Changes to the US kidney allocation system approved in 2019 could result in worsening geographic disparities in access to a kidney transplant (KT) when measured against the burden of end-stage kidney disease (ESKD) within a particular region, according to investigators.

“Paradoxically, the largely urban areas with much higher transplant rates gain from the new allocation policy, whereas rural areas with low transplant rates, vulnerable patient populations, and a much higher ESKD burden lose access to deceased donor organs,” Derek A. DuBay, MD, of the Medical University of South Carolina in Charleston, and colleagues concluded in a paper published online ahead of print in JAMA Surgery.

The changes to allocation policy, which were approved by the Organ Procurement and Transplantation Network (OPTN), were meant to address geographic inequities in waiting time for a deceased donor kidney transplant. OPTN had argued that the allocation system failed to minimize geographic location in the prioritization of distribution of available organs, Dr DuBay and colleagues pointed out. Research has shown that geographic location remains the factor most associated with transplant access.

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“Our analysis demonstrates that states with the lowest transplant rates normalized for ESKD burden will not benefit from the changes by the OPTN, and several are projected to experience significant decreases in kidney organ allocation volume,” the investigators wrote.

They also observed, “Until the playing field is level, it is important for the OPTN to not create policies that potentially worsen disparities in access to transplant.”

Dr DuBay’s team conducted a cross-sectional population-based economic evaluation in a study that included 122,659 patients with ESKD. They estimated the probability of a patient with ESKD being placed on the transplant wait list or receiving a deceased donor kidney transplant. The investigators compared states and donor service areas (DSAs) with respect to gains and losses in rates of transplant kidneys under the revised allocation system. They normalized transplant rates for ESKD burden.

As a result of the policy changes, Dr DuBay’s team estimates that New York City had the largest increase (124%) and Nevada had the greatest decrease (-74%) in allocation of deceased donor kidneys of any DSA in the United States in 2017. The probability of a patient with ESKD receiving a deceased donor kidney transplant during 2017 ranged from 6.36% in West Virginia to 18.68% in the District of Columbia.

“Regrettably, ESKD burden is completely ignored in the changes approved by the OPTN to the kidney allocation system in late 2019,” Dr DuBay and colleagues wrote. “This is an especially important principle for regions of the US with long-standing racial and socioeconomic disparities in transplant waiting list registrations, the starting point for the approved allocation changes.”

In a statement issued in response to the study, the United Network for Organ Sharing, a nonprofit organization that serves as the OPTN under contract with the federal government, said the organization strives “to improve the equitable allocation of organs to patients on the waiting list no matter where they live. The kidney allocation policy is expected to improve equity and access for candidates nationwide who are listed for kidney transplantation.”

As the study authors point out, however, only local physicians and transplant centers can assess and list patients for transplantation, the UNOS statement reads.

“Additionally, we agree with the authors that the ideal solution to mitigate disparities in access to transplantation is to improve health care infrastructure throughout the US. We support improving access to the waiting list and have initiated a significant research effort designed to identify factors that drive inequities in access to transplantation.”


DuBay DA, Morinelli TA, Su Z, et al. Association of high burden of end-stage kidney disease with decreased kidney transplant rates with the updated US kidney allocation policy. JAMA Surg. Published online May 26, 2021. doi:10.1001/jamasurg.2021.1489