Trends in Survival and Unmet Need Across Solid Organ Transplantation

Solid organ transplantation is often the definitive therapy for individuals with end-stage organ failure. Treatment outcomes rely on a complex interplay of technological advances, surgical success, and organ availability. Intention-to-treat (ITT) survival is the most comprehensive single metric for assessing progress as it incorporates waitlist survival, transplant rate, and posttransplant survival. This study aims to quantify changes in unmet need and ITT survival over time to capture the system's capacity to effectively treat transplant candidates.

In this cohort, national database study, adult candidates (N = 1,409,764) listed for solid organ transplantation were considered from January 1987 to July 2024 in the United Network for Organ Sharing database. Kaplan-Meier method with log-rank tests was used to calculate survival; Cox proportional hazards modeling quantified survival for decades. Cohorts were divided on the basis of primary organ. Within each cohort, the influence of decade on ITT survival was assessed in a multivariable analysis that considered demographic confounders.

From 1988 to 2023, 1-year ITT and posttransplant survival improved significantly across all organ types. Lung and kidney candidates showed the most dramatic ITT survival gains, whereas posttransplant survival improved most for lung and pancreas recipients. Kidney transplant had the highest and most persistent unmet need, with little change since the mid-2010s. In contrast, the unmet need for lung and pancreas transplants declined substantially.

Although survival after listing and transplant has improved markedly across all organs, persistent disparities in unmet need, particularly for kidney transplantation, highlight ongoing challenges in access to care. Recent policy changes and emerging technologies are promising and remain critical to achieving equitable transplant outcomes.