Kidney

Abstract

Kidney transplant provides significant survival, cost, and quality-of-life benefits over dialysis in patients with end-stage kidney disease, but the number of kidney transplant candidates on the waiting list continues to grow annually. By the end of 2014, nearly 100,000 adult candidates and 1500 pediatric candidates were waiting for kidney transplant. Not surprisingly, waiting times also continued to increase, along with the number of adult candidates removed from the list due to death or deteriorating medical condition. Death censored graft survival has increased after both living and deceased donor transplants over the past decade in adult recipients. The majority of the trends seen over the past 5 years continued in 2014. However, the new allocation system was implemented in late 2014, providing an opportunity to assess changes in these trends in the coming years.

Keywords: End-stage renal disease; kidney transplant; organ allocation; waiting list.

© Copyright 2015 The American Society of Transplantation and the American Society of Transplant Surgeons.

Figures

Figure KI 1.1. Adults waiting for kidney transplant

Candidates concurrently listed at multiple centers are counted once. Candidates who are active at at least one program are considered active; otherwise they are inactive. Active status is determined on day 7 after first listing. A new patient is one who first joined the list during the given year without ever listing in a prior year, or one who listed and underwent transplant in a prior year and relisted in the given year.

Figure KI 1.2. Distribution of adults waiting for kidney transplant

Candidates waiting for transplant at any time in the given year. Candidates listed concurrently at multiple centers are counted once. Age is determined at the later of listing date or January 1 of the given year. Time on the waiting list and on dialysis are determined at the earlier of December 31 or removal from the waiting list. PRA is the highest value during the year. Active and inactive candidates are included. CKD, cystic kidney disease; DM, diabetes. HTN, hypertension. GN, glomerulonephritis. ECD, expanded criteria donor.

Figure KI 1.3. Prevalent dialysis patients waitlisted for kidney transplant, by age

Estimated percentage of prevalent dialysis patients waitlisted for kidney-alone transplant. Percentage calculated as the sum of point prevalent waitlist candidates divided by the sum of point prevalent dialysis patients on December 31 of each year. Dialysis data from the Consolidated Renal Operations in a Web-enabled Network (CROWN) dataset. Age calculated on December 31 of given year.

Figure KI 1.4. Deceased donor kidney transplant rates among active adult waitlist candidates

Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of active waiting in a given year. Individual listings are counted separately. Rates with less than 10 patient-years of exposure are not shown. Rates by PRA/CPRA are computed in a time-dependent manner. GN, glomerulonephritis.

Figure KI 1.5. Percentage of adults who underwent deceased donor kidney transplant within 5 years of listing in 2009, by DSA

Candidates listed concurrently in a single DSA are counted once in that DSA; candidates listed in multiple DSAs are counted separately per DSA.

Figure KI 1.6. Three-year outcomes for adults waiting for kidney transplant, new listings in 2011

Adults waiting for any kidney transplant and first listed in 2011. Candidates concurrently listed at more than one center are counted once, from the time of earliest listing to the time of latest removal. DD, deceased donor; LD, living donor.

Figure KI 1.7. Median years to deceased donor kidney transplant for waitlisted adults

Observations censored on December 31, 2014; Kaplan-Meier competing risk methods used to estimate time to transplant. Analysis performed per candidate not per listing. If an estimate is not plotted, 50% of the cohort listed in that year had not undergone transplant by the censoring date. Only the first transplant is counted.

Figure KI 1.8. Adults willing to accept an ECD kidney, by age

Adults waiting for kidney transplant on December 31 of the given year. Candidates concurrently listed at more than one center are counted once, from the time of earliest listing to the time of latest removal. Candidates are considered willing to accept an ECD kidney if so identified in at least one listing. In 2014, willingness to accept an ECD kidney also included willingness to accept a kidney with kidney donor profile index > 85%.

Figure KI 1.9. Mortality rates among adults waitlisted for kidney transplant

Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Individual listings are counted separately. Rates with less than 10 patient-years of exposure are not shown. Age is determined at the later of listing date or January 1 of the given year. CKD, cystic kidney disease; DM, diabetes. HTN, hypertension. GN, glomerulonephritis.

Figure KI 2.1. Demographics of deceased kidney donors

Deceased donors with at least one kidney recovered for transplant. Donors whose kidneys were recovered en-bloc are counted once, and donors whose kidneys were recovered separately are counted twice.

