Objective: This study evaluates the impact of the UNOS kidney allocation policy change requiring offers be made first to candidates at transplant hospitals within a 250-mile nautical radius of the donor hospital based on median allocation time expended by one large OPO with 78 transplant centers (including 14 local centers) that span 5 UNOS regions and 15 DSAs within its primary sharing radius.

Methods: This was a single OPO, multi-center observational study. Renal distribution time (RDT) defined as the time from donor cross-clamp to when a kidney is available to a center for a specific recipient including complete donor information and a compatible final cross match was evaluated for kidneys allocated 12 months pre and post policy change.  Median RDT and utilization rates were evaluated for kidneys with KDPI < 60% and kidneys with KDPI >= 60%. The OPO continued hardwired best practices pre-recovery post policy change that included transplant center review of the offer, confirming patient(s) readiness and a final cross match for at least 5 candidates prior to recovery. The OPO also required an understanding with the accepting center at final kidney acceptance including confirmation of patient status, intent for pulsatile preservation, identified center back up patients and timing of transplant surgery.

Results: Between 3/15/2020 and 3/14/2021 pre policy change, the OPO recovered 1171 kidneys with a 73% utilization rate resulting in the transplantation of 859 kidneys. Between 3/15/2021 and 3/14/2022 post policy change, the OPO recovered 1336 kidneys with a 75% utilization rate resulting in the transplantation of 1005 kidneys. The proportion of kidneys placed locally decreased from 60% to 23% X2 (1, N = 1864) = 253.0262, p < 0.01. Median RDT for kidneys with KDPI >= 60% increased significantly from 6.4 hours to 9.5 hours.

Conclusions: OPOs face increased challenges executing efficient kidney allocation, interacting with more centers per donor. Increased RDTs can be attributed to the number of transplant centers and patients within 250 nautical miles, increased interactions between OPOs and transplant centers, and transplant center use of third-party services that insulate the surgeon or nephrologist.