 OPTN/SRTR Annual Report, Table 1.13.

Table I-4 shows the percentage of transplanted organs that are still functioning (graft survival) one and five years after transplantation by type of organ [Table 1.13]. Like patient survival, graft survival is calculated based on the same most recent cohorts for which sufficient follow-up was available. Graft survival rates are lower than corresponding patient survival rates because patients may survive a graft failure by receiving a second transplant or with an alternative therapy, such as dialysis for kidney transplant recipients or insulin therapy for pancreas transplant recipients.

Table I-4. Unadjusted One- and Five-Year Graft Survival by Organ

Organ Transplanted	1-Year Survival	5-Year Survival
Kidney
Deceased donor	89.5%	67.1%
Living donor	95.1%	80.3%
Pancreas alone	72.8%	53.4%
Pancreas after kidney	78.7%	56.4%
Kidney-pancreas (kidney)	91.8%	76.3%
Kidney-pancreas (pancreas)	85.2%	71.1%
Liver
Deceased donor	82.4%	67.4%
Living donor	84.0%	68.8%
Intestine	78.5%	40.1%
Heart	87.5%	72.6%
Lung	83.3%	48.9%
Heart-lung	64.1%	41.5%

Source: 2006 OPTN/SRTR Annual Report, Table 1.13.

TRANSPLANTATION AT A GLANCE

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The full-page figures at the end of this chapter (Figures I-3 to I-10) offer "dashboard" views of the state of transplantation for different organs. Sets of summary graphics are included for six organs (kidney, pancreas, liver, intestine, heart, and lung) as well as two common multi-organ procedures (simultaneous pancreas-kidney and pancreas after kidney). For this overview, we have omitted separate figures for heart-lung transplants, given the extremely small numbers of these procedures. Below we describe the three graphs shown for each organ.

Number of Transplants and Size of Active Waiting List

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These figures compare, for each of the last 10 years, the size of the active waiting list and the number of transplants performed. The size of the waiting list is a snapshot of the number of candidates active on the waiting list at the end of the year, although additional patients were listed or removed at some time during the year. The number of transplants includes all transplants performed over the year. This difference in ways of counting explains why for some organs (e.g., lung), the number of transplants performed during a certain year may exceed the number of people awaiting that organ on the last day of the same year. Other instances of the narrowing gap between waiting list size and number of transplant reflect changes in allocation policy and wait-listing practices.  [TOC]

Age Distribution of Recipients and Active Waiting List

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In this overview we have grouped all pediatric patients (<18 years) together, for ease of viewing. The OPTN/SRTR Annual Report data tables (and the accompanying chapters analyzing them) break this group out into several age groups: <1 year, 1-5 years, 6-10 years, and 11-17 years. See Chapter III for details. Here we have included only the data for 1996 and 2005; additional detail may be found in the organ-specific chapters of this report (Chapters IV to VI).  [TOC]

Unadjusted Patient and Graft Survival

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These overview figures show survival of the transplanted organ (graft) and survival of transplant recipients (patient) at various time points following transplantation: three months, one year, three years, and five years. The figures are based on information about the most recent cohorts possible that still allow sufficient follow-up time for data collection and ascertainment.

CHAPTERS IN THE 2006 OPTN/SRTR ANNUAL REPORT

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The graphics above give a quick view of the major trends addressed and analyzed in each of the organ-specific chapters of this report. Chapters on kidney and pancreas (Chapter IV), liver and intestine (Chapter V), and heart and lung (Chapter VI) provide detailed trends in donation, waiting time, allocation, Post transplant outcomes, and the demographics of both candidates and recipients. Additionally, these chapters supplement the reporting of 10-year trends with updates on recent changes in allocation policy, immunosuppression, clinical practice, and other areas relevant to the transplantation of different organ types.

In this year's report, the three organ-specific chapters are preceded by a review of trends in organ donation and utilization (Chapter II) including recent efforts to increase the number of donors, and a chapter devoted to the particular outcomes and policy concerns of pediatric transplantation (Chapter III).

This year's report concludes with three "special-focus" chapters that look closely at issues of recent interest to the transplant community. A chapter on organ acceptance rates (Chapter VII) examines what happens when transplant centers turn down kidneys offered by an organ procurement organization, as low acceptance rates may contribute to inefficiency in organ distribution. A chapter on geographic variability in access to kidney transplantation (Chapter VIII) examines rates in wait-listing, receiving a living donor kidney transplant, and receiving a deceased donor kidney transplant after being placed on the waiting list, identifying wide disparities in access across the US. Lastly, a chapter on repeat transplantation (Chapter IX) focuses on the growing trend of same-organ retransplantation and its effects on the transplant community as a whole and on individual recipients, who are more likely to have inferior outcomes following retransplantation. These chapters all include special analyses performed by the SRTR and touch on topics that are timely and have implications for policy and clinical practice.

REFERENCES

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1. Marks WH, Wagner D, Pearson TC, et al. The 2005 SRTR Report on the State of Transplantation: Organ Donation and Utilization, 1995-2004: Entering the Collaborative Era. Am J Transplant 6:1101-1110, 2006.

2. Egan TM, Murray S, Bustami RT, et al. The 2005 SRTR Report on the State of Transplantation: Development of the New Lung Allocation System in the United States. Am J Transplant 6:1212-1227, 2006.

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