Abstract
Introduction
The Kidney Donor Profile Index (KDPI) is a percentile score based on the relative risk of allograft failure for deceased donor kidneys, where higher scores indicate shorter estimated allograft longevity. The Organ Procurement and Transplantation Network policy requires patients to proactively opt-in via written consent to receive offers for “high-KDPI” (> 85%) kidneys before being considered for organs in this category.
Methods
This retrospective cohort study examined United States (US) candidates and recipients from 2012 to 2022 to determine if consent for less-than-ideal organs impacted organ allocation, efficiency, and utilization.
Results
Among 138,242 deceased donor transplants, 7031 (5%) were from KDPI of 80% to 85% kidneys, 4847 (4%) from KDPI of 86% to 90% kidneys, and 6089 (4%) from KDPI > 90%. Among transplants with KDPI of 86% to 90% kidneys, representing the best quality among high-KDPI organs, 10% of recipients in 2014 were top-ranked candidates compared with 5% in 2015 and 4% in 2022. The number of declined offers for KDPI of 86% to 90% kidneys increased following implementation of the Kidney Allocation System (11 [interquartile range, IQR: 2–52] in 2014 versus 21.5 [IQR: 6–109] in 2015 vs. 52 [IQR: 12–323] in 2022).
Conclusion
These findings demonstrate changes in the centers’ willingness to accept high KDPI kidneys on behalf of their patients after the introduction of the KDPI label and other changes in allocation policy and regulatory oversight in the system.
Keywords: high KDPI, kidney allocation, kidney transplant
Graphical abstract
Transplantation is the ideal treatment for patients with end-stage kidney disease. However, access to kidney transplantation remains limited, even among those who are fortunate enough to reach the national transplant waitlist for a deceased donor transplant.1,2 To balance the demand for these life-saving organs, the US has an objective allocation algorithm matching patients with available deceased donor kidneys in order of priority.3, 4, 5, 6 Transplant centers have the ability to decline an organ offer for the patient to whom that organ is allocated, in the hope that the patient will receive an offer for a better quality organ in a relatively short time frame.7 Based on Organ Procurement and Transplantation Network data, the extent to which patients are involved in organ offer declines appears to be relatively low given that patients are unaware of the majority of declined offers.7, 8, 9
Changes to the kidney allocation system (KAS) in 2014 introduced the Kidney Donor Risk Index (KDRI), which is based on the relative risk of allograft failure associated with risk factors of a deceased donor kidney.6 This is considered an indicator of organ quality that incorporates donor demographics, comorbidities, race, cause of death, and kidney function as measured by creatinine.6 The KDRI is converted to a percentile score, the KDPI, based on the range of the quality of deceased donor organs procured in the previous year.6 Higher KDPI scores suggest shorter estimated function, and thus, the current Organ Procurement and Transplantation Network policy requires that patients are educated about their options. Patients must proactively opt-in to receive offers for “high KDPI” (KDPI > 85%) kidneys with a written consent before they can be considered for organs in this category. Consequently, the match run for kidneys with a KDPI > 85% only includes patients who have consented to accept these kidneys. Ideally, the process of approaching and consenting patients for high KDPI kidneys is limited to those individuals who are thought to benefit from these organs.
In addition, in 2021, the allocation system was updated again, expanding organ donation service areas to 250-nautical miles of each organ procurement organization where the organ was recovered. Referred to as “KAS250,” these new donation boundaries have been shown to contribute to marked increases in organ offers, particularly in denser populations in the US with larger proportions of disease burden.3,5,10
We attempted to determine if the consent of patients who have expressed interest in receiving offers, and who have been identified by their centers as likely to benefit from these less-than-ideal organs, impacts organ allocation, efficiency, and utilization. We assessed the impact of allocation policy changes as well as the impact of using the KDPI label on the utilization of these deceased donor kidneys.
