Trends in Survival and Unmet Need Across Solid-Organ Transplantation

BACKGROUND: 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 post-transplant 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. STUDY DESIGN: 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 within the United Network for Organ Sharing database. Kaplan-Meier method with log-rank tests were utilized to calculate survival; Cox-proportional hazards modeling quantified survival over decades. Cohorts were divided based on primary organ. Within each cohort, the influence of decade on ITT survival was calculated in a multivariable analysis that considered demographic confounds. RESULTS: From 1988 to 2023, one-year ITT and post-transplant survival improved significantly across all organ types. Lung and kidney candidates showed the most dramatic ITT survival gains, while post-transplant 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, unmet need for lung and pancreas transplants declined substantially. CONCLUSIONS: While 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.