New National Allocation Policy for Deceased Donor Kidneys in the United States and Possible Effect on Patient Outcomes

TLDR

The 2013 national deceased donor kidney allocation policy introduced the kidney donor profile index (KDPI), a 0–100 % score based on ten donor factors, and lower KDPI scores are linked to better post‑transplant survival. The policy prioritizes kidneys with KDPI ≤ 20 % to candidates in the top 20 % of estimated post‑transplant survival, incorporates dialysis initiation time, grants priority points for CPRA > 19 %, expands sharing for CPRA ≥ 99 % and KDPI > 85 %, eliminates the payback system, and allocates A2/A2B kidneys to blood type B candidates, as evaluated by simulation. Simulations predict the policy increases median allograft life by 0.25 years, improves transplant likelihood for highly sensitized, blood type B, and younger (18–49) candidates, while slightly reducing access for those aged ≥ 50, with minimal impact on racial/ethnic equity.

Abstract

In 2013, the Organ Procurement and Transplantation Network in the United States approved a new national deceased donor kidney allocation policy that introduces the kidney donor profile index (KDPI), which gives scores of 0%-100% based on 10 donor factors. Kidneys with lower KDPI scores are associated with better post-transplant survival. Important features of the new policy include first allocating kidneys from donors with a KDPI≤20% to candidates in the top 20th percentile of estimated post-transplant survival, adding waiting time from dialysis initiation, conferring priority points for a calculated panel-reactive antibody (CPRA)>19%, broader sharing of kidneys for candidates with a CPRA≥99%, broader sharing of kidneys from donors with a KDPI>85%, eliminating the payback system, and allocating blood type A2 and A2B kidneys to blood type B candidates. We simulated the distribution of kidneys under the new policy compared with the current allocation policy. The simulation showed increases in projected median allograft years of life with the new policy (9.07 years) compared with the current policy (8.82 years). With the new policy, candidates with a CPRA>20%, with blood type B, and aged 18-49 years were more likely to undergo transplant, but transplants declined in candidates aged 50-64 years (4.1% decline) and ≥65 years (2.7% decline). These simulations demonstrate that the new deceased donor kidney allocation policy may improve overall post-transplant survival and access for highly sensitized candidates, with minimal effects on access to transplant by race/ethnicity and declines in kidney allocation for candidates aged ≥50 years.