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On November 24, 2017, US lung transplant policy replaced donor service area with 250-nautical-mile radius as the first unit of allocation. Understanding this policy's economic impact is important, because the United States is poised to adopt the broadest feasible geographic organ distribution. All lung transplant recipients from January 1, 2015, to December 31, 2018, in the Scientific Registry of Transplant Recipients, were included. Recipients before and after November 24, 2017 were in the donor service area-first and 250-nautical-mile donor service area-free periods, respectively. Travel time was estimated using a Google application; mode was assigned as flying when driving time was longer than 60 min. Travel costs were estimated by mode and distance. Travel distance and time for organ procurement increased under the policy change. The estimated proportion of organs traveling by air increased from 61% to 76%. Estimated average costs increased by $14 051 if travel mode changed to flying, resulting in an average increase of $1264 for all transplants. Travel costs were highest for candidates

The number of lung transplants performed continues to increase annually and reached an all-time high in 2019, with decreasing waitlist mortality. These trends are attributable to an increasing number of candidates listed for transplant each year and a continuing increase in the number of donors. Despite these favorable trends, 6.4% of lungs recovered for transplant were not transplanted in 2019, and strategies to optimize use of these available organs may reduce the number of waitlist even further. Time to transplant continued to decrease, as over 50% of candidates waited 3 months or less in 2019, yet regional heterogeneity remained despite policy changes intended to improve allocation equity. Small gains continued in posttransplant survival, with 1-year survival at 88.8%; 3 year, 74.4%; 5 year, 59.2%, and 10 year, 33.1 %.

Posttransplant outcome assessments are publicly reported for patient and regulatory use. However, the currently reported 1-year posttransplant graft survival assessments are commonly criticized for not identifying clinically meaningful differences between programs, and not providing information about longer-term posttransplant outcomes. We investigated the association of different posttransplant outcome assessments available to patients at the time of listing with subsequent posttransplant graft survival. The posttransplant assessments were from period prevalent, rather than incident, cohorts with more timely 1-, 3-, and 5-year follow-up and 6-, 12-, 18-, 24-, and 30-month cohort windows. The association of these assessments at listing with subsequent posttransplant graft survival included candidates listed between July 12, 2011, and December 15, 2015, who subsequently underwent transplant before December 31, 2018. The assessments with 1-year follow-up had uniformly weaker associations than the assessments with 3- and 5-year follow-up. The assessments with 5-year follow-up had the strongest association in kidney and liver transplantation. For kidney, liver, and lung transplantation, assessment windows of at least 18 months typically had the strongest associations with subsequent graft survival. Posttransplant assessments with 5-year follow-up and 18-30-month cohort windows are better than the current posttransplant assessment with 1-year follow-up, particularly at the time of listing.

The overall number of pancreas transplants continued to increase to 1027 in 2018, after a nadir of 947 in 2015. New additions to waiting list remained stable, with 1485 candidates added in 2018. Proportions of patients with type II diabetes waiting for transplant (14.6%) and undergoing transplant (14.8%) have steadily increased since 2016. Waiting times for simultaneous pancreas/kidney transplant have decreased; median months to transplant was 13.5 for simultaneous pancreas/kidney transplant and 19.7 for pancreas transplant alone in 2018. Outcomes, including patient and kidney survival, as well as rejection rates, have improved consistently over the past several years. Pancreas graft survival data are being collected by the Organ Procurement and Transplantation Network and will be included in a future report once there are sufficient cohorts for analysis.

The primary goal of US lung allocation policy is to ensure that candidates with the highest risk for mortality receive appropriate access to lung transplant. In 2018, 2562 lung transplants were performed in the US, reflecting a 31% increase over the past 5 years. More candidates are being listed for lung transplant, and the number of donors has increased substantially. Despite an increase of 84 lung transplants in 2018, 365 adult candidates died or became too sick to undergo transplant. In 2018, 24 new child (ages 0-11 years) candidates were added to the lung transplant waiting list. Fifteen lung transplants were performed in recipients aged 0-11 years, three in recipients aged younger than 1 year, two in recipients aged 1-5 years, and ten in recipients aged 6-11 years. Of 27 child candidates removed from the waiting list in 2018, 16 (59.3%) were removed due to undergoing transplant, six (22.2%) due to death, one (3.7%) due to improved condition, and one (3.7%) due to becoming too sick to undergo transplant.

The C-statistic of the risk-adjustment model is often used to judge the accuracy of program evaluations. However, the C-statistic depends on the variability in risk for individual transplants and may be inappropriate for determining the accuracy of program evaluations. A simulation study investigated the association of the C-statistic with several metrics of program evaluation accuracy, including categorizing programs into the 5-tier system and identifying programs for regulatory review. The simulation study used data from deceased donor kidney-alone transplants for adult recipients in the program-specific reports released January 2018. A range of C-statistics was generated by changing the variability in risk for individual transplants. The C-statistic had no association with any metric of program evaluation accuracy. Instead, the number of expected events at a program was the most important factor. For example, Spearman’s rho, which is the correlation of ranks, was −0.27 and −0.72 between the true program-specific hazard ratios and assigned tiers for programs with, respectively, less than 3 and more than 10 expected events. Presence of unadjusted risk factors did not modify the associations, although the accuracy of program evaluations was systematically lower. Therefore, the C-statistic provides no information on the accuracy of program evaluations.

