Figure 7.1
Number of transplants, by donor type
Transplant counts as known to the USRDS (reconciled from various sources).
Figure 7.2
Counts of transplants from living donors, by donor relation
Transplant counts as known to the USRDS (reconciled from various sources).
Figure 7.3
Wait list patient counts, by age, gender, & race
pts listed for kidney or kidney-pancreas transplant on Dec. 31 of each year. Multiple listings not counted. Age as of Dec. 31 of the given year.
Figure 7.4
Wait list counts & listings
pts listed for kidney or kidney-pancreas transplant on Dec. 31 of each year.
Figure 7.5
Wait list counts, by type of listing
pts listed for kidney or kidney-pancreas transplant on Dec. 31 of each year. Pts listed for both are counted once for each type.
Figure 7.6
Observed & projected median wait times by year of listing, overall & by race, blood type, & PRA
First-time, kidney-only transplants. Observed data plotted when Kaplan-Meier (KM) median is observed; otherwise, median projected with linear regression, & 95 percent CIs are given.
Figure 7.7
Median wait times, by year of transplant, age, race, blood type, & PRA
pts receiving deceased donor, kidney-only first transplants; unadjusted. Year is year of transplant, not year patient first listed.
Figure 7.8
Median wait times (in years), by state, 2005
pts receiving deceased donor, kidney-only first transplants, 2005, unadjusted. State is state of residence of the transplant recipient.
Figure 7.9
Patients wait-listed or transplanted within one year of ESRD initiation, by age, gender, & race
pts certified as having ESRD in the given year; includes transplants of all donor types. KM method.
Figure 7.10
Patients wait-listed or transplanted within one year of ESRD initiation (%), by state, 2004
pts certified as having ESRD in 2004; percents estimated using a Cox model, & adjusted for age, gender, race, & primary diagnosis. Includes transplants of all donor types.
Figure 7.11
Listings willing to accept an ECD kidney
New listings: pts first wait-listed for a kidney-only transplant between January 1 & Dec. 31 of the given year. Prevalent listings: pts on wait list for a kidney-only transplant any time during the given year, regardless of date first listed. Multiple listings not counted.
Figure 7.12
Listings willing to accept an ECD kidney, by age, gender, & race, 2004–2005
New listings: pts first wait-listed for a kidney-only transplant between Jan. 1, 2004, & Dec. 31, 2005. Prevalent listings: pts on wait list for a kidney-only transplant between Jan. 1, 2004, & Dec. 31, 2005, regardless of date first listed. Multiple listings not counted.
Figure 7.13
Listings willing to accept an ECD kidney (percent), by state, 2004–2005
Multiple listings within a state or region not counted, but a pt may be listed in more than one state or region.
Figure 7.14
Listings willing to accept an ECD kidney, by OPTN region, 2004–2005
Multiple listings within a state or region not counted, but a pt may be listed in more than one state or region.
Figure 7.15
Likelihood of receiving a transplant within one year of listing, 1995–2004
First-time listings, age 20+; KM method.
Figure 7.16
Likelihood of dying while awaiting transplant, 1995–2004
First-time listings, age 20+; KM method, with pts censored at transplant or removal from list.
Figure 7.17
Likelihood of being alive one year after listing, 1995–2004
First-time listings, age 20 & above; KM method, with no censoring at transplant or removal from list.
Figure 7.18
Outcomes for first-time wait-listed patients five years after listing, 2000
pts listed for kidney-only transplant in 2000; transplanted pts may have subsequent outcomes within follow-up period.
Figure 7.19
Incident ESRD & transplant rates
Transplant rates among all ESRD patients in the given year.
Figure 7.20
Transplant rates (per 100 dialysis patients years), by state, 2005
per 100 dialysis patient years, 2005, adjusted for age, gender, race, & primary diagnosis.
Figure 7.21
Percentage of transplant patients in the ESRD population
December 31 point prevalent ESRD patients.
Figure 7.22
Transplant counts, by state in which transplant occurs, 2005
All transplants performed at U.S. centers, 2005; does not include transplants performed in Puerto Rico.
Figure 7.23
Transplant counts, by state of recipient’s residence, 2005
