Transplant centers with discretion over kidney placement often skip candidates with the highest priority on the kidney transplant waiting list in favor of lower-ranked candidates, a new study finds.

“This introduces a subjective element into an otherwise objective allocation system with potential negative consequences for skipped candidates,” according to Sumit Mohan, MD, MPH, of Vagelos College of Physicians and Surgeons, Columbia University Medical Center in New York, New York, and colleagues.

To characterize “list diving,” the investigators studied placement of kidneys from 3136 deceased donors in 4668 recipients at 11 transplant centers during 2015-2019. These centers had a 1-to-1 relationship with their local organ procurement organization due to geographic isolation.

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Among 4668 kidney transplants, 1499 (32%) were place in the highest-ranked candidate on the match-run, whereas 3169 (68%) were placed in a lower-ranked candidate at the same center who was typically third to eighth on the waiting list, the investigators reported in JAMA Network Open.

The top-ranked candidates on the match-runs received only 44% of “high-quality” kidneys with a kidney donor profile index (KDPI) of 0% to 20%. They also received 24% of “lower-quality” kidneys with a KDPI of at least 85%.

Centers commonly cited donor age or organ quality (65%) as the reason for declining kidney offers for higher-ranked candidates. Patient refusal (16%) or immunologic concerns (11%) were less common reasons. Yet estimated posttransplant survival scores between the skipped candidates and the ultimate recipients across all KDPI categories were both better and worse, the investigators reported. They noted that delisting without transplantation and even death are possible outcomes for skipped patients.

“Future allocation policies need to take into consideration potential recipients’ characteristics and preferences in a manner that results in match runs that are viewed by clinicians as providing more appropriate organ offers for their patients,” Dr Mohan’s team wrote. “This would ideally lower or eliminate declined offers (and out-of-sequence offers) by reducing or eliminating inappropriate offers for given recipients, thus dramatically improving allocation efficiency and organ placement in a patient-centered manner.”


King KL, Husain SA, Yu M, Adler JT, Schold J, Mohan S. Characterization of transplant center decisions to allocate kidneys to candidates with lower waiting list priority. JAMA Netw Open. Published online June 1, 2023. doi:10.1001/jamanetworkopen.2023.16936