Rationale: Referrals for lung transplant and transplant rates in the United States are lower than in Canada for patients with advanced cystic fibrosis (CF) lung disease. Further study of factors limiting access are needed to optimize referral and transplant for this population. Objectives: To determine the effect of socioeconomic position, while accounting for disease severity, on the likelihood of wait-listing for lung transplant in the United States. Methods: A case–control study of 3,110 patients (1,555 wait-listed, 1,555 never wait-listed) in the linked CF Foundation Patient Registry/Scientific Registry of Transplant Recipients was performed with 1:1 matching for age, forced expiratory volume in 1 second, and year. Logistic regression was performed with univariate and multivariate analyses accounting for eight clinical factors (sex, oxygen use, body mass index, hemoptysis, forced vital capacity, methicillin-resistant Staphylococcus aureus, multidrug-resistant Pseudomonas aeruginosa, and i.v. antibiotic days) and six socioeconomic factors (race, marital status, education, health insurance, median zip code income, and distance to transplant program). The CF Health Score and Socioeconomic Barrier Score were created based on summation of variables. Interactions between scores were calculated. Results: We found an inverse relationship between the probability of wait-listing and CF Health Score and Socioeconomic Barrier Score. As the CF Health Score decreased (less healthy), the probability of wait-listing increased by 69.3% from a score of 7 to 2. As the Socioeconomic Barrier Score decreased (fewer barriers), the probability of wait-listing increased by 31.7% from a score of ≥5 to 1). Regardless of illness severity, socioeconomic barriers presented an impediment to wait-listing. Individuals with higher Socioeconomic Barrier Scores accessed transplant about half as often as those with lower scores at the same level of medical severity. Analysis of interactions demonstrated a higher probability of wait-listing for individuals with moderate health severity and fewer social barriers compared with sicker individuals with more socioeconomic barriers. Conclusions: Accrual of socioeconomic barriers limits access to lung transplant irrespective of disease severity, a finding of substantial concern for patients with CF and for transplant providers. Future interventions can focus on this at-risk population early in the disease course.

Data on adult liver transplants performed in the US in 2018 are notable for (1) continued growth in numbers of new waitlist registrants (11,844) and transplants performed (8250); (2) continued increase in the transplant rate (54.5 per 100 waitlist-years); (3) a precipitous decline in waitlist registrations and transplants for hepatitis-C-related indications; (4) increases in waitlist registrants and recipients with alcoholic liver disease and with clinical profiles consistent with non-alcoholic fatty liver disease; (5) increased use of hepatitis C virus antibody-positive donor livers; and (6) continued improvement in graft survival despite changing recipient characteristics such as older age and higher rates of obesity and diabetes. Variability in transplant rates remained by candidate race, hepatocellular carcinoma status, urgency status, and geography. The volume of pediatric liver transplants was relatively unchanged. The highest rate of pre-transplant mortality persisted for children aged younger than 1 year. Children underwent transplant at higher acuity than in the past, as evidenced by higher model for end-stage liver disease/pediatric end-stage liver disease scores and listings at status 1A and 1B at transplant. Despite higher illness severity scores at transplant, pediatric graft and patient survival posttransplant have improved over time.

Despite the ongoing severe mismatch between organ need and supply, data from 2018 revealed some promising trends. For the fourth year in a row, the number of patients waiting for a kidney transplant in the US declined and numbers of both deceased and living donor kidney transplants increased. These encouraging trends are tempered by ongoing challenges, such as a large proportion of listed patients with dialysis time longer than 5 years. The proportion of candidates aged 65 years or older continued to rise, and the proportion undergoing transplant within 5 years of listing continued to vary dramatically nationwide, from 10% to nearly 80% across donation service areas. Increasing trends in the recovery of organs from hepatitis C positive donors and donors with anoxic brain injury warrant ongoing monitoring, as does the ongoing discard of nearly 20% of recovered organs. While the number of living donor transplants increased, racial disparities persisted in the proportion of living versus deceased donors. Strikingly, the total number of kidney transplant recipients alive with a functioning graft is on track to pass 250,000 in the next 1-2 years. The total number of pediatric kidney transplants remained steady at 756 in 2018. Deeply concerning to the pediatric community is the persistently low level of living donor kidney transplants, representing only 36.2% in 2018.

Medicare costs vary for solid organ transplant recipients by outcome: survival with graft function, survival with graft failure, and death. Average per-person per-year reimbursement was $75 thousand for kidney recipients who survived the first year posttransplant with a functioning graft, $171 thousand for those who required a return to dialysis or retransplant, and $350 thousand for those who died with function. For pancreas recipients: $105 thousand for those who survived the first year with a functioning graft, $120 thousand for those who survived pancreas failure, and $443 thousand for those who died with function. For liver recipients: $154 thousand for those who survived with a functioning graft, $388 thousand for those who required retransplant, and $740 thousand who died with function. For intestine recipients: $301 thousand for those who survived with a functioning graft and $1 million for those who died with function. For heart recipients: $272 thousand for those who survived with a functioning graft and $1.2 million for those who died with function. For lung recipients: $196 thousand for those who survived with a functioning graft, $642 thousand for those who required retransplant, and $761 thousand for those who died with function.

Data on adult liver transplants performed in the US in 2016 are no-table for (1) the largest total number of transplants performed (7841); (2) the shortest median waiting time in recent history (11.3 months); (3) continued reduction in waitlist registrations and transplants for hepatitis C-related indications; (4) increasing numbers of patients whose clinical profiles are consistent with non-alcoholic fatty liver disease; and (5) equilibration of transplant rates in patients with and without hepatocellular carcinoma. Despite the increase in the number of available organs, waitlist mortality remained an important concern. Graft survival rates continued to improve. In 2016, 723 new active candidates were added to the pediatric liver transplant waiting list, down from a peak of 826 in 2005. The number of prevalent candidates (on the list on December 31 of the given year) was stable, 408 active and 169 inactive. The number of pediatric living donor liver transplants decreased from a peak of 79 in 2015 to 62 in 2016, with most from donors closely related to the recipients. Graft survival continued to improve over the past decade among recipients of deceased donor and living donor livers.

In 2016, 2692 candidates aged 12 years or older were added to the lung transplant waiting list; 2345 transplants were performed, the largest number of any prior year. The median waiting time for listed candidates in 2016 was 2.5 months, and waiting times were shortest for group D candidates. The transplant rate increased to 191.9 transplants per 100 waitlist years in 2016, with a slight decrease in waitlist mortality to 15.1 deaths per 100 waitlist years. Short-term survival continued to improve, with a 6-month death rate of 6.6% and a 1-year death rate of 10.8% among recipients in 2015 compared with 8.0% and 13.3%, respectively, among recipients in 2014. Long-term survival rates remained unchanged; 55.6% of recipients were alive at 5 years. In 2016, 23 new candidates aged 0-11 years were added to the waiting list and 16 lung transplants were performed. Incidence of posttransplant mortality for lung transplant recipients aged 0-11 years who underwent transplant in 2014-2015 was 13.8% at 6 months and 19.6% at 1 year. Changes in waitlist and transplant demographic features continued to evolve following implementation of the revised lung allocation score in 2015. Some early trends that may be attributable to the revised LAS are shorter waiting times, stabilization of the number of group D candidates listed for transplant, and convergence of LAS with lower prevalence of extremely high scores.