Methods
This study used data from the Scientific Registry of Transplant Recipients (SRTR). The SRTR data system includes data on all donors, wait-listed candidates, and transplant recipients in the US, submitted by the members of the Organ Procurement and Transplantation Network. The Health Resources and Services Administration, US Department of Health and Human Services provides oversight to the activities of the Organ Procurement and Transplantation Network and SRTR contractors. The data reported here have been supplied by the Hennepin Healthcare Research Institute as the contractor for the SRTR. The interpretation and reporting of these data are the responsibility of the author(s) and in no way should be seen as an official policy of or interpretation by the SRTR or the US Government. This study used potential transplant recipient match run data and the standard analysis files from the SRTR as of March 2023. All analyses were performed in Stata MP version 17.0 (StataCorp, College Station, TX). This study was approved by the Columbia University Irving Medical Center Institutional Review Board. The study activities are consistent with the principles of the Declaration of Istanbul.
We identified all match runs for deceased donor kidneys in the US from 2012 through 2022. We excluded offers to candidates listed at the same center for kidney-pancreas or another solid organ at any time during their kidney waitlisting period. We excluded automatically bypassed offers except for those with refusal codes 883: minimum acceptance criteria not met, and 886: offer filters criteria met, which correspond to centers’ voluntary offer filters that are self-selected to help streamline the allocation process. Pediatric recipients aged < 18 years at the time of transplant were excluded. Using each year’s respective scaling factors to calculate KDPI, kidney offers in the study cohort were categorized into the following 4 groups: (i) KDPI < 80% (standard quality organs), (ii) 80% to 85% (representing the worst quality of the non–“high KDPI” organs), (iii) 86% to 90% (representing the best quality of the “high KDPI” or low quality organs), and (iv) > 90% (the lowest quality organs).
Incident Waitlisted Candidates who Received High KDPI Offers
We examined all incident waitlisted candidates who received at least 1 high KDPI offer for a kidney that was eventually transplanted (N = 134,439 patients). Candidates were grouped into 5 categories based on their outcome during the study period as follows: (i) received a deceased donor transplant, (ii) received a living donor transplant, (iii) died without undergoing a transplant, (iv) removed from the waitlist (due to deteriorating condition, transfer to another center, inability to be contacted, or for a reason other than death or transplant), or (v) still awaiting a transplant by the end of the study period. We evaluated the range of KDPI among their organ offers, including the KDPI of their first offer and their last offer. For transplant recipients, the KDPI of their last offer would be the KDPI of their final accepted offer. We also examined the number of high KDPI kidney offers received before candidates’ outcomes.
Transplanted Kidneys
Among all transplanted kidneys in the study cohort (n = 138,242 kidneys), we quantified the number of organs allocated to the top-ranked candidate in each KDPI group. For each organ, we quantified the total number of candidates who declined the offer for that kidney before the transplant event.
Organ Offer Acceptance and Consent Rates for High KDRI or KDPI Kidneys
We assessed the variation in consent rates for high KDPI kidneys, stratified by transplant center, among prevalent waitlisted patients and compared these consent rates with the organ offer acceptance rates for high KDRI kidneys as reported by the SRTR in the July 2023 program specific reports. Given that most individuals who opt-in to being considered for less-than-ideal kidneys do so at the time of initial listing, we looked at the proportion of individuals opting in by the year of waitlisting. To account for possible variability from low-volume transplant centers, we assessed high KDPI consent and organ offer acceptance rates among only centers within the top 3 quartiles by volume.
Results
Incident Waitlisted Candidates who Received High KDPI Offers
Among 134,439 incident, waitlisted candidates who received at least 1 high KDPI offer from 2012 to 2022, 49,175 (36.6%) received a deceased donor transplant, 15,029 (11.2%) received a living donor transplant, 13,932 (10.4%) died without undergoing a transplant, 24,367 (18.1%) were removed from the waitlist, and 31,936 (23.7%) were still awaiting a transplant by the end of 2022 (Table 1). Overall, candidates’ offers ranged from a minimum KDPI of 9% (4%–19%) to a maximum of 96% (91%–99%), and candidates received a median of 3 (IQR: 1-10) high KDPI offers before their outcome.
Table 1.
KDPI of kidney offers among incident waitlist candidates who received at least 1 high KDPI (> 85%) offer in 2012 to 2022
| Median (IQR) | Total |
Deceased donor transplant |
Living donor transplant |
Died on waitlist |
Removed from waitlist |
Remained on waitlist |
|---|---|---|---|---|---|---|
| N = 134,439 | n = 49,175 (36.6%) | n = 15,029 (11.2%) | n = 13,932 (10.4%) | n = 24,367 (18.1%) | n = 31,936 (23.7%) | |
| Number of offers before event | 38 (15–86) | 35 (14–79) | 16 (7–35) | 35 (14–79) | 35 (16–74) | 69 (30–139) |
| Number of high KDPI offers before event | 3 (1–10) | 3 (1–10) | 2 (1–5) | 4 (2–12) | 4 (2–12) | 4 (1–13) |
| Lowest KDPI offered | 9 (4–19) | 10 (4–20) | 14 (6–28) | 11 (5–20) | 10 (5–20) | 5 (3–14) |
| Highest KDPI offered | 96 (91–99) | 95 (90–99) | 94 (90–98) | 97 (91–99) | 97 (91–99) | 96 (90–98) |
| KDPI of first offer | 64 (45–81) | 64 (45–82) | 65 (45–83) | 66 (46–82) | 64 (45–82) | 63 (44–78) |
| KDPI of first high KDPI offer | 90 (88–94) | 90 (88–94) | 90 (88–94) | 91 (88–94) | 91 (88–94) | 91 (87–95) |
| KDPI of last offer | 61 (38–80) | 56 (34–77) | 67 (46–84) | 67 (47–82) | 66 (46–83) | 58 (35–75) |
IQR, interquartile range; KDPI, Kidney Donor Profile Index.
Although patients who died and patients who had a deceased donor transplant received the same number of offers before their event (35 [14–79], P = 0.22), as well as initial organ offers of similar quality (KDPI: 66% [46%–82%] vs. 64% [45%–82%], P = 0.32), patients’ last offers were significantly different between the groups (KDPI: 67% [47%–82%] vs. 56% [34%–77%], P < 0.001).
Transplanted Kidneys
We examined 138,242 deceased donor kidney transplants occurring from 2012 through 2022. Of the transplants, 120,275 (87%) were from KDPI < 80% kidneys, 7031 (5%) from KDPI of 80% to 85% kidneys, 4847 (4%) from KDPI of 86% to 90% kidneys, and 6089 (4%) from KDPI > 90% kidneys (Figure 1 and Supplementary Table S1).
Figure 1.
Temporal trends in transplants of the highest KDPI kidneys. KDPI, Kidney Donor Profile Index.
Among standard quality kidneys, the proportion of organs placed with the candidate at the top of the match run decreased during the study period from 24% of recipients in 2014 to 18% in 2015 following changes to the allocation system and decreased further to only 12% in 2022 after the introduction of KAS250 (Figure 2). Similarly, among transplants of kidneys with KDPI of 80% to 85%, 15% were transplanted into the top-ranked candidate compared with 8% in 2015 and 4% in 2022. Among transplants with KDPI of 86% to 90% kidneys, representing the best quality among high KDPI organs, 10% of recipients in 2014 were top-ranked candidates compared with 5% in 2015 and 4% in 2022. Among transplants with KDPI > 90% kidneys, 15% of recipients in 2014 were top-ranked candidates compared with 4% in 2015, dropping to a low of just < 3% in 2022.
Figure 2.
Temporal trends in the proportion of kidneys placed with top-ranked candidates. The black vertical lines indicate KAS policy changes in 2014 and KAS250 in 2021, respectively. KAS, Kidney Allocation System; KDPI, Kidney Donor Profile Index.
Overall, the median number of declined offers for transplanted kidneys increased from 3 (IQR: 0–10) at the start of the study period to 9 (IQR: 2–47) at the end of the study period (Figure 3). Annual trends among KDPI > 90% kidneys, the lowest quality organs, showed successive increases in the median number of declined offers, with the most dramatic effect noted after the introduction of KAS (8 [IQR: 2–90] in 2014 vs. 53 [IQR: 9–199] in 2015), and again after KAS250 (64 [IQR: 18–255] in 2021 vs. 83.5 [IQR: 22–385.5] in 2022). KDPI of 86% to 90% kidneys showed similar increases in declined offers following KAS (11 [IQR: 2–52] in 2014 vs. 21.5 [IQR: 6–109] in 2015), and then again after the introduction of KAS250 (40.5 [IQR: 9–192] in 2021 vs. 52 [IQR: 12–323] in 2022). In contrast, there was no discernible change in the number of declined offers for transplanted kidneys of KDPI < 80%. Kidneys in the KDPI of 80% to 85% range experienced a small uptick in the median number of offers necessary before an organ could be successfully transplanted after KAS, but a more notable increase was seen associated with the introduction of KAS250.
