To the Editor:
Schold et al.1 showed that deceased-donor kidney offers were highly concentrated in the US—15% of candidates received 55% of offers, the median was 17, and high-frequency candidates received at least 74 offers. Their 2021 to 2024 analysis excluded bypassed match-run appearances, included only kidneys ultimately transplanted, and excluded candidates with no offer.
We examined kidney-alone candidate registrations eligible for Eurotransplant standard allocation from January 2021 through December 2023. Among 26,187 registrations, 15,756 (60.2%) received at least 1 potential offer. Offers were similarly concentrated—the top 15% of exposed registrations accounted for 51% of 103,791 potential offers. The median was 4 during the available 3-year Eurotransplant window versus 17 during the 4-year US study window, and only 13 registrations reached at least 74 potential offers.
Our permissive potential-offer definition required only a filtered match-list position above the eventual recipient and did not necessarily indicate a patient-specific transplant opportunity. Only 17,299 events resulted in center contact and 16,344 in a patient-specific offer; among registrations with at least 1 respective event, the median was 1 for both definitions (Table 1). Although the analyses are not equivalent, the markedly lower counts under formal-offer definitions are consistent with efficient organ placement within Eurotransplant, while reflecting differences in allocation rules and offer definitions.
Table 1.
Eurotransplant offer-count distributions under increasingly restrictive definitions, 2021–2024
| Offer definition | Recorded events, n | Median | p85 | p95 | Maximum |
|---|---|---|---|---|---|
| Filtered match-list appearance above eventual recipient | 103,791 | 4 | 12 | 22 | 127 |
| Center contacted | 17,299 | 1 | 3 | 5 | 58 |
| Patient-specific offer | 16,344 | 1 | 3 | 5 | 57 |
p, percentile.
Counts refer to kidney-alone standard allocation at any time during the observation period. Combined transplantation, the Acceptable Mismatch program, and rescue allocation (including recipient-oriented extended and competitive rescue allocation) were excluded. Percentiles were calculated among candidate registrations with at least 1 event under the respective definition.
Candidate records were aggregated by registration ID; relisted individuals could therefore contribute more than 1 registration. Inactive registrations did not appear on match lists and generated no offers. A filtered match-list appearance above the eventual recipient is a permissive exposure measure and does not imply that the center or candidate received a formal offer.
Offer concentration is not inherently unfair, provided that it reflects explicit allocation objectives such as waiting time. The opposite tail requires separate assessment. In Eurotransplant, 39.8% of registrations had no recorded potential offer during the study period—the group excluded from the US analysis. This heterogeneous group includes registrations with limited time at risk, but highly sensitized candidates and those with rare human leukocyte antigen phenotypes or human leukocyte antigen–D–related antigen homozygosity remain disadvantaged.2,3 Since 1996, the Eurotransplant Kidney Allocation System has awarded mismatch probability points to improve access for difficult-to-match candidates.4 Residual disparities nevertheless highlight the need for continued allocation adjustment.
Offer-frequency surveillance should therefore report both tails, distinguish match-list exposure, center contact, and patient-specific offers, and interpret them against the complementary objectives of efficient placement and equitable, transparent access.
Data Availability Statement
The aggregated summary data were derived from Eurotransplant Registry data and are reported with Eurotransplant approval. The underlying data are not publicly available because of data-protection and governance requirements.
Declaration of AI and AI-Assisted Technologies in the Writing Process
During preparation of this work, the corresponding author used OpenAI ChatGPT to assist with language editing and manuscript organization. The authors reviewed and edited the content as needed and take full responsibility for the content of the article.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The aggregated summary data were derived from Eurotransplant Registry data and are reported with Eurotransplant approval. The underlying data are not publicly available because of data-protection and governance requirements.
Declaration of AI and AI-Assisted Technologies in the Writing Process
During preparation of this work, the corresponding author used OpenAI ChatGPT to assist with language editing and manuscript organization. The authors reviewed and edited the content as needed and take full responsibility for the content of the article.