In December 2014, a new kidney allocation system (KAS) was implemented in the United States in an attempt to improve access to transplant for historically underrepresented groups, and to incorporate longevity matching such that donor kidneys with the longest projected graft survival are given to recipients with the longest projected patient survival. The development of organ allocation policies is often guided by simulated allocation models, computer programs that simulate the arrival of donated organs and new candidates on the waiting list over a 1-year period to project outcomes under a new allocation method. We examined the early outcomes under the new KAS using quarterly data beginning in 2013, revealing whether trends were already underway before implementation. Quarterly data also serve to reveal any bolus effect, or a rapid rise or fall in the proportion of transplants in a given group due to reordering of the list, followed by tapering toward a new steady state. Post-KAS changes were notable for an increase in the proportion of transplants among younger candidates, black and Hispanic candidates, highly sensitized candidates, and those on dialysis for at least 5 years. Transplants among blood type B candidates increased slightly but these candidates remain underrepresented relative to their prevalence on the waiting list. Regional and national sharing increased under the new KAS, but transplants of kidneys with a kidney donor profile index above 85% decreased. Early graft survival appears unchanged, but given the increases in regional sharing, cold ischemia time, and transplants among highly sensitized candidates and candidates with long pretransplant dialysis time, long-term graft survival will need to monitored.

Intestine and intestine-liver transplant remains important in the treatment of intestinal failure, despite decreased morbidity associated with parenteral nutrition. In 2015, 196 new patients were added to the intestine transplant waiting list, with equal numbers waiting for intestine and intestine-liver transplant. Among prevalent patients on the list at the end of 2015, 63.3% were waiting for an intestine transplant and 36.7% were waiting for an intestine-liver transplant. The pretransplant mortality rate decreased dramatically over time for all age groups. Pretransplant mortality was notably higher for intestine-liver than for intestine transplant candidates (respectively, 19.9 vs. 2.8 deaths per 100 waitlist years in 2014-2015). By age, pretransplant mortality was highest for adult candidates, at 19.6 per 100 waitlist years, and lowest for children aged younger than 6 years, at 3.6 per 100 waitlist years. Pretransplant mortality by etiology was highest for candidates with non-congenital types of short-gut syndrome. Numbers of intestine transplants without a liver increased from a low of 51 in 2013 to 70 in 2015. Intestine-liver transplants increased from a low of 44 in 2012 to 71 in 2015. Short-gut syndrome (congenital and non-congenital) was the main cause of disease leading to intestine and to intestine-liver transplant. Patient survival was lowest for adult intestine-liver recipients and highest for pediatric intestine recipients.

The number of heart transplant candidates and transplants performed continued to rise each year. In 2015, 2819 heart transplants were performed. In addition, the number of new adult candidates on the waiting list increased 51% since 2004. The number of adult heart transplant survivors continued to increase, and in 2015, 29,172 recipients were living with heart transplants. Patient mortality following transplant has declined. The number of pediatric candidates and transplants performed also increased. New listings for pediatric heart transplants increased from 451 in 2004 to 644 in 2015. The number of pediatric heart transplants performed each year increased from 297 in 2004 to 460 in 2015. Among pediatric patients who underwent transplant in 2014, death occurred in 7.2% at 6 months and 9.6% at 1 year.

The number of pancreas transplants performed in the United States stabilized over the last 3 years after nearly a decade of steady decline. Numbers of new additions to the list also stabilized during the same period. Notably, the persistent decline in pancreas after kidney transplants also seems to have abated, at least for now. The first full year of data after implementation of the new pancreas allocation system revealed no change in the distribution of organs between simultaneous pancreas-kidney (SPK) transplant and pancreas transplant alone. The percentage of kidneys used in SPK transplants was also unchanged. While a uniform definition of pancreas graft failure was approved in June 2015, it is awaiting implementation. Meanwhile, SRTR will refrain from publishing pancreas graft failure data in the program-specific reports. Therefore, it is difficult to track trends in outcomes after pancreas transplant over the past 2 years. New initiatives by the OPTN/UNOS Pancreas Transplantation Committee include facilitated pancreas allocation and broadened allocation of pancreata across compatible ABO blood types to increase organ utilization.

BACKGROUND The thoracic simulated allocation model (TSAM) is used by the Scientific Registry of Transplant Recipients to predict the relative effect of organ allocation policy changes. A new lung allocation policy changing the first unit of allocation from donation service area to 250 nautical miles took effect on November 24, 2017. We studied TSAM's ability to correctly predict trends caused by changes in allocation policy. METHODS We compared the population characteristics from the TSAM cohort, 6,386 lung transplant candidates from 2009 to 2011, with the observed cohort of 7,601 candidates from the year before the policy change on November 24, 2017, and the year after. Simulations were run 10 times. Waitlist mortality and transplant rates were calculated and compared with observed mortality and transplant rates in the years before and after the policy change. RESULTS TSAM correctly predicted no change in overall waitlist mortality or transplant rates with the policy change. Observed waitlist mortality values were higher, as were transplant rates, because of increased organ donation and population change. TSAM predicted increased transplant rates for diagnosis group D (idiopathic pulmonary fibrosis), decreased rates for group A (chronic obstructive pulmonary disease), and increased rates for candidates with lung allocation score ≥50, but these changes did not occur in the waitlist and transplant populations after the policy change. CONCLUSIONS TSAM correctly predicted the relative trends caused by a change in allocation policy but smaller sub-group predictions were not seen.

