Trends and Results for Organ Donation and Transplantation in the United States, 2004

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Trends and Results for Organ Donation and Transplantation in the United States, 2004

Government document

By: Scientific Registry of Transplant Recipients, Organ Procurement and Transplantation Network

Date: 2004

Source: U.S. Department of Health and Human Services. "2004 Annual Report of the U.S. Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients: Transplant Data 1994–2003." Washington, D.C.: U.S. Government Printing Office, 2004.

About the Author: The U.S. Department of Health and Human Services (DHHS) is the Government agency responsible for protecting the health of all Americans and providing essential services, especially to those least able to help themselves. The Organ Procurement and Transplantation Network (OPTN), which deals with the supply and distribution of organs for transplant, is administered by the United Network for Organ Sharing (UNOS) under contract to the DHHS. The OPTN was set up by the U.S. Congress under the National Organ Transplant Act of 1984.

INTRODUCTION

It is now over half a century since the surgeon Joseph E. Murray (1919–) carried out the world's first kidney transplant in Boston, Massachusetts. In 1967, Christiaan Barnard (1922–2001) performed the first human heart transplant in Cape Town, South Africa, and, in the same year, Thomas Starzl (1926–) reported the first liver transplant at the University of Colorado Health Sciences Center in the U.S. Although Dr. Murray received the Nobel Prize for Physiology or Medicine in 1990 for his work, organ transplantation was controversial for many years. Many saw it as risky and unethical. Today, organ transplantation has become almost routine thanks to advances in both science and logistics, as well as to changes in public opinion.

In the early days, people receiving new kidneys, hearts, and livers were often extremely sick and not expected to survive without a new organ. This alone could, perhaps, justify the risks of surgery. However, even if the patient did survive the operation, the graft often did not survive because the body, naturally, rejected it as "foreign." A good deal of new research was needed to better understand the rejection process and to develop methods to persuade the recipient's body to accept the transplanted organ.

The introduction of the drug cyclosporine in 1978 changed the face of organ transplantation. Cyclosporine is an immunosuppressant. As the name suggests, it is able to suppress the immune system sufficiently to stop transplant rejection. However, interfering with the immune system is potentially dangerous, because this system normally protects the body from infection and cancer. Therefore, the dosage of cyclosporine post-transplant must be precise—too little and the new organ will be rejected, too much and the patient is vulnerable to infection, cancer, and other complications.

The other major development that brought organ transplantation into mainstream medicine was the establishment, in the U.S., of the United Network for Organ Sharing (UNOS). This network resulted from the enactment of the National Organ Transplant Act in 1984, the law that set a legal framework for organ transplantation. UNOS handles the logistics of the donor organ supply and matches organs to suitable recipients through the Organ Procurement and Transplantation Network (OPTN). It brings together medicine, science, public policy, and technology to facilitate every organ transplant performed in the U.S. Its research department collects regular statistics on organ transplantation and produced the report extracted here.

PRIMARY SOURCE

INTRODUCTION

… This publication is intended to be useful for patients, the transplant community, the public, and the Federal Government; its goal is to improve patient care and enhance equitable access to transplantation….

SUMMARY STATISTICS FOR 2002–2003 ON TRANSPLANTATION IN THE UNITED STATES

During 2003, more than 25,000 organs were transplanted in the United States—over 18,000 from deceased donors and almost 7,000 from living donors. Compared to data from the prior year (2002), these numbers reflect an increase in the number of deceased donor transplants by 2.2% overall and by 1.9% for deceased donors; a greater increase was noted for living donors (2.9%). During the same period, more than 7,000 patients were reported to have died while waiting for a transplant. The number of deaths on the waiting list did not change substantially from 2002 to 2003; however, there was a decrease in the overall death rate because of the increase in waiting list size.

The waiting list for deceased donor transplants has increased at more than twice the rate of increase in the number of transplants during the past year, by 5.1% versus 1.9%. This large increase is a continuation from earlier years and provides a strong indication of the ever-increasing demand for organs. The total number of patients on the waiting list reached almost 86,500 in 2003…. When the number of patients waiting for a transplant increases, it demonstrates that the demand exceeds the supply—more patients are added to the list than are removed from it. Hopefully these removals occur because of transplantation, but they also represent death and (occasionally) recovery from organ failure. The … demand for kidney and pancreas transplants increased steeply; lung and liver transplant demand also increased, though to a lesser degree. By contrast, the number of patients awaiting heart, heart-lung and intestine transplants decreased in 2003 compared to the prior year. Longer time trends for the past decade are demonstrated for each organ in the organ-specific chapters that follow.