All transplants, 2005, of patients residing in the 50 states or the District of Columbia.
Figure 7.24
Transplant rates, by age, gender, race, & primary diagnosis
Adjusted for age, gender, race, & primary diagnosis.
Figure 7.25
Transplant rates, by donor type
Unadjusted; transplants from donors of unknown type are omitted.
Figure 7.26
Geographic variations in Bayesian transplantation ratios, by state, 2005
Bayesian Poisson model, adjusted for age, gender, race, & primary diagnosis.
Figure 7.27
Deceased donor transplants: extended vs. standard criteria donors
First-time, deceased-donor, kidney-only transplants. Extended Criteria Donors (ECDs) are age 60 or older, or age 50–59 ith two or more of the following: death attributed to CVA, history of hypertension, or creatinine > 1.5 mg/dl.
Figure 7.28
Cause of death in deceased donors
Deceased-donor transplants; cause of death as reported by OPTN.
Figure 7.29
Deceased donor transplants from a non-heart beating donor
Deceased donor transplants; non-heart beating status as reported by OPTN.
Figure 7.30
Donation rates, by age, gender, & race
Donors with a known age younger than 70, whose organs are eventually transplanted
Figure 7.31
Geographic variations in donation rates (per million population), by state, 2005
Donation rates per million population, 2005, unadjusted.
Figure 7.32
Deceased donations per 100 deaths, by state, 2004–2005
Donations per 100 deaths, July 1, 2004, to July 1, 2005; unadjusted.
Figure 7.33
Percentage of transplants with primary non-function, by donor type
All transplants, 1995–2005.
Figure 7.34
Transplants with delayed graft function
Patients with functioning grafts upon discharge.
Figure 7.35
Counts of graft failures
Preemptive retransplantations are counted as a return to dialysis. For total patients starting or restarting dialysis, refer to figure p.2 in the Précis.
Figure 7.36
Outcomes: deceased donor transplants
First-time, kidney-only transplants. Cumulative incidences are estimated using the Kaplan-Meier method. Half-life estimates are adjusted for age, gender, race, & primary diagnosis, using Cox proportional hazards models. Conditional half-life estimates are conditional on first-year graft survival.
Figure 7.37
Outcomes: living donor transplants
First-time, kidney-only transplants. Cumulative incidences are estimated using the Kaplan-Meier method. Half-life estimates are adjusted for age, gender, race, & primary diagnosis, using Cox proportional hazards models. Conditional half-life estimates are conditional on first-year graft survival.
Figure 7.38
Most recent serum creatinine, 1995–2005 transplants
Transplants 1995–2005; most recent creatinine as reported to OPTN.
Figure 7.39
Patients retransplanted within one year of failure
Includes preemptive retransplants, & excludes failures due to death.
Figure 7.40
Graft survival preceding return to dialysis or preemptive retransplant
Includes return to dialysis & preemptive retransplants, & excludes failures due to death.
Figure 7.41
Graft survival preceding death with function
Includes death with functioning transplant.
Figure 7.42
Outcomes after transplant
Adjusted for age, gender, & race. Preemptive retransplantations are counted as a return to dialysis.
Figure 7.43
Acute rejections as reported to the OPTN
First-time, kidney-only transplants, 1999–2004. One-year cumulative incidence of acute rejection for transplants in the given year, as identified from OPTN follow-up data. Does not include acute rejection episodes at the time of transplant or acute rejections listed as the cause of graft failure. Kaplan-Meier methodology.
Figure 7.44
Post-transplant renal biopsies
Recipients of first-time, kidney-only transplants, 2000–2002, with Medicare as primary payor. Biopsies identified from Medicare claims; see Appendix A for further details.
Figure 7.45
Bayesian graft failure ratios, by transplant center
First-time, kidney-only transplants, 1995–2004. Significantly below & above average adjusted graft failure ratios assessed at the 0.05 level of significance.
Figure 7.46
Hospitalization rates in the first year post-transplant, by cause, age, race, & donor type / first-time, kidney-only transplants
Patients with first-time, kidney-only transplants, transplanted in the given year & followed for one year after discharge, & with Medicare as primary payor.
Figure 7.47
