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Direct acting antivirals (DAAs) have fundamentally changed the treatment of hepatitis C virus (HCV) infection and reduced the discard rate of HCV‐infected organs by offering a treatment option with a high likelihood of cure posttransplant. This has spurred increased interest in transplanting organs from HCV‐positive donors into recipients both with and without HCV. In this chapter, we examine data from 2007 to 2018 to determine trends in HCV(+) donor transplants across various organ types. Since 2015, willingness to accept HCV(+) organs increased for candidates waitlisted for kidney, lung, heart, and pancreas transplant, but decreased for those listed for intestine transplant. For candidates listed for liver transplant, willingness to accept HCV(+) organs decreased from 2007 to 2017, but began increasing in 2017. Willingness to accept was not concentrated in a single USgeographic area, and there was substantial variation among transplant programs and donation service areas. Numbers of anti‐HCV(+) donor kidney, heart, lung, and liver transplants have increased considerably in the past few years. Short‐term allograft survival for kidney and liver transplant recipients of anti‐HCV(+) organs appears to be comparable to that for recipients of anti‐HCV(‐) organs in an unadjusted analysis. However, an unadjusted analysis indicates that long‐term allograft survival may be worse. Kidney transplant between HCV‐infected donors and uninfected recipients with posttransplant DAAtreatment is an emerging area. Short‐term data are promising, with similar 1‐year allograft survival compared with HCV‐uninfected donor to HCV‐uninfected recipient kidney transplants in unadjusted analyses. However, long‐term data are lacking and close monitoring in the future is warranted.

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 IIdiabetes 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.

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 USdeclined 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.

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 OPTNPancreas 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.

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.

The Scientific Registry of Transplant Recipients (SRTR)is considering more prominent reporting of program‐specific adjusted transplant rate ratios (TRRs). To enable more useful reporting of TRRs, SRTRupdated the transplant rate models to adjust explicitly for components of allocation priority. We evaluated potential associations between TRRs and components of allocation priority that could indicate programs' ability to manipulate TRRs by denying or delaying access to low‐priority candidates. Despite a strong association with unadjusted TRRs, we found no candidate‐level association between the components of allocation priority and adjusted TRRs. We found a strong program‐level association between median laboratory Model for End‐stage Liver Disease (MELD) score at listing and program‐specific adjusted TRRs (r= .37; P <.001). The program‐level association was likely confounded by regional differences in donor supply/demand and listing practices. In kidney transplantation, higher program‐specific adjusted TRRs were weakly associated with better adjusted posttransplant outcomes (r= −.14; P =.035) and lower adjusted waitlist mortality rate ratios (r= −.15; P =.022), but these associations were absent in liver, lung, and heart transplantation. Program‐specific adjusted TRRs were unlikely to be improved by listing candidates with high allocation priority and can provide useful information for transplant candidates and programs. Program‐specific adjusted transplant rate ratios are not associated with allocation priority, posttransplant outcomes, or adjusted waitlist mortality rate ratios. See Patzer's editorial on page 1301.

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 OPTNBoard of Directors in 2015 and will be implemented in early 2018. Meanwhile, SRTRcontinues to refrain from reporting pancreas graft failure data. The OPTN/UNOSPancreas Transplantation Committee is seeking to broaden allocation of pancreata across compatible ABOblood types in a proposal out for public comment July 31 to October 2, 2017. A new initiative to provide guidance on the benefits of PAKtransplants 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).