As a consequence of the steeply increasing demand for transplants and slowly increasing supply of organs, the waiting list is getting longer and the waiting times for transplant candidates, which are already long, are getting longer. The urgent need for more donor organs is suggested by many of the chapters in this report; it is particularly pronounced for kidneys, pancreata, and livers.

Evaluation of the number of transplants performed by organ in 2003 compared with the prior year reveal large differences. Kidney transplantation leads organ transplantation, and living donor kidney transplants accounted for 44% of all kidney transplants in 2003. Liver transplantation too continues to show a substantial growth (6%). By contrast, the number of living donor liver transplants decreased by 11% to 320 during the recent year. Living donor liver transplantation accounts for only 6% of all liver transplants. Heart transplantation decreased by 4.2% to 2,024 transplants in 2003. Lung transplants number just over 1,000 per year, and showed a 3.7% increase since 2002. Living lung transplants account for less than 2% of all lung transplants. Pancreas transplantation for Type 1 diabetics is most commonly performed simultaneously with kidney transplantation. It showed a reduction in 2003 compared to the prior year, which is consistent for all types of pancreas transplants. In 2003 there were 52 small intestine transplants, which suggests a substantial recent increase.

Two critical measures describe key outcomes after transplantation: the function of the transplanted graft and survival of the transplant recipient. Patient survival after transplantation has been generally improving over time…. One-year patient survival for kidney and pancreas transplants were around 95%-97%; corresponding survival rates were about 86% for liver and heart, about 80% for lung and intestine, and lowest for combined heart-lung recipients.

Functional survival of the transplanted organ, i.e. graft survival, has improved substantially over the past decade and has been relatively stable in recent years…. Compared to the data for patient survival, figures for graft failure are usually lower. This is due to the fact that patients may survive a graft failure by receiving a timely second transplant, by returning to dialysis (for kidney transplant recipients), or by returning to insulin therapy (for pancreas transplant recipients). More detailed trends over longer time spans are provided in the organ-specific chapters of this report….

CONCLUSION

This report provides a great deal of information on the current state of transplantation in the United States. The observed time trends over the past decade and most recent two years give important perspectives on many areas of organ donation, immunosuppression, organ-specific issues, and overall outcomes. Numerous impressive improvements are documented in this report, as are areas that need to be addressed with great urgency—such as enhancing organ donation to reduce the annually increasing gap between available organs and the growing need for life-saving transplantation.

SIGNIFICANCE

The report highlights the increase in the waiting list for organ transplants and, consequently, the growing gap between demand and supply. Clearly, the waiting list is growing faster than donor organs become available for transplant. There are various reasons to explain the growth in the number of patients awaiting an organ transplant. First, the skill and experience of transplant surgeons and doctors, both in performing these operations and in caring for the recipients, has increased dramatically over the last decade. Once seen as the last option for the desperately sick, a kidney, heart, or liver transplant is now seen as a realistic and cost-effective alternative to ongoing medical treatment, such as kidney dialysis.

In addition, the population is aging rapidly. At one time, physicians would not consider doing a transplant on a recipient over the age of fifty-five. Now that barrier has been crossed because research has shown that older recipients, if carefully selected, can do as well as younger ones. This means that there are now many older people on the transplant waiting list and the number is bound to increase in the future.

The growth of the waiting list has led to efforts to increase the supply of donor organs. Just as surgeons are now operating on older recipients, they also are accepting older donors. At one time, the typical organ donor was a young, healthy man or woman who had been killed in a traffic accident. Now there is a wide range of donors—including the living (for livers and kidneys). There has been an increase in the use of living donors—usually, but not always, a relative of the recipient. Needless to say, this has raised ethical questions, since taking a healthy organ from a living person, however willing that person is, does harm. This impact on the living donor has to be carefully balanced against the benefit to the recipient.

Ongoing study of transplant recipients is another major development in the field of organ transplantation. At one time, the main goal of the transplant operation was the survival of the recipient and the new organ. Now that thousands of transplant recipients have survived for many years, there has been the opportunity to study their health, both physical and psychological. Transplant recipients are vulnerable to a number of health problems, many of which arise from the use of immunosuppressants, which must be taken for life by transplant recipients. As a result, post-transplant medication regimes have been fine-tuned and many advances have been made to improve the health care of transplant recipients.