Hospitalization rates in the second through third years post-transplant, by cause, age, race, & donor type / first-time, kidney-only transplants
Patients with first-time, kidney-only transplants, transplanted in the given year & followed in years two & three after discharge, & with Medicare as primary payor.
Figure 7.48
Primary diagnosis of cardiac & infectious hospitalizations
Patients receiving a kidney transplant, 2001–2003, with Medicare as primary payor; cause-specific hospitalizations up to three years post-transplant. CHF: congestive heart failure; CVA: cerebrovascular accident; TIA: transient ischemic attack; AMI: acute myocardial infarction; UTI: urinary tract infection; CMV, cytomegalovirus infection.
Figure 7.49
Stress testing
Wait list: first listing with Medicare as primary payor, 1999–2004; censored at transplant. Transplants: first transplant with Medicare as primary payor, 1999–2004. High-risk: age greater than 50, comorbid diabetes, or history of cardiovascular disease. Rates estimated using Kaplan-Meier method.
Figure 7.50
Coronary angiography
Wait list: first listing with Medicare as primary payor, 1999–2004; censored at transplant. Transplants: first transplant with Medicare as primary payor, 1999–2004. High-risk: age greater than 50, comorbid diabetes, or history of cardiovascular disease. Rates estimated using Kaplan-Meier method.
Figure 7.51
Stress testing or coronary angiography
Wait list: first listing with Medicare as primary payor, 1999–2004; censored at transplant. Transplants: first transplant with Medicare as primary payor, 1999–2004. High-risk: age greater than 50, comorbid diabetes, or history of cardiovascular disease. Rates estimated using Kaplan-Meier method.
Figure 7.52
Echocardiogram
Wait list: first listing with Medicare as primary payor, 1999–2004; censored at transplant. Transplants: first transplant with Medicare as primary payor, 1999–2004. High-risk: age greater than 50, comorbid diabetes, or history of cardiovascular disease. Rates estimated using Kaplan-Meier method.
Figure 7.53
Coronary revascularization
Wait list: first listing with Medicare as primary payor, 1999–2004; censored at transplant. Transplants: first transplant with Medicare as primary payor, 1999–2004. High-risk: age greater than 50, comorbid diabetes, or history of cardiovascular disease. Rates estimated using Kaplan-Meier method.
Figure 7.54
Cumulative incidence of cardiovascular events
First transplant patients with Medicare as primary payor, 2000–2004 combined; adjusted for age, gender, race, primary diagnosis, & prior dialysis time. AMI: acute myocardial infarction; CHF: congestive heart failure; CVA: cerebrovascular accident; TIA: transient ischemic attack.
Figure 7.55
Cumulative incidence of diabetes
First-time, kidney-only transplant recipients, 1998–2002 combined; incidence estimated from Cox proportional hazards models & adjusted for multiple covariates as described in Appendix A.
Figure 7.56
Cumulative incidence of malignancy
First-time, kidney-only transplant recipients, 1998–2002 combined; incidence estimated from Cox proportional hazards models & adjusted for multiple covariates as described in Appendix A.
Figure 7.57
Baseline calcineurin inhibitor use
First-time, kidney-only transplants, 1995–2005. Immunosuppression as identified to OPTN.
Figure 7.58
Baseline antimetabolite use
First-time, kidney-only transplants, 1995–2005. Immunosuppression as identified to OPTN.
Figure 7.59
Rapamycin use
First-time, kidney-only transplants, 1995–2005. Immunosuppression as identified to OPTN.
Figure 7.60
Steroid use
First-time, kidney-only transplants, 1995–2005. Immunosuppression as identified to OPTN.
Figure 7.61
Antibody induction
First-time, kidney-only transplants, 1995–2005. Immunosuppression as identified to OPTN.
Figure 7.62
Most common immunosuppression regimens at time of transplant: 2003–2005
First-time, kidney-only transplants, 2003–2005. Maintenance immunosuppression as identified to OPTN.
Figure 7.63
Patients with OPTN follow-up, by years post-transplant
Period prevalent transplant patients transplanted in 1995 or later (7.63) or 2000 or later (7.64). Kaplan-Meier method. Location of follow-up care as identified to OPTN.
Figure 7.64
Location of follow-up care
Period prevalent transplant patients transplanted in 1995 or later (7.63) or 2000 or later (7.64). Kaplan-Meier method. Location of follow-up care as identified to OPTN.