Figure 3.
Temporal trends in the median number of declined offers for kidneys before transplant. The black vertical lines indicate KAS policy changes in 2014 and KAS250 in 2021, respectively. Offers which correspond to voluntary center-selected bypass filter criteria are included in the count of declined offers. KAS, Kidney Allocation System; KDPI, Kidney Donor Profile Index.
Organ Offer Acceptance and Consent Rates for High KDRI or KDPI Kidneys
There was considerable center-level variation in the proportion of patients who have consented to high KDPI kidneys. Consent rates varied from 0% to 100%, with a median of 6% consented across 310 transplant centers (Figure 4a). The proportion of patients consented to receive KDPI > 85% kidneys by year of waitlisting increased steadily from 36% in 2015 to 41% in 2022 (Figure 4b). These proportions remained unchanged when excluding low-volume transplant centers, with no significant relationship between centers’ high KDPI consent rates and their offer acceptance ratios (Supplementary Figure S1).
Figure 4.
The relationship between center-level proportion of candidates consented to high KDPI kidneys among the prevalent waitlist population and the SRTR-reported center-level offer acceptance ratio for high KDRI kidneys. (a) The red line references an offer acceptance ratio of 1. (b) The proportion of the prevalent population that consented to high KDPI kidneys has been relatively stable, except lower rates in 2014 to 2015, which were likely a function of the recent introduction and implementation of the KAS in late 2014. KAS, Kidney Allocation System; KDPI, Kidney Donor Profile Index; SRTR, Scientific Registry of Transplant Recipients.
Discussion
Patients with end-stage kidney disease have a clear benefit from transplant compared with dialysis; however, an increasing proportion of organ offers are declined by transplant centers on behalf of their patients. Many of these patients eventually die or are removed from the national waitlist without receiving a kidney transplant.
It is important to note that only individuals who have opted in to receive offers for high KDPI kidneys are included on the match run for these organs with KDPI > 85%. In other words, these individuals have presumably been identified by transplant centers as likely to benefit from these organs and have indicated, via written consent, a willingness to accept these kidneys. This preselection of patients should make the process of organ placement more efficient, yet we see that high KDPI organs are placed much lower in the allocation sequence, suggesting decreased allocation efficiency. This finding suggests that perhaps centers are consenting patients for high KDPI organs even when they are not completely convinced that accepting a marginal kidney more quickly would be in the patient’s best interest. This phenomenon may explain the fact that centers with the highest rates of consent for high KDPI organs tend to have some of the lowest organ offer acceptance rates for these organs and that there is no real relationship between the proportion of candidates consented to high KDPI organs and the willingness of the center to accept these organs. Alternatively, centers may be actively overlooking the clearly stated preference of the patient to be considered for these less-than-ideal kidneys, declining these offers on the patient’s behalf.11
It is notable that centers that have the highest rate of consent for high KDPI kidneys are among those with the lowest acceptance rates of high KDPI organs. In contrast, centers that have the highest acceptance rates of these organs have much lower consent rates, suggesting a more judicious approach to the selection of patients who have consented to these organs, consistent with the original intent of this pathway. If all transplant centers were to do this, we would have, in essence, a true expedited pathway for high KDPI kidneys with a match run that exclusively includes patients who will benefit from these organs and have already consented to accepting them. This would represent a true transparent expedited pathway that is accessible to all centers and patients allowing for appropriate utilization while ensuring equitable access, unlike the current out of sequence allocation processes.3,12, 13, 14, 15
Our analysis shows that deceased donor kidneys with a KDPI > 85% are clearly viewed as less desirable, as evidenced by the dramatic increase in the number of offers declined for these organs that are eventually accepted for transplant. The sharp uptick in declined offers in 2014, coinciding with the introduction of the percentile score, suggests a labeling effect. Before 2014, consent for marginal organs was applied to “extended criteria donor” kidneys rather than those with high KDPI. Though the KDPI is a continuous scale that incorporates more donor characteristics than the dichotomous extended criteria donor classification, there is a significant overlap between these 2 classifications of less-than-ideal donor organs. As a result, the stable organ offer acceptance rates of kidneys that meet the high KDPI definition but were not all labeled as extended criteria donor provides an approximation of the desirability of these organs before the introduction of the KDPI labels. In other words, the frameshift of using a percentile score to evaluate an organ in terms of relative risk of graft failure for the patient, relative to other organs, appears to have increased the reluctance to use these organs.
