Obesity and Waitlist Access to Out-of-Sequence Deceased Donor Kidney Transplