*Purpose: The general population of the United States has changed considerably over the past 15 years. This study evaluates longitudinal changes in potential organ donors and resultant effects on donor utilization for transplantation.

*Methods: OPTN Standard Transplant Analysis and Research file was evaluated for all potential deceased organ donors between 2005-2019 and divided into Era 1 (2005-2009), Era 2 (2010-2014), and Era 3 (2015-2019). Donor characteristics were evaluated. Donors were considered utilized if at least one organ was transplanted; multi-organ donors donated two or more types of organs. Utilization rates were determined from total donor pool. Standard statistical analyses were applied. Multivariable analyses were performed for likelihood of donor utilization; odds ratios (OR) and 95% confidence intervals (CI) are reported. Given the large population, p-values <0.01 were considered significant.

*Results: Over the study period, 132,783 donors were identified of which 124,654 (93.9%) were utilized for transplantation of at least one organ. Era 3 had the most potential and utilized donors. The number of donation after circulatory death (DCD) donors increased over time, accounting for 9.5% of potential donors in Era 1 versus 19.1% in Era 3. There was a significant shift in the most common cause of death (COD) from trauma in Era 1 (36.4%) to anoxia in Era 3 (41.9%, p<0.001). Donor body mass index (BMI) increased over time, with 32.0% of utilized donors being obese (BMI>30kg/m²) in Era 3 from 25.8% in Era 1 (p<0.001). Rates of diabetes and hypertension were similar across Eras, while metabolic syndrome increased from 4.3% to 5.6% (p<0.001). Donor utilization increased for kidney (76.7% Era 1 vs 77.8% Era 3), heart (28.2% vs 31.5%), and lung transplantation (17.3% vs 22.1%), while it decreased for liver transplantation (76.9% vs 72.7%; p<0.001 for all). There was an increase in multi-organ donors amongst brain dead donors (DBD; 70.3% Era 1 vs 73.6% Era 3; p<0.001). Conversely, 33.9% of DCD donors were multi-organ in Era 1 compared to only 26.3% in Era 3 (p<0.001). On multi-variable analysis, donor utilization was more likely in Era 3 compared to Era 1 for DBD donors (OR 1.42, 95% CI 1.32-1.53, p<0.001), but not DCD donors despite increased volume (0.97, 0.85-1.10, p=0.08). Hepatitis C virus positive donor utilization more than doubled from Era 1 to Era 3 (OR 2.38, 95% CI 1.96-2.90, p<0.001). Donors with trauma as COD were most likely to be used in all eras, regardless of DCD/DBD status.

*Conclusions: Over the past 15 years, increased donor identification has provided more opportunities for organ transplantation. However, this may represent more marginal donors, and recognizing changes in donor population, in concert with the implementation of machine perfusion and DCD heart procurements, provides opportunities to improve transplantation in the United States.

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