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Expedited Transplant Allocation Using a Paired Kidney Cohort
Miko E Yu1,2, S Ali Husain1,2, Emma G Tucker1,2
1Vagelos College of Physicians & Surgeons, Columbia University, New York, New York.
JAMA Network Open
|March 4, 2026
Summary
Organ procurement organizations are increasingly using expedited (out-of-sequence) kidney transplants to maximize organ utility. This study found that these transplants have similar patient and graft survival rates compared to standard in-sequence transplants.
Area of Science:
- Nephrology
- Transplant Surgery
- Public Health Policy
Background:
- Organ procurement organizations (OPOs) are increasingly utilizing expedited (out-of-sequence) deceased donor kidney allocations.
- This practice aims to maximize the utility of kidneys at risk of nonuse.
- Understanding the outcomes of these expedited transplants is crucial for optimizing organ allocation systems.
Purpose of the Study:
- To identify and compare kidney pairs from the same donor where one kidney was transplanted in sequence and the other out of sequence.
- To evaluate the incidence and survival outcomes of unilateral out-of-sequence kidney transplants.
Main Methods:
- Retrospective cohort study utilizing US kidney transplant registry data from the Scientific Registry of Transplant Recipients (SRTR).
- Analysis included deceased donors from 2020-2024 with at least one kidney transplanted out of sequence.
- Comparison of recipient demographics and survival outcomes between unilateral in-sequence and out-of-sequence kidney transplants.
Main Results:
- A total of 15,602 kidneys from 8,544 deceased donors were analyzed, with 50.5% having a unilateral out-of-sequence kidney.
- Recipients of unilateral out-of-sequence kidneys were more likely to be older, Asian, White, male, have private insurance, and receive preemptive transplants (all P < .001).
- Adjusted Cox models showed no significant difference in patient survival (HR, 0.84; P = .08) or graft survival (HR, 0.87; P = .20) for unilateral out-of-sequence transplants compared to in-sequence transplants.
Conclusions:
- Unilateral out-of-sequence kidney transplants have become more common, increasing from 97 instances in 2020 to 1,698 in 2024 across all US OPOs.
- The study highlights the importance of understanding donor and allocation factors driving these expedited transplants.
- These findings are critical for designing future organ allocation systems to improve organ use rates while maintaining patient outcomes.
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