Data on adult liver transplants performed in the US in 2017 are notable for (1) continued growth in numbers of new waitlist registrants (11,514) and of transplants performed (8,082); (2) continued increase in the transplant rate (51.5 per 100 waitlist-years); (3) a precipitous decrease in waitlist registrations and transplants for hepatitis C-related indications; (4) reciprocal increases in waitlist registrants and recipients with alcoholic liver disease and with clinical profiles consistent with non-alcoholic fatty liver disease; and (5) continued improvement in graft survival despite changing recipient characteristics such as older age and higher rates of obesity. Variability in transplant rates remained by candidate race, presence of hepatocellular carcinoma, urgency status (status 1A versus model for end-stage liver disease (MELD) score >35), and geography. More than half of all children listed for liver transplant in 2017 were aged younger than 5 years in 2017, and the highest rate of pretransplant mortality persisted for children aged younger than 1 year. Children underwent transplant at higher acuity than the past, as evidenced by higher MELD/pediatric end-stage liver disease scores and listings at status 1A and 1B. Higher acuity at transplant is likely due to lack of access to suitable donor organs, which has been compensated for by persistent trends toward use of partial or split liver grafts and ABO-incompatible grafts. Despite higher illness severity scores at transplant, pediatric graft and patient survival posttransplant have improved over time.

Each year since 2012, the number of lung transplants has increased, reflecting an increase in the number of donors, improved use of recovered organs, and more candidates being listed for transplant. However, the need for organs continues to outpace available donors. Despite an increase of 126 donors in 2017, 1360 candidates remained on the waiting list at the end of the year, and 326 patients died or became too sick to undergo transplant. Approximately 14,000 individuals were living with a lung transplant in 2017; 9492 were aged 50 years or older, 4075 were aged 18-49 years, and 408 were aged younger than 18 years.

Many positive trends in kidney transplantation were notable in 2017. Deceased donor kidney transplant rates and counts continued to rise, the kidney transplant waiting list declined for the third year in a row after decades of growth, and both short- and long-term allograft survival continued to improve year over year. In total, more than 220,000 patients were living in the United States with a functioning allograft. With 3 years of data available since implementation of the new kidney allocation system, better prediction of longer-term results of the allocation policy changes became possible. The data also reveal several areas in need of improvement and attention. Overall, the challenge of providing adequate access to kidney transplant persisted nationally, with additional dramatic regional variation. The proportion of living donor kidney transplants in both adults and children continued to fall, and racial disparities in living donor kidney transplant grew in the past decade.

In 2017, 1492 patients were added to the pancreas transplant waiting list, 964 listed as active, a slight increase from 2016. This is significant because for the first time in the past decade, the steady downward trend in additions to the waiting list has been reversed. Proportions of pancreas donors with cerebrovascular accident as cause of death decreased, with a concomitant increase in proportions with anoxia and head trauma. This is partly a result of the national opioid crisis, and it reflects increasing use of younger donors for pancreas transplant. The 2017 outcome report remains compromised by previous variation in reporting graft failure. Although the OPTN Pancreas Transplantation Committee has approved more precise definitions of pancreas graft failure, implementation of these definitions took place recently, and the data are not reflected in this report.

US pediatric transplant candidates have limited access to lung transplant due to the small number of donors within current geographic boundaries, leading to assertions that the current lung allocation system does not adequately serve pediatric patients. We hypothesized that broader geographic sharing of pediatric (adolescent, 12-17 years; child

To improve accessibility of program-specific reports to patients, the Scientific Registry of Transplant Recipients released a 5-tier system for categorizing 1-year posttransplant program evaluations. Whether this system predicts subsequent posttransplant outcomes at the time patients are wait-listed has been questioned. We investigated the association of tier at listing and the corresponding continuous score used for tier assignment, which ranges from 0 (poor outcomes) to 1 (good outcomes), with eventual 1-year posttransplant graft survival for candidates listed July 12, 2011-June 16, 2014, who underwent transplant before December 31, 2016. One additional tier at listing was associated with better 1-year posttransplant outcomes in liver (hazard ratio [HR], (0.89)0.93(0.97)) and lung transplantation (HR, (0.84)0.90(0.97)), but not kidney (HR, (0.92)0.96(1.01)) or heart transplantation (HR, (0.93)1.02(1.10)). In liver and lung transplantation, longer time between listing and transplant was associated with stronger protective effects for high-tier programs. In kidney, liver, and lung transplantation, posttransplant evaluations at listing had non-linear associations with eventual posttransplant outcomes: relatively flat for 5-tier scores below 0.5 and decreasing for scores above 0.5. After adjusting for measured recipient and donor risk factors, posttransplant evaluations at listing predicted differences in eventual outcomes in liver and lung transplantation, providing useful information to patients.

The Scientific Registry of Transplant Recipients (SRTR) is responsible for understandable reporting of program metrics, including transplant rate, waitlist mortality, and posttransplant outcomes. SRTR developed 5-tier systems for each metric to improve accessibility for the public. We investigated the associations of the 5-tier assignments at listing with all-cause candidate mortality after listing, for candidates listed July 12, 2011-June 16, 2014. Transplant rate evaluations with one additional tier were associated with lower mortality after listing in kidney (hazard ratio [HR], (0.93)0.95(0.97)), liver (HR, (0.87)0.90(0.92)), and heart (HR, (0.92)0.96(1.00)) transplantation. For lung transplant patients, mortality after listing was highest at programs with above- and below-average transplant rates, and lowest at programs with average transplant rates, suggesting that aggressive acceptance behavior may not always provide a survival benefit. Waitlist mortality evaluations with one additional tier were associated with lower mortality after listing in kidney (HR, (0.94)0.96(0.99)) transplantation, and posttransplant graft survival evaluations with one additional tier were associated with lower mortality after listing in lung (HR, (0.90)0.94(0.98)) transplantation. Transplant rate typically had the strongest association with mortality after listing, but the strength of associations differed by organ.

The number of pancreas transplants performed in the United States increased by 7.0% in 2016 over the previous year, the first such increase in more than a decade, largely attributable to an increase in simultaneous kidney pancreas transplants. Transplant rates increased in 2016, and mortality on the waiting list decreased. The declining enthusiasm for pancreas after kidney (PAK) transplants persisted. The uniform definition of graft failure was approved by the OPTN Board of Directors in 2015 and will be implemented in early 2018. Meanwhile, SRTR continues to refrain from reporting pancreas graft failure data. The OPTN/UNOS Pancreas Transplantation Committee is seeking to broaden allocation of pancreata across compatible ABO blood types in a proposal out for public comment July 31 to October 2, 2017. A new initiative to provide guidance on the benefits of PAK transplants is also out for public comment.

