Associations between OPOs' Responses to Scrutiny about Out of Sequence Allocation and Changes in Deceased Donor Kidney Transplantation.

Abstract

U.S. organ procurement organizations allocate select deceased donor kidneys "out-of-sequence" (AOOS) by offering a kidney judged at risk of nonuse to a chosen center instead of according to the in-sequence allocation list. In 2025, AOOS practices were scrutinized by the media (February 26: high profile news article) and regulators (August 5: OPTN email deeming AOOS "not consistent with OPTN policy"). Using OPTN data from 1/1/24-2/26/25 ("pre-article") and 8/6/25-2/28/26 ("post-email"), we studied the association between OPO-level changes in AOOS and kidney transplant activity. Kidney transplant volume fell by 7% for the 33 OPOs with large AOOS reductions but rose by 1% for the other 22 OPOs, a statistically significant difference in changes (p=0.0007). Though DCD kidney recovery volume rose by just 1% for large-AOOS-drop OPOs, it rose by 14% among other OPOs (interaction p<0.0001). By contrast, cross-era changes in the probability of offered and recovered kidneys being transplanted did not differ between OPO groups. The non-use rate among recovered kidneys did not increase, suggesting any negative effects of restricting AOOS on kidney transplant volume were mediated by fewer kidney recoveries, not by increased difficulty in placing recovered kidneys. Scrutiny into AOOS practices may have led to fewer kidney transplants.