Mortality Among Solid Organ Waitlist Candidates During COVID-19 in the United States

Jonathan Miller; Andrew Wey; Donald Musgrove; Yoon Son Ahn; Allyson Hart; Bertram L. Kasiske; Ryutaro Hirose; Ajay K. Israni; Jon J. Snyder


American Journal of Transplantation. 2021;21(6):2262-2268. 

In This Article


Adjusted Effects of COVID

The hazard of mortality among kidney transplant candidates was 37% higher in the first 10 weeks after the COVID-19 national emergency than before (adjusted hazard ratio [aHR], 1.37; 95% CI, 1.23–1.52). The hazard of waitlist mortality for liver (aHR, 0.94; 95% CI, 0.78–1.15), pancreas (aHR, 1.01; 95% CI, 0.49–2.07), lung (aHR, 1.00; 95% CI, 0.59–1.70), and heart (aHR, 0.94; 95% CI, 0.57–1.54) candidates were similar before and after COVID-19 (Figure 1). Additionally adjusting for time-varying candidate inactive status did not meaningfully change the hazard ratios (Supplemental File 1).

Figure 1.

Impact of COVID-19 on mortality hazard among organ waitlist candidates

Preliminary analysis of time trends using the December 2020 SAF showed that the hazard ratios for waitlist mortality among kidney candidates declined from the peak immediately following COVID-19 but remained high. The hazard ratios for other organs did not notably vary from month to month and did not increase after COVID-19 (Figure 2).

Figure 2.

Time trends in waitlist mortality hazard among organ waitlist candidates

Geographic Variability

The hazard of waitlist mortality among kidney candidates in the New York City DSA was 2.52 times higher after the COVID-19 national emergency declaration than before, even after accounting for the higher hazard of waitlist mortality in the United States (Figure 3). Similarly, waitlist mortality was higher among kidney candidates after than before COVID-19 in New Jersey (aHR, 1.84) and Michigan (aHR, 1.56). Differences across DSAs in waitlist mortality for liver transplant candidates were notably smaller. The largest difference after, compared with before, COVID-19 occurred in DSAs serving primarily Milwaukee, Wisconsin (aHR, 1.11) and Hartford, Connecticut (aHR, 1.10). Models for lung, heart, and pancreas candidates were not estimated due to an insufficient number of deaths after March 13, 2020 (Supplemental File 2).

Figure 3.

Geographic variation in waitlist mortality hazard for kidney transplant across the United States after COVID-19 compared to before [Color figure can be viewed at]

Demographic Variability

Only kidney and liver transplants had a sufficient number of deaths on the waiting list after COVID-19 to estimate differences in waitlist mortality across candidate subgroups. African American kidney waitlist candidates were the only subgroup with early signs of higher waitlist mortality rates after than before COVID-19 (aHR, 1.41; 95% CI, 1.07–1.86, compared with White candidates, Table 1). Liver candidates had dramatically higher waitlist mortality rates at higher MELD scores prior to COVID; this trend remained but was notably attenuated after the emergence of COVID-19 (Table 1). However, the confidence intervals for many subgroups, especially among liver transplant candidates, were notably wide, indicating relatively imprecise estimates.