Data from 2016 show ongoing positive trends in short- and long-term allograft survival, and a decrease in the number of active listed candi- dates for the first time in more than a decade, with a concomitant in- crease in deceased donor kidney transplants. Transplant rates that had changed dramatically for some groups after implementation of the new kidney allocation system in 2014 are stabilizing, allowing for evaluation of new steady states and trends. Many challenges remain in adult kid- ney transplantation, including stagnant rates of living donor transplant, geographic disparities in access to transplant, racial disparities in living donor transplant, and overall a continuing demand for kidneys that far outpaces the supply. For pediatric recipients, a decline in the proportion of living donor transplants is of concern. In 2016, only 34.2% of pediatric transplants were from living donors, compared with 47.2% in 2005. The number of related donors decreased dramatically over the past decade, and the number of unrelated directed transplants performed in pediatric candidates remained low (50).

Variation in heart and lung offer acceptance practices may affect numbers of transplanted organs and create variability in waitlist mortality. To investigate these issues, offer acceptance ratios, or adjusted odds ratios, for heart and lung transplant programs individually and for all programs within donation service areas (DSAs) were estimated using offers from donors recovered July 1, 2016-June 30, 2017. Logistic regressions estimated the association of DSA-level offer acceptance ratios with donor yield and local placement of organs recovered in the DSA. Competing risk methodology estimated the association of program-level offer acceptance ratios with incidence and rate of waitlist removals due to death or becoming too sick to undergo transplant. Higher DSA-level offer acceptance was associated with higher yield (odds ratios [ORs]: lung, (1.04)1.11(1.19); heart, (1.09)1.21(1.35)) and more local placement of transplanted organs (ORs: lung, (1.01)1.12(1.24); heart, (1.47)1.69(1.93)). Higher program-level offer acceptance was associated with lower incidence of waitlist removal due to death or becoming too sick to undergo transplant (hazard ratios [HRs]: heart, (0.80)0.86(0.93); lung, (0.67)0.75(0.83)), but not with rate of waitlist removal (HRs: heart, (0.91)0.98(1.06); lung, (0.89)0.99(1.10)). Heart and lung offer acceptance practices affected numbers of transplanted organs and contributed to program-level variability in the probability of waitlist mortality.

Lungs are allocated to adult and adolescent transplant candidates (aged ⩾ 12 years) on the basis of age, geography, blood type compatibility, and the lung allocation score (LAS), which reflects risk of waitlist mortality and probability of posttransplant survival. In 2013, the most adult candidates, 2394, of any year were added to the list. Overall median waiting time for candidates listed in 2013 was 4.0 months. The preferred procedure remained bilateral lung transplant, representing approximately 70% of lung transplants in 2013. Measures of short-term and longterm survival have plateaued since the implementation of the LAS in 2005. The number of new child candidates (aged 0-11 years) added to the lung transplant waiting list increased to 39 in 2013. A total of 28 lung transplants were performed in child recipients, 3 for ages younger than 1 year, 9 for ages 1 to 5 years, and 16 for ages 6 to 11 years. The diagnosis of pulmonary hypertension was associated with higher survival rates than cystic fibrosis or other diagnosis (pulmonary fibrosis, bronchiolitis obliterans, bronchopulmonary dysplasia). For child candidates, infection was the leading cause of death in year 1 posttransplant and graft failure in years 2 to 5.

Pancreas listings and transplants decreased during the past decade, most notably pancreas after kidney transplants. Center-reported outcomes of pancreas transplant across all groups, short-term and long-term, improved during the same period. Changes to the pancreas allocation system creating an efficient, uniform national system will be implemented in late 2014. Pancreas-alone and simultaneous pancreas-kidney (SPK) candidates will form a single match-run list with priority to most SPK candidates ahead of kidney-alone candidates to decrease waiting times for SPK candidates, given their higher waitlist mortality compared with nondiabetic kidney transplant candidates. The changes are expected to eliminate local variability, providing more consistent pancreas allocation nationwide. Outcomes after pancreas transplant are challenging to interpret due to lack of a uniform definition of graft failure. Consequently, SRTR has not published data on pancreas graft failure for the past 2 years. The Organ Procurement and Transplantation Network Pancreas Transplantation Committee is working on a definition that could provide greater validity for future outcomes analyses. Challenges in pancreas transplantation include high risk of technical failures, rejection (early and late), and surgical complications. Continued outcome improvement and innovation has never been more critical, as alternatives such as islet transplant and artificial pancreas move closer to clinical application.

While the costs to Medicare of solid organ transplant are varied and considerable, the total Medicare expenditure of $4.4 billion for solid organ transplant recipients was less than 1 remains one of the most cost-effective surgical interventions in medicine. Heart transplant, the most expensive of the major transplants, is likely cost-effective; SRTR has released an Excel-based tool for investigators to use in exploring this question further. It is likely that most solid organ transplants are cost-effective, given the results presented here and the relatively high cost of heart transplant. However, this must be verified with further study.

While the costs to Medicare of solid organ transplants are varied and considerable, the total Medicare expenditure of $4.4 billion for solid organ transplant recipients in 2014 remained less than 1% of all Medicare expenditures. For patients covered by Medicare, the ratio of pre- to posttransplant cost of care varied widely by organ and within some organ categories by patient characteristics. This chapter reports pretransplant costs for all solid organ candidates covered by Medicare to allow investigators to further explore the relative cost of transplant compared with alternative management.

The first full year of data after implementation of the new kidney allocation system reveals an increase in deceased donor kidney transplants among black candidates and those with calculated panel-reactive antibodies 98%-100%, but a decrease among candidates aged 65 years or older. Data from 2015 also demonstrate ongoing positive trends in graft and patient survival for both deceased and living donor kidney transplants, but the challenges of a limited supply of kidneys in the setting of increasing demand remain evident. While the total number of patients on the waiting list decreased for the first time in a decade, this was due to a combination of a decrease in the number of candidates added to the list and an increase in the number of candidates removed from the list due to deteriorating medical condition, as well as an increase in total transplants. Deaths on the waiting list remained flat, but this was likely because of an increasing trend toward removing inactive candidates too sick to undergo transplant.

Several notable developments in adult liver transplantation in the US occurred in 2015. The year saw the largest number of liver transplants to date, leading to reductions in median waiting time, in waitlist mortality for all model for end-stage liver disease categories, and in the number of candidates on the waiting list at the end of the year. Numbers of additions to the waiting list and of liver transplants performed in patients with hepatitis C virus infection decreased for the first time in recent years. However, other diagnoses, such as non-alcoholic fatty liver disease and alcoholic cirrhosis, became more prevalent. Despite large numbers of severely ill patients undergoing liver transplant, graft survival rates continued to improve. The number of new active candidates added to the pediatric liver transplant waiting list in 2015 was 689, down from a peak of 826 in 2005. The number of prevalent pediatric candidates (on the list on December 31 of the given year) continued to decline, to 373 active and 195 inactive candidates. The number of pediatric liver transplants peaked at 613 in 2008 and was 580 in 2015. The number of living donor pediatric liver transplants increased to its highest level, 79, in 2015; most were from donors closely related to the recipients. Pediatric graft survival rates continued to improve.

For most end-stage renal disease patients, successful kidney transplant provides substantially longer survival and better quality of life than dialysis, and preemptive transplant is associated with better outcomes than transplants occurring after dialysis initiation. However, kidney transplant numbers in the us have not changed for a decade. Since 2004, the total number of candidates on the waiting list has increased annually. Median time to transplant for wait-listed adult patients increased from 2.7 years in 1998 to 4.2 years in 2008. The discard rate of deceased donor kidneys has also increased, and the annual number of living donor transplants has decreased. The number of pediatric transplants peaked at 899 in 2005, and has remained steady at approximately 750 over the past 3 years; 40.9% of pediatric candidates undergo transplant within 1 year of wait-listing. Graft survival continues to improve for both adult and pediatric recipients. Kidney transplant is one of the most cost-effective surgical interventions; however, average reimbursement for recipients with primary Medicare coverage from transplant through 1 year posttransplant was comparable to the 1-year cost of care for a dialysis patient. Rates of rehospitalization are high in the first year posttransplant; annual costs after the first year are lower.

On June 5, 2013, a US Federal Court ordered a temporary restraining order to allow two children within the court's jurisdiction to be registered on the adolescent lung transplant waiting list. On June 10, 2013, the Organ Procurement and Transplantation Network's Executive Committee altered lung allocation policy to offer candidates aged younger than 12 years greater access to adult lungs at the discretion of the national Lung Review Board. The Scientific Registry of Transplant Recipients reviewed trends over time in deceased donor lung transplant waitlist mortality and transplant rates, comparing children and adults. Mortality rates of candidates active on the waiting list have been higher for children aged 0-5 years, but have not differed for children aged 6-11 years compared with adolescents aged 12-17 years or adults aged 18 years or older. Transplant rates among active waitlist candidates have been comparable across all age groups. Thus, there is little evidence that the allocation system led to differences in waitlist mortality or transplant rates for children compared with adults. However, these comparisons are difficult to interpret given that current policies likely led to unaccounted differences in the severity of illness at the time of listing.

Liver transplant in the us remains a successful life-saving procedure for patients with irreversible liver disease. In 2012, 6256 adult liver transplants were performed, and more than 65,000 people were living with a transplanted liver. The number of adults who registered on the liver transplant waiting list decreased for the first time since 2002; 10,143 candidates were added, compared with 10,359 in 2011. However, the median waiting time for active wait-listed adult candidates increased, as did the number of candidates removed from the list because they were too sick to undergo transplant. The overall deceased donor transplant rate decreased to 42.3 per 100 patient-years, and varied geographically from 18.9 to 228.0 per 100 patient-years. Graft survival continues to improve, especially for donation after circulatory death livers. The number of new active pediatric candidates added to the waiting list also decreased. Almost 75% of pediatric candidates listed in 2009 underwent transplant within 3 years; the 2012 rate of deceased donor transplants among active pediatric wait-listed candidates was 136 per 100 patient-years. Graft survival for deceased donor pediatric transplants was 92.8% at 30 days. Medicare paid for some or all of the care for more than 30% of liver transplants in 2010.

Purpose To identify novel variables associated with waitlist (WL) and posttransplant (PT) mortality for cystic fibrosis (CF) lung transplant patients. To analyze the impact of including new variables in the lung allocation score (LAS) system. Methods The Cystic Fibrosis Foundation Patient Registry (CFFPR) collects data for CF patients prior to listing and the US Scientific Registry of Transplant Recipients Registry collects broad data after listing. These databases were merged by a deterministic algorithm to represent CF patients pre- to posttransplant. The study included candidates and recipients, 1/1/2011-12/31/2014. CFFPR variables known to be important for mortality in CF were considered in Kaplan-Meier univariate time-to-event analyses; significant variables were considered in multivariable Cox proportional hazard regression analysis. LAS and rank, based on models including new variables, were calculated and compared by diagnosis. Results The study cohort consisted of 1020 WL candidates with CF and 677 transplant recipients. Relative drop in FEV1 ≥ 30%, presence of Burkholderia sp., 28-42 days hospitalized, and hemoptysis increased WL mortality. Pulmonary exacerbation time of 15-28 days increased risk of PT mortality. Relative change in FEV1 ≥ 10% increased mortality in chronic obstructive pulmonary disease (COPD) candidates. Including these new variables in the LAS calculation resulted in (1) CF candidates with increased variability in LAS and rank; (2) COPD candidates with higher LAS values and lower rank, indicating increased access to transplant; (3) minimal impact on candidates with other diagnoses. Conclusion Addition of CF-specific variables increased the predictive power of LAS for candidates with CF and COPD. Incorporating CF-specific variables could potentially decrease waitlist mortality for candidates with CF.

Lungs are allocated in part based on the Lung Allocation Score (LAS), which considers risk of death without transplant and posttransplant. Wait-list additions have been increasing steadily after an initial decline following LAS implementation. In 2011, the largest number of adult candidates were added to the waiting list in a single year since 1998; donation and transplant rates have been unable to keep pace with wait-list additions. Candidates aged 65 years or older have been added faster than candidates in other age groups. After an initial decline following LAS implementation, wait-list mortality increased to 15.7 per 100 wait-list years in 2011. Short- and long-term graft survival improved in 2011; 10-year graft failure fell to an all-time low. Since 1998, the number of new pediatric (aged 0-11 years) candidates added yearly to the waiting list has declined. In 2011, 19 pediatric lung transplants were performed, a transplant rate of 34.7 per 100 wait-list years. The percentage of patients hospitalized before transplant has not changed. Both graft and patient survival have continued to improve over the past decade. Posttransplant complications for pediatric lung transplant recipients, similar to complications for adult recipients, include hypertension, renal dysfunction, diabetes, bronchiolitis obliterans syndrome, and malignancy.

Since 2006, the number of new intestinal transplant candidates listed each year has declined, likely reflecting increased medical and surgical treatment for intestinal failure. Historically, intestinal transplant occurred primarily in the pediatric population; in 2011, 41% of prevalent candidates on the waiting list were aged 18 years or older. The most common etiology of intestinal failure remains short-gut syndrome, which encompasses several diagnoses. The proportion of candidates with high medical urgency status decreased and time on the waiting list increased in 2011. The overall rate of transplant decreased from a peak of 92.7 transplants per 100 wait-list years in 2005 to 49.2 in 2011. The number of intestines recovered and transplanted per donor has decreased since 2007, possibly due to fewer listed patients. Almost 50% of deceased donor intestines were transplanted with another organ in 2011. Historically, the most common organ transplanted with the intestine was the liver, but in 2011 it was the pancreas. Graft survival has continued to improve over the past decade, and the number of recipients alive with a functioning intestinal graft has steadily increased since 1998. Hospitalization is common, occurring in 84.8% of recipients by 6 months posttransplant and in almost all by 4 years.

Metabolic syndrome is associated with coronary heart disease (CHD) and new-onset diabetes after kidney transplant (NODAT). Using data collected from transplant centers worldwide for the Patient Outcomes in Renal Transplantation study, we examined associations of metabolic syndrome (n = 2253 excluding recipients with diabetes pretransplant), CHD (n = 2253), and NODAT (n = 1840 further excluding recipients with diabetes in the first year post-transplant), with the primary outcome of allograft failure. We assessed risk factors associated with secondary outcomes of metabolic syndrome, NODAT, and CHD after adjusting for type of baseline immunosuppression and transplant center effects. Metabolic syndrome prevalence was 39.8% at 12-24 months post-transplant and 35.4% at 36-48 months. Metabolic syndrome was independently associated with NODAT (hazard ratio 3.46, 95% confidence interval 2.40-4.98, P < 0.0001), CHD (2.03, 1.16-3.52, P = 0.013), and allograft failure (1.36, 1.03-1.79, P = 0.028). Allograft failure occurred in 218 patients (14.6%). After adjustment for metabolic syndrome, NODAT (1.63, 1.18-2.24, P = 0.003) and CHD (5.48, 3.27-9.20, P < 0.0001) remained strongly associated with increased risk of allograft failure. Metabolic syndrome, NODAT, and CHD are risk factors for allograft failure. NODAT and CHD are risk factors for allograft failure, independent of metabolic syndrome.

Background. Cardiovascular disease (CVD) is the most common cause of death after kidney transplantation. Nevertheless, the use of potentially protective CVD medications has not been examined in a large international cohort of kidney transplant patients. Methods. Using the Patient Outcomes in Renal Transplantation database, we retrospectively examined CVD medication use in 14,236 kidney transplant patients from 10 centers worldwide at 4 and 12 months posttransplant. Results. Use of CVD medications posttransplant increased between 1990 to 1994 and 2000 to 2006, with a 12-fold increase in the use of statins (odds ratio [OR] 12.28,95% confidence interval [CI] 10.18―14.80). Use of β-blockers also increased (OR 3.74,95% CI 3.20―4.38), as did use of angiotensin converting enzyme inhibitors or angiotensin II receptor blockers (OR 3.68 95% CI 3.07―4.40) and antiplatelet agents (OR 1.93, 95% CI 1.66―2.24). Use of most CVD medications was not higher ir patients with diabetes than in patients without diabetes, despite a higher risk of CVD among patients with diabetes. Although use of several CVD medications was higher in patients with previous CVD events than in patients with no previous CVD, less than 75% of patients with previous CVD were using a statin or antiplatelet agent. Conclusion. Although use of CVD medications after kidney transplant has increased in recent years, use of potentially cardioprotective medications may be suboptimal given the high CVD risk in kidney transplant patients.

Ibrahim HN, Skeans MA, Li Q, Ishani A, Snyder JJ. Blood transfusions in kidney transplant candidates are common and associated with adverse outcomes. Clin Transplant 2011: 25: 653–659. © 2011 John Wiley & Sons A/S. Abstract: Surprisingly, there are no data regarding transfusion frequency, factors associated with transfusion administration in patients on the kidney transplant waiting list, or transfusion impact on graft and recipient outcomes. We used United States Renal Data System data to identify 43 025 patients added to the waiting list in 1999–2004 and followed through 2006 to assess the relative risk of post-listing transfusions. In 69 991 patients who underwent transplants during the same time period, we assessed the association between pre-transplant transfusions and level of panel-reactive antibody (PRA) at the time of transplant, and associations between PRA and patient outcomes. The three-yr cumulative incidence of transfusions was 26% for patients added to the waiting list in 1999, rising to 30% in 2004. Post-listing transfusions were associated with a 28% decreased likelihood of undergoing transplant, and a more than fourfold increased risk of death. There was a graded association between percent PRA at the time of transplant and adjusted risk of death-censored graft failure, death with function, and the combined event of graft failure and death. These data demonstrate that transfusions remain common and confirm the adverse association between transfusions and PRA, and high PRA and inferior graft and patient outcomes.

Background Surprisingly few tools have been developed to predict outcomes after kidney transplant. Study Design Retrospective observational cohort study. Setting & Participants Adult patients from US Renal Data System (USRDS) data who underwent deceased donor kidney transplant in 2000-2006. Predictor Full and abbreviated prediction tools for graft loss using candidate predictor variables available in the USRDS registry, including data from the Organ Procurement and Transplantation Network and the Centers for Medicare & Medicaid Services End-Stage Renal Disease Program. Outcomes Graft loss within 5 years, defined as return to maintenance dialysis therapy, preemptive retransplant, or death with a functioning graft. Measurements We used Cox proportional hazards analyses to develop separate tools for assessment (1) pretransplant, (2) at 7 days posttransplant, and (3) at 1 year posttransplant to predict subsequent risk of graft loss within 5 years of transplant. We used measures of discrimination and explained variation to determine the number of variables needed to predict outcomes at each assessment time in the full and abbreviated equations, creating simple user-friendly prediction tools. Results Although we could identify 32, 29, and 18 variables that predicted graft loss assessed pretransplant and at 7 days and 1 year posttransplant ("full" models), 98% of the discriminatory ability and >80% of the variability explained by the full models could be achieved using only 11, 8, and 6 variables, respectively. Limitations Comorbidity data were from the Centers for Medicare & Medicaid Medical Evidence Report, which may significantly underreport comorbid conditions; C statistic values may indicate only modest ability to discriminate risk for an individual patient. Conclusions This method produced risk-prediction tools that can be used easily by patients and clinicians to aid in understanding the absolute and relative risk of graft loss within 5 years of transplant.

Graft survival among adult African American kidney transplant patients remains low compared to whites, but little information is available for children and adolescents. We examined trends in graft failure among US incident primary kidney transplant patients aged

Background Ventricular assist devices (VADs) have improved survival among end-stage heart disease patients. Since 2002, heart transplant candidates with VADs have been afforded 30 days of elective time at the highest urgency category (Status 1A) under Organ Procurement and Transplantation Network (OPTN) policy. We aimed to determine the effect of increasing elective time at the highest urgency category for heart transplant candidates with VADs. This analysis was requested by OPTN during its evaluation of heart allocation policy. Methods We simulated several allocation schemes wherein elective Status 1A time was increased to 45, 60, and 90 days; results were compared with a baseline simulation of 30 days and with the actual observed heart transplant waiting list cohort. Results The simulations showed that increasing elective Status 1A time for candidates with VADs did not substantially change waiting list mortality overall or for sub-groups of concern, which were candidates with VADs listed at a lower-urgency category (Status 1B), those with with VAD complications, total artificial heart, or intraaortic balloon pump support; or those with extracorporeal membrane oxygenation. Across the different time allowances, the average post-transplant death rate remained stable. It also remained stable for recipients previously listed as Status 1A or 1B categories for VAD and for recipients with VAD complications or an intraaortic balloon pump at transplant, on extracorporeal membrane oxygenation, and those without devices. Conclusions Our results suggest that increasing time in the highest urgency category for candidates with VADs would not improve waiting list mortality or post-transplant outcomes for heart transplant candidates overall.

A new kidney allocation system, expected to be implemented in late 2014, will characterize donors on a percent scale (0%-100%) using the kidney donor profile index (KDPI). The 20% of deceased donor kidneys with the greatest expected posttransplant longevity will be allocated first to the 20% of candidates with the best expected posttransplant survival; kidneys that are not accepted will then be offered to remaining 80% of candidates. Waiting time will start at the time of maintenance dialysis initiation (even if before listing) or at the time of listing with an estimated glomerular filtration rate of 20 mL/min/1.73 m(2) or less. Under the current system, the number of candidates on the waiting list continues to increase, as each year more candidates are added than are removed. Median waiting times for adults increased from 3 years in 2003 to more than 4.5 years in 2009. Donation rates have not increased. Short-term outcomes continue to improve; death-censored graft survival at 90 days posttransplant was 97% or higher for deceased donor transplants and over 99% for living donor transplants. In 2013, 883 pediatric candidates were added to the waiting list; 65.8% of pediatric candidates on the list in 2013 underwent deceased donor transplant. Five-year graft survival was highest for living donor recipients aged younger than 11 years (89%) and lowest for deceased donor recipients aged 11 to 17 years (68%).

The number of heart transplants performed annually continues to increase gradually, and the number of adult candidates on the waiting list increased by 34.2% from 2003 to 2013. The heart transplant rate among active adult candidates peaked at 149.0 per 100 waitlist years in 2007 and has been declining since then; in 2013, the rate was 87.4 heart transplants per 100 active waitlist years. Increased waiting times do not appear to be correlated with an overall increase in waitlist mortality. Since 2008, the proportion of patients on life support before transplant increased from 53.4% to 65.8% in 2013. Medical urgency categories have become less distinct, with most patients listed in higher urgency categories. Approximately 500 pediatric candidates are added to the waiting list each year; the number of pediatric transplants performed each year increased from 293 in 2003 to 411 in 2013. Patient survival among pediatric recipients continues to improve; 5-year patient survival for transplants performed from 2001 through 2008 was 70% to 80%. Medicare paid for some or all of the care for 42.2% of all heart transplant recipients in 2012.

Despite improvements in medical and surgical treatment of intestinal failure over the past decade, intestine transplant continues to play an important role. Of 171 new patients added to the intestine transplant waiting list in 2013, 49% were listed for intestine-liver transplant and 51% for intestine transplant alone or with an organ other than liver. The pretransplant mortality rate decreased dramatically over time for all age groups, from 30.3 per 100 waitlist years in 2002-2003 to 6.9 for patients listed in 2012-2013. The number of intestine transplants decreased from 91 in 2009 to 51 in 2013; intestine-liver transplants decreased from 135 in 2007 to a low of 44 in 2012, but increased slightly to 58 in 2013. Ages of intestine and intestineliver transplant recipients have changed substantially; the number of adult recipients was double the number of pediatric recipients in 2013. Graft survival improved over the past decade. Graft failure in the first 90 days posttransplant occurred in 14.1% of intestine recipients and in 11.2% of intestine-liver recipients in 2013. The number of recipients alive with a functioning intestine graft has steadily increased since 2002, to 1012 in 2013; almost half were pediatric intestine-liver transplant recipients.