Figure 7.65
Medicare coverage in patients younger than 62, by years post-transplant
Kidney transplant patients age younger than 62, 1998–2002.
Figure 7.66
Medicare coverage, by year
All kidney transplant patients; Medicare coverage determined at time of transplant.
Figure 7.67
HbA1c testing in diabetic transplant & general Medicare patients
Transplant: diabetic Medicare transplant recipients, 1995–2004, whose grafts function for at least one, two, & three years, respectively. General Medicare: prevalent beneficiaries (from 5 percent sample) who survive the two-year interval. Diabetic status determined from claims during first year; HbA1c & test strip use determined in second year.
Figure 7.68
Lipid monitoring in transplant & general Medicare patients
Transplant population: Medicare transplant recipients, 1995–2004, whose grafts function for at least one, two, & three years, respectively. Lipid tests occur at least 30 days apart. General Medicare: prevalent beneficiaries (from 5 percent sample) who survive the entire year.  Lipid tests occur at least 30 days apart.
Figure 7.69
Prescribed (per day) diabetic test strips in transplant & general Medicare patients
Transplant: diabetic Medicare transplant recipients, 1995–2004, whose grafts function for at least one, two, & three years, respectively. General Medicare: prevalent beneficiaries (from 5 percent sample) who survive the two-year interval. Diabetic status determined from claims during first year; HbA1c & test strip use determined in second year.
Figure 7.70
Eye examinations in diabetic transplant patients, by age, gender, & race
Prevalent patients initiating therapy 90 days prior to January 1 of the year before the measurement year, alive & age 18–75 on December 31 of the measurement year, with Medicare as primary payor during the two-year period, & with diabetes in the measurement year. For patients with diabetes as the primary cause of ESRD, claims for eye exams are searched during the measurement year; for other diabetics, claims are searched during the measurement year & previous year.
Figure 7.71
Influenza vaccinations in transplant patients, by age, gender, & race
Prevalent patients initiating therapy 90 days prior to September 1 of the measurement year, living through December 31 of that year, & with Medicare as primary payor from September to December.
Figure 7.72
Pap smears, by population (transplant & general Medicare), & by age & race/ethnicity (transplant only)
Transplant: female Medicare beneficiaries, age 18–61 at time of transplant, transplanted 2001–2005. Percent screened within first three years post-transplant; Kaplan-Meier method. General Medicare: period prevalent female beneficiaries (from 5 percent sample), 2003–2005, who survive through 2005 & are age 21–64 at the end of 2005.
Figure 7.73
Mammograms, by population (transplant & general Medicare), & by age & race/ethnicity (transplant only)
Transplant: female Medicare beneficiaries, age 50–67 at time of transplant, transplanted 2001–2005. Percent screened within the first two years post-transplant; Kaplan-Meier method. General Medicare: period prevalent female beneficiaries (from 5 percent sample), 2004–2005, who survive through 2005 & are age 52–69 at the end of 2005.
Figure 7.74
Prostate screening, by population (transplant & general Medicare), & by age & race/ethnicity (transplant only)
Transplant: male Medicare beneficiaries, age 50 & older at time of transplant, transplanted 2001–2005. Percent screened within the first three years post-transplant; Kaplan-Meier method. General Medicare: period prevalent male beneficiaries (from 5 percent sample), 2003–2005, who survive through 2005 & are 53 & older at the end of 2005.
Figure 7.75
Colonoscopies, by population (transplant & general Medicare), & by gender, age, & race/ethnicity (transplant only)
Transplant: Medicare beneficiaries, age 50 & older at time of transplant, transplanted 2001–2005. Percent with colonoscopy or sigmoidoscopy within the first three years post-transplant; Kaplan-Meier method. General Medicare: period prevalent beneficiaries (from 5 percent sample), 2003–2005, who survive through 2005 & are age 53 & older at the end of 2005.
2007 Anual Data Repot (ADR) Text Based
Atlas of End-Stage Renal Disease in the United States

 

7 - Transplantation

Introduction

Since the early 1970s, when only one-half of kidney transplant recipients survived one year with a functioning kidney, there has been a remarkable improvement in outcomes. The norm for one-year allograft survival—i.e., patients surviving at least one year with a functioning kidney—is now approaching 90 percent. This improvement in short-term allograft survival has shifted attention to the two major remaining challenges in kidney transplantation: the shortage of organs and the lack of improvement in the rate of allograft failure after the first post-transplant year.

Many of the moral and ethical dilemmas facing kidney transplantation today are a direct result of the organ shortage. This shortage has given rise to lengthening waiting times for deceased donor kidneys. It has also created ethnic and geographic disparities in waiting times that continue to fuel a national debate on the best method for allocating deceased donor kidneys.
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In addition, it has created increasing pressure to use deceased donor kidneys that may function sub-optimally after transplantation. The Extended Criteria Donor (ECD) kidney allocation program of the Organ Procurement and Transplantation Network (OPTN) is one example of efforts to use deceased donor kidneys that would formerly have been discarded.

Similarly, the deceased donor kidney shortage has created enormous pressure for patients and their physicians to find living donors. Use of these donors is increasing, despite medical risks that would have precluded donation at most transplant centers just a few years ago. Increasing numbers of patients are also traveling abroad to purchase living donor kidneys. “Transplant tourism” and “organ trafficking” exploit the poor and disadvantaged for the purpose of obtaining kidneys for those with the means to do so, and these practices all result from the organ shortage.

In this chapter we chronicle the growth in the wait list and the increase in wait times in the U.S. We show trends in the use of ECD kidneys under the OPTN’s ECD program, as well as outcomes for patients on the deceased donor waiting list. We look as well at trends in transplantation rates by patient characteristics and geographic location, and show rates of donation from deceased and living donors, expressed both per million population and per 100 deaths.

The second major problem plaguing transplantation is the failure to improve patient and graft survival rates late after transplantation, e.g., after the first post-transplant year. We report here on the most recent trends in overall outcomes. Newer and better immunosuppressive medications have helped reduce early acute rejection and improve short term survival rates, and, indeed, one-year graft survival has improved. But conditional half lives have changed very little, being slightly more than ten years for deceased donors and approximately 20 years for living donors. Why is this?

Immunosuppressive medications that reduce rejection have adverse effects that may contribute to graft dysfunction, as well as patient morbidity and mortality late after transplantation. Calcineurin inhibitors, for example, which have become the mainstay of immunosuppressive drug regimens, may cause acute and chronic nephotoxicity. Indeed, it is possible that much of the chronic allograft injury that accompanies progressive graft dysfunction is caused by calcineurin inhibitors. Too much immunosuppression can also result in higher rates of infection and malignancy. Similarly, several of the most commonly used immunosuppressive medications adversely affect a number of cardiovascular disease risk factors, including blood pressure, dyslipidemia, and glucose intolerance. This chapter illustrates trends in rates of hospitalization in the first year after discharge from the initial hospitalization for transplantation, overall and by reason for the hospitalization.

One way to prevent at least some of the complications of transplantation and immunosuppressive medications is to screen for disease and risk factors, and to use preventive measures for some of the most common post-transplant complications. We look here at the percentage of patients undergoing cardiac procedures in the year before and the years after wait listing and transplantation. We also show the cumulative incidence of cardiovascular disease events, new onset diabetes, and post-transplant malignancies, trends in the use of different immunosuppressive agents, and the use of common screening measures in the transplant population.

Figures not mentioned in text.

Figure 7.1 - Number of transplants, by donor type
Transplant counts as known to the USRDS (reconciled from various sources).

Figure 7.2 - Counts of transplants from living donors, by donor relation
Transplant counts as known to the USRDS (reconciled from various sources).

Transplant wait li