Case Studies
Case studies showcase real-world applications of policies and innovations, offering insights into improving outcomes and efficiency. They enhance problem-solving skills, highlight best practices, and engage through storytelling for education and transparency.
Interest(s): Advanced Practice Professionals, Brain Death / Death by Neurologic Criteria, Donation after Circulatory Death (DCD), Donor Management, Electronic Medical Records (EMR), Emerging Technology, Growth in Transplantation, Innovation, Marginal / Increased Risk Organs, Organ Allocation (Offer and Acceptance), Organ Preservation and Perfusion, Organ Transportation / Logistics, Patient Safety, Quality Assurance and Performance Improvement (QAPI)
Organ(s): Kidney
Patient Group(s): Adult
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Early Impact of a Revised Expedited Kidney Allocation Pathway on Placement Patterns and Sequence Integrity in Partnership with Transplant Centers
Geoffrey
Funk
, Southwest Transplant Alliance
The Challenge
In early 2025, one organ procurement organization (OPO) implemented a revised, evidence-based expedited kidney allocation pathway designed to reduce organ discard and improve timely and equitable placement of kidneys at risk of non-use while maintaining the integrity of the list. This pathway prioritizes potential recipients most in need by offering organs to patients at the top of the match run (with difficult match characteristics). Thereafter, patients at transplant programs with demonstrated histories of accepting higher-risk organs in the form of the top ten regional and then top ten national programs (if necessary) are prioritized in a data-driven approach. This necessarily required the engagement of transplant surgeons at these centers to evaluate the organ for all potential recipients. This study evaluates the impact of this process on organ non-utilization, kidney characteristics, allocation geography and sequence number to assess early trends in efficiency and utilization.
The Approach
With the bi-annual release of SRTR data, the OPO performs a sum-of-ranks methodology to assess each transplant center’s acceptance patterns, factoring in their willingness to accept hard-to-place kidneys and adjusted for geographic considerations. We then compared the clinical profiles of kidneys transplanted through the expedited pathway. examined key donor risk factors—age, Kidney Donor Profile Index (KDPI), Kidney Donor Risk Index (KDRI), terminal creatinine, donation after cardiopulmonary death (DCD), history of alcohol or cigarette use, diabetes, and hypertension. Student’s t tests and Fisher’s exact tests were used; missing values were excluded. Placement geography was categorized as local (within the OPO’s designated service area), regional (within the OPTN-defined region), or national (outside the region). Chi-square and Fisher’s exact tests were used for categorical comparisons, and the Wilcoxon test was used to compare allocation sequence numbers due to skewness. Significance was determined at α = 0.05. Kidneys recovered and allocated through this expedited pathway were compared before (1/1/2024–12/31/2024) and after (1/1/2025–3/31/2025) this expedited process was instituted.
The Results
Compared to the pre-policy period, kidneys accepted post-revision had significantly higher KDPI (+14.6%, p = .0003), higher KDRI (+0.23, p = .0001), and older donor age (+5.3 years, p = .0204), suggesting a shift toward acceptance of kidneys previously deemed marginal or even “non-transplantable”. No statistically significant differences were observed in many historically used donor risk variables between the groups (see Table 1). In 2024, only 42% of kidneys utilizing the expedited pathway were transplanted. Among those transplanted, 49% were placed locally, 24% regionally, and 27% nationally. In the first quarter of 2025, 49% of kidneys utilizing the new expedited pathway were transplanted. Of those transplanted, 60% were placed locally, 17% regionally, and 23% nationally. The shift in geographic distribution was not statistically significant (χ²(2, N = 304) = 2.27, p = .3222; Fisher’s exact p = .3699). However, the median match run sequence number decreased significantly from 385 to 95.5 (p = .0111), indicating more equitable placement of organs.
Insights & Lessons Learned
The revised expedited kidney allocation pathway is showing early effectiveness as evidenced by a 7% reduction in non-utilization rate and a statistically significant decrease in median sequence number by 290. This is inclusive of an increased effort to transplant kidneys more at-risk from both the OPO and transplant center perspective. Although the geographic distribution of allocations has not significantly changed, the earlier placement of kidneys on the match run suggests that the revised system is improving timely access to transplantable organs without bypassing organ allocation policies. Continued evaluation will be critical to ensure the policy’s alignment with equitable allocation standards and long-term transplant outcomes. Initial findings suggest that the revised expedited allocation policy is facilitating the transplant of kidneys with higher KDPI and donor age, organs that might otherwise have been discarded. These results indicate early success in balancing urgency with quality and transparency. Ongoing monitoring is essential to ensure equitable access, appropriate utilization, and alignment with national allocation standards.