The more recent uptick in offer declines for high KDPI kidneys coincided with the introduction of KAS250, suggesting that a sharp increase in organ offers in the new allocation system has exacerbated reluctance to use these kidneys, especially for individuals who have gained significant allocation priority. This is similar to what is observed for even lower KDPI kidneys in the national allocation system.16 Although KDPI of 86% to 99% represents a large range of organ quality, our analysis demonstrates similar but somewhat attenuated increases in organ offer declines for the “highest quality” among these high KDPI organs.
The current failure of the high KDPI consent process to improve allocation efficiency raises some important logistical and implementation concerns. Transplant centers should be encouraged to only consent patients who they truly believe would benefit from these organs, rather than having every patient opt-in because of fear of missing out.17 Improving the high KDPI consent process may be preferable to eliminating it altogether, because elimination would result in every candidate being included on the match run for these organs, further diminishing the efficiency of allocation for these organs.
In general, the majority of offers are being declined without input from the intended patient.17,18 This is true for high KDPI kidneys as well, even though the intended recipients have actively indicated their preference by providing written consent for these organs. Taken together, this raises concerns about how patient preferences are being considered in the acceptance of organ offers.11,19
There are limitations to our analysis. The data used shows whether patients consented to receiving an offer for a high KDPI kidney but may not reflect other variations in practice patterns that exist within centers that may help explain the low organ offer acceptance rates among centers with the highest rates of consent. Transplantation is a multistep process involving different physicians and coordinators, who may have different workflow perspectives and logistical constraints regarding high KDPI kidneys, both within and between centers.19,20 For example, the person consenting the patient for a high-KDPI kidney and the person evaluating the organ offer might be misaligned in their risk or value assessments. We should also note that the expected cold ischemia time influences organ offer acceptance but currently this data is not available, limiting our ability to account for it in our analysis. However, we should note that while cold ischemia times are important, they should not adversely impact the willingness to accept an organ offer early in the allocation process.21
In summary, we demonstrate a clear change in the willingness to accept high KDPI kidneys with the introduction of the KDPI label by KAS in 2014, as well as changes that appear to coincide with changes in allocation policy, along with the changes in regulatory measures for organ procurement organizations and transplant centers. This highlights the detrimental effect of a label that shifts the frame of reference by providing the relative quality of the organ to other organs, rather than the quality of the organ to the patient. In addition, we show that the KDPI opt-in process does not appear to have contributed to an improved or more efficient allocation system as currently implemented, nor does it appear to improve engagement with waitlisted patients in the organ acceptance process. Our findings suggest the need to revise our system for allocating high KDPI kidneys by encouraging transplant centers to limit the consent to patients who are likely to have a survival benefit with these organs. This would potentially improve allocation efficiency by expediting the allocation of these organs to the appropriate patients in a timely manner, thereby creating a true expedited pathway for marginal organs that remains objective, transparent and equitable.
Disclosure
SM receives grant funding from the NIH, and personal fees from Sanofi, Kidney International Reports, Specialist Direct and Health Services Advisory Group, outside of the submitted work; and was Chair of the UNOS Data Advisory Committee and Board Member for the Alliance for Organ Donation and Transplantation. JDS reports consultancy for eGenesis and Sanofi Corporation; research funding from the Department of Defense, Gift of Life Foundation, Kidney Transplant Collaborative, NIH/NIDDK, and One Legacy Foundation; honoraria from eGenesis and Sanofi Inc.; advisory or leadership roles as a member of the Data Safety Monitoring Board for Bristol Myers Squibb and Chair of the UNOS Data Advisory Committee; and a speaker bureau for Sanofi. SAH reports funding from the NIH and being a member of the National Kidney Foundation Transplant Advisory Council. All the other authors declared no competing interests.