Figure KI 2.2. Deceased donor kidney donation rates (per 1000 deaths), by state, 2011–2013

Numerator: Deceased donors aged http://www.naphsis.org/programs/vital-statistics-data-research-request-process). Donors whose kidneys were recovered en-bloc are counted once, and donors whose kidneys were recovered separately are counted twice.

Figure KI 2.3. Rates of organs recovered for transplant and not transplanted

Percentages of kidneys not transplanted out of all kidneys recovered for transplant. Kidneys recoverd en-bloc are counted once, and kidneys recovered separately are counted twice. CNS, central nervous system; CVA, cerebrovascular accident.

Figure KI 2.4. Kidneys recovered for transplant and not transplanted, by donor type

Percentages of kidneys not transplanted out of all kidneys recovered for transplant, by DCD/DBD and KDPI donor classification. The reference population for the KDRI to KDPI conversion is all deceased donor kidneys recovered for transplant in the US in 2014. Kidneys recovered en-bloc are counted once. DBD, donation after brain death; DCD, donation after circulatory death; KDPI, kidney donor profile index; KDRI, kidney donor risk index.

Figure KI 2.5. Donor-specific components of the kidney donor risk index

Donors with at least one transplanted kidney. The donor-specific components of the kidney donor risk index are shown, except for donor height and hepatitis C virus positive status. CVA, cerebrovascular accident; DCD, donation after circulatory death; SCr, serum creatinine.

Figure KI 2.6. Cause of death among deceased kidney donors

Deceased donors whose kidneys were transplanted. Each donor is counted once. CNS, central nervous system.

Figure KI 3.1. Kidney transplants from living donors, by donor relation

Numbers of living donor donations; characteristics recorded on the OPTN Living Donor Registration Form.

Figure KI 3.2. Living kidney donors, by age, sex and race

As reported on the OPTN Living Donor Registration Form.

Figure KI 3.3. Intended living kidney donor procedure type

As reported on the OPTN Living Donor Registration Form. Right-hand panel shows percentages of intended laparoscopic procedures converted to open.

Figure KI 3.4. Rehospitalization in the first 6 weeks, 6 months, and 1 year among living kidney donors, 2009–2013

Cumulative hospital readmission. The 6-week time point is recorded at the earliest of discharge or 6 weeks after donation.

Figure KI 3.5. Kidney complications among living kidney donors, 2009–2013

Complications reported on the OPTN Living Donor Registration and Living Donor Follow-up Forms at each time point. Complications include readmission, re-operation, vascular complications, and other complications requiring intervention. Multiple complications may be reported at any time point.

Figure KI 3.6. BMI among living kidney donors

Donor height and weight reported on the OPTN Living Donor Registration Form.

Figure KI 4.1. Total kidney transplants

All kidney transplant recipients, including adult and pediatric, retransplant, and multi-organ recipients.

Figure KI 4.2. Kidney transplants

All kidney transplant recipients, including adult and pediatric, retransplant, and multi-organ recipients. GN, glomerulonephritis.

Figure KI 4.3. Kidney transplants by kidney donor profile index

All adult recipients of deceased donor kidneys, including multi-organ transplants. The reference population for the KDRI to KDPI conversion is all deceased donor kidneys recovered for transplant in the US in 2014. Kidneys recovered en-bloc are counted once. KDPI, kidney donor profile index; KDRI, kidney donor risk index.

Figure KI 4.4. Immunosuppression in adult kidney transplant recipients

One-year posttransplant data are limited to patients alive with graft function at 1 year posttransplant. Mycophenolate includes mycophenolate mofetil and mycophenolate sodium. IL2-RA, interleukin-2 receptor antagonist; mTOR, mammalian target of rapamycin.

Figure KI 4.5. PRA at time of kidney transplant in adult recipients

From December 1, 2007, through September 30, 2009, CPRA was used if greater than 0; otherwise, the maximum pretransplant PRA was used. Before December 1, 2007, the maximum pretransplant PRA was used unconditionally. CPRA is used after September 30, 2009, unless it is missing; if it is missing, the maximum pretransplant PRA is used. Kidney-alone transplants only.

Figure KI 4.6. Total HLA A, B, and DR mismatches among adult kidney transplant recipients, 2010–2014

Donor and recipient antigen matching is based on OPTN antigen values and split equivalences policy as of 2014.

Figure KI 5.1. Outcomes among adult kidney transplant recipients: deceased donor

Percentage for each outcome is unadjusted, computed using Kaplan-Meier competing risk methods. Death with function (DWF) is defined as no graft failure before death; death-censored graft failure (DCGF) is defined as return to dialysis or retransplant; all-cause graft failure (GF) is defined as any graft failure.

Figure KI 5.2. Outcomes among adult kidney transplant recipients: living donor

Percentage for each outcome is unadjusted, computed using Kaplan-Meier competing risk methods. Death with function (DWF) is defined as no graft failure before death; death-censored graft failure (DCGF) is defined as return to dialysis or retransplant; all-cause graft failure (GF) is defined as any graft failure.

Figure KI 5.3. Graft survival among adult kidney transplant recipients, 2009: deceased donors

Graft survival estimated using unadjusted Kaplan-Meier methods. CKD, cystic kidney disease; DCD, donation after circulatory death; GN, glomerulonephritis; KDPI, kidney donor profile index.

Figure KI 5.4. Graft survival among adult kidney transplant recipients, 2009: living donors

Graft survival estimated using unadjusted Kaplan-Meier methods. CKD, cystic kidney disease; GN, glomerulonephritis.

Figure KI 5.5. Recipients alive with a functioning kidney graft on June 30 of the year, by age at transplant

Recipients are assumed to be alive with function unless a death or graft failure is recorded. A recipient may experience a graft failure and be removed from the cohort, undergo retransplant, and re-enter the cohort.

Figure KI 5.6. Incidence of acute rejection in year 1 posttransplant among adult kidney transplant recipients

Acute rejection is defined as a record of acute or hyperacute rejection, as reported on the OPTN Transplant Recipient Registration or Transplant Recipient Follow-up Form. Only the first rejection event is counted. Cumulative incidence is estimated using the Kaplan-Meier competing risk method.

Figure KI 5.7. Posttransplant diabetes among adult kidney transplant recipients

Percentage of adult deceased donor kidney recipients who were free of diabetes at transplant and developed diabetes posttransplant. Posttransplant diabetes is reported on the Transplant Recipient Follow-up Form. Death and graft failure are treated as competing events.

Figure KI 5.8. Incidence of PTLD among adult kidney transplant recipients, by recipient EBV status at transplant, 2008–2012

Cumulative incidence is estimated using the Kaplan-Meier competing risk method. PTLD is identified as a reported complication or cause of death on the OPTN Transplant Recipient Follow-up Form or the Posttransplant Malignancy Form as polymorphic PTLD, monomorphic PTLD, or Hodgkin disease. Only the earliest date of PTLD diagnosis is considered. EBV, Epstein-Barr virus; PTLD, posttransplant lymphoproliferative disorder.

Figure KI 5.9. Distribution of eGFR at discharge and at 6 months posttransplant among adult kidney transplant recipients

GFR (mL/min/1.73 m2) estimated using the Chronic Kidney Disease Epidemioogy Collaboration equation, and computed for patients alive with graft function at the given time point.

Figure KI 6.1. Pediatric candidates waiting for kidney transplant

Candidates concurrently listed at multiple centers are counted once. Candidates who are active at at least one program are considered active; otherwise they are inactive. Active status is determined on day 7 after first listing. A new patient is one who first joined the list during the given year without ever listing in a prior year, or one who listed and underwent transplant in a prior year and relisted in the given year. Patients on the list on December 31 were pediatric at listing.

Figure KI 6.2. Distribution of pediatric candidates waiting for kidney transplant

Candidates waiting for transplant any time in the given year. Candidates listed concurrently at multiple centers are counted once. Age is determined at the later of listing date or January 1 of the given year. Time on the waiting list is determined at the earlier of December 31 or removal from the waiting list. Diagnosis categories follow North American Pediatric Renal Trials and Collaborative Studies recommendations. PRA is the highest value during the year. Active and inactive patients are included. FSGS, focal segmental glomerulosclerosis; GN, glomerulonephritis; CAKUT, congenital anomalies of the kidney and urinary tract.

Figure KI 6.3. Primary cause of ESRD in pediatric candidates for kidney transplant, by age, 2010–2014

Includes candidates first listed 2010–2014. Candidates concurrently listed at more than one center are counted once. Patients who were listed, underwent transplant, and were relisted during the time period are counted more than once. Age is computed at earliest listing date. FSGS, focal segmental glomerulosclerosis; GN, glomerulonephritis; CAKUT, congenital anomalies of the kidney and urinary tract.

Figure KI 6.4. Three-year outcomes for pediatric candidates waiting for kidney transplant, new listings in 2011

Candidates waiting for any kidney transplant and first listed in 2011. Candidates concurrently listed at more than one center are counted once, from the time of earliest listing to the time of latest removal. DD, deceased donor; LD living donor.

Figure KI 6.5. Deceased donor kidney transplant rates among active pediatric waitlist candidates

Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of active waiting in a given year. Individual listings are counted separately. Rates with less than 10 patient-years of exposure are not shown. Rates by PRA/CPRA at computed in a time-dependent manner. The age category 18 years or older includes candidates listed when aged younger than 18 years but still on the list in the given year.

Figure KI 6.6. Pretransplant mortality rates among pediatric kidney transplant candidates

Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year. Individual listings are counted separately. Age is determined at the later of listing date or January 1 of the given year.

Figure KI 6.7. Pediatric kidney transplants, by donor type

All pediatric kidney transplant recipients, including retransplant, and multi-organ recipients.

Figure KI 6.8. Pediatric kidney transplants from living donors

Relationship of living donor to recipient is as indicated on the OPTN Living Donor Registration Form.

Figure KI 6.9. Immunosuppression in pediatric kidney transplant recipients

One-year posttransplant data are limited to patients alive with graft function at 1 year posttransplant. Mycophenolate includes mycophenolate mofetil and mycophenolate sodium. IL2-RA, interleukin-2 receptor antagonist; mTor, mammalian target of rapamycin.

Figure KI 6.10. Induction use by CPRA among pediatric kidney transplant recipients, 2010–2014

IL2-RA, interleukin-2 receptor antagonist.

Figure KI 6.11. Total HLA A, B, and DR mismatches among pediatric kidney transplant recipients, 2010–2014

Donor and recipient antigen matching is based on OPTN antigen values and split equivalences policy as of 2014.

Figure KI 6.12. Outcomes among pediatric kidney-alone transplant recipients: deceased donor

Percentage for each outcome is unadjusted, computed using Kaplan-Meier competing risk methods. Death with function (DWF) is defined as no graft failure before death; death-censored graft failure (DCGF) is defined as return to dialysis or retransplant; all-cause graft failure (GF) is defined as any graft failure.

Figure KI 6.13. Outcomes among pediatric kidney-alone transplant recipients: living donor

Percentage for each outcome is unadjusted, computed using Kaplan-Meier competing risk methods. Death with function (DWF) is defined as no graft failure before death; death-censored graft failure (DCGF) is defined as return to dialysis or retransplant; all-cause graft failure (GF) is defined as any graft failure.

Figure KI 6.14. Graft survival among pediatric kidney transplant recipients, by age and donor type, 2005–2009

Graft survival estimated using unadjusted Kaplan-Meier methods. DD, deceased donor; LD, living donor.

Figure KI 6.15. Incidence of PTLD among pediatric kidney transplant recipients, by recipient EBV status at transplant, 2002–2012

Cumulative incidence is estimated using the Kaplan-Meier competing risk method. Posttransplant lymphoproliferative disorder (PTLD) is identified as a reported complication or cause of death on the OPTN Transplant Recipient Follow-up Form or on the Posttransplant Malignancy form as polymorphic PTLD, monomorphic PTLD, or Hodgkin disease. Only the earliest date of PTLD diagnosis is considered. EBV, Epstein-Barr virus.

Figure KI 6.16. Incidence of acute rejection in year 1 posttransplant among pediatric kidney transplant recipients, by age

Acute rejection is defined as a record of acute or hyperacute rejection, as reported on the OPTN Transplant Recipient Registration Form or Transplant Recipient Follow-up Form. Only the first rejection event is counted. Cumulative incidence is estimated using the Kaplan-Meier competing risk method.

Figure KI 6.17. Distribution of eGFR at discharge and at 6 and 12 months posttransplant, among pediatric kidney-alone transplant recipients

GFR (mL/min/1.73 m2) estimated using the bedside Schwartz equation, and computed for patients alive with graft function at the given time point. Equation: eGFR = 0.413*Height(cm)/Creatinine (mg/dL).

Figure KI 7.1. Centers performing adult transplants or listing active adult kidney candidates, within DSAs, 2012–2014

Figure KI 7.2. Centers performing pediatric transplants or listing active pediatric kidney candidates, within DSAs, 2012–2014