Acknowledgments
This work was partly supported by Health Resources and Services Administration contract 234-2005-370011C. The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government.
Funding
SM was supported by NIH grants DK114893, DK116066, DK126739, DK130058 and MD014161 and a Nelson Family Faculty Development Award. SAH was supported by NIDDK grant K23DK133729 and a Nelson Family Faculty Development Award. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Data Availability Statement
The data that support the findings of this study are available on request from the Scientific Registry of Transplant Recipients (SRTR). Restrictions apply to the sharing of these data due to privacy or ethical restrictions.
Author Contributions
SM conceptualized the study. SM, SAH, and JDS were responsible for data curation and methodology. MY was responsible for formal analysis and visualization. SM was responsible for funding acquisition, resources, and supervision. SM, MY, and LM were responsible for writing the original draft. All the authors reviewed and edited the manuscript.
Footnotes
Figure S1. The relationship between center-level proportion of candidates consented to high Kidney Donor Profile Index (KDPI) kidneys in the prevalent waitlist population and the Scientific Registry of Transplant Recipients (SRTR)-reported center-level offer acceptance ratio for high Kidney Donor Risk Index (KDRI) kidneys, excluding transplant centers in the lowest quartile by volume.
Table S1. The number of kidneys recovered, transplanted, and discarded among the highest Kidney Donor Profile Index (KDPI) kidneys within the study cohort.
STROBE checklist.
Supplementary Material
Figure S1. The relationship between center-level proportion of candidates consented to high Kidney Donor Profile Index (KDPI) kidneys in the prevalent waitlist population and the Scientific Registry of Transplant Recipients (SRTR)-reported center-level offer acceptance ratio for high Kidney Donor Risk Index (KDRI) kidneys, excluding transplant centers in the lowest quartile by volume. Table S1. The number of kidneys recovered, transplanted, and discarded among the highest Kidney Donor Profile Index (KDPI) kidneys within the study cohort. STROBE checklist.
References
- 1.Schold J.D., Mohan S., Huml A., et al. Failure to advance access to kidney transplantation over two decades in the United States. J Am Soc Nephrol. 2021;32:913–926. doi: 10.1681/ASN.2020060888. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.King K.L., Husain S.A., Schold J.D., et al. Major variation across local transplant centers in probability of kidney transplant for wait-listed patients. J Am Soc Nephrol. 2020;31:2900–2911. doi: 10.1681/ASN.2020030335. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Adler J.T., Husain S.A., King K.L., Mohan S. Greater complexity and monitoring of the new Kidney Allocation System: implications and unintended consequences of concentric circle kidney allocation on network complexity. Am J Transplant. 2021;21:2007–2013. doi: 10.1111/ajt.16441. [DOI] [PubMed] [Google Scholar]
- 4.Cron D.C., Husain S.A., King K.L., Mohan S., Adler J.T. Increased volume of organ offers and decreased efficiency of kidney placement under circle-based kidney allocation. Am J Transplant. 2023;23:1209–1220. doi: 10.1016/j.ajt.2023.05.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Puttarajappa C.M., Hariharan S., Zhang X., et al. Early effect of the circular model of kidney allocation in the United States. J Am Soc Nephrol. 2022;34:26–39. doi: 10.1681/ASN.2022040471. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Israni A.K., Salkowski N., Gustafson S., et al. New national allocation policy for deceased donor kidneys in the United States and possible effect on patient outcomes. J Am Soc Nephrol. 2014;25:1842–1848. doi: 10.1681/ASN.2013070784. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Husain S.A., King K.L., Pastan S., et al. Association between declined offers of deceased donor kidney allograft and outcomes in kidney transplant candidates. JAMA Netw Open. 2019;2 doi: 10.1001/jamanetworkopen.2019.10312. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.King K.L., Husain S.A., Yu M., Adler J.T., Schold J., Mohan S. Characterization of transplant center decisions to allocate kidneys to candidates with lower waiting list priority. JAMA Netw Open. 2023;6 doi: 10.1001/jamanetworkopen.2023.16936. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Mohan S., Husain S.A. Improving the utilization of deceased donor kidneys by prioritizing patient preferences. Clin J Am Soc Nephrol. 2022;17:1278–1280. doi: 10.2215/CJN.08500722. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Cron D.C., Husain S.A., Adler J.T. The new distance-based kidney allocation system: implications for patients, transplant centers, and organ procurement organizations. Curr Transplant Rep. 2022;9:302–307. doi: 10.1007/s40472-022-00384-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Husain S.A., Brennan C., Michelson A., et al. Patients prioritize waitlist over posttransplant outcomes when evaluating kidney transplant centers. Am J Transplant. 2018;18:2781–2790. doi: 10.1111/ajt.14985. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.King K.L., Husain S.A., Perotte A., Adler J.T., Schold J.D., Mohan S. Deceased donor kidneys allocated out of sequence by organ procurement organizations. Am J Transplant. 2022;22:1372–1381. doi: 10.1111/ajt.16951. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Yu M., Husain S.A., Adler J.T., Maclay L., Schold J.D., Mohan S. Out-of-sequence placement of deceased donor kidneys is exacerbating inequities. J Am Soc Nephrol. 2024;35 doi: 10.1681/ASN.2024yww8epy2. [DOI] [Google Scholar]
- 14.Tucker E.G., Yu M.E., Adler J.T., et al. Underrecognition of deceased donor kidney out-of-sequence allocation due to increasing use of free-text coding. Am J Transplant. 2025 doi: 10.1016/j.ajt.2025.04.002. S1600-6135(25)00173-X. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Cron D.C., Husain S.A., Kuk A.E., Mohan S., Adler J.T. Increasing incidence of out-of-sequence allocation of deceased-donor kidneys. Kidney360. 2025;360:145–149. doi: 10.34067/KID.0000000640. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Mohan S., Yu M., King K.L., Husain S.A. Increasing discards as an unintended consequence of recent changes in United States kidney allocation policy. Kidney Int Rep. 2023;8:1109–1111. doi: 10.1016/j.ekir.2023.02.1081. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Roll G.R., Hirose R. Toward a more efficient organ placement system (and defeating FOMO) Am J Transplant. 2022;22:1511–1512. doi: 10.1111/ajt.17004. [DOI] [PubMed] [Google Scholar]
- 18.Mohan S., Chiles M.C. Achieving equity through reducing variability in accepting deceased donor kidney offers. Clin J Am Soc Nephrol. 2017;12:1212–1214. doi: 10.2215/CJN.06220617. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Mohan S., Foley K., Chiles M.C., et al. The weekend effect alters the procurement and discard rates of deceased donor kidneys in the United States. Kidney Int. 2016;90:157–163. doi: 10.1016/j.kint.2016.03.007. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.King K.L., Husain S.A., Cohen D.J., Mohan S. Deceased donor kidneys are harder to place on the weekend. Clin J Am Soc Nephrol. 2019;14:904–906. doi: 10.2215/CJN.00620119. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Mohan S., Schold J.D. Accelerating deceased donor kidney utilization requires more than accelerating placement. Am J Transplant. 2022;22:7–8. doi: 10.1111/ajt.16866. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Figure S1. The relationship between center-level proportion of candidates consented to high Kidney Donor Profile Index (KDPI) kidneys in the prevalent waitlist population and the Scientific Registry of Transplant Recipients (SRTR)-reported center-level offer acceptance ratio for high Kidney Donor Risk Index (KDRI) kidneys, excluding transplant centers in the lowest quartile by volume. Table S1. The number of kidneys recovered, transplanted, and discarded among the highest Kidney Donor Profile Index (KDPI) kidneys within the study cohort. STROBE checklist.
Data Availability Statement
The data that support the findings of this study are available on request from the Scientific Registry of Transplant Recipients (SRTR). Restrictions apply to the sharing of these data due to privacy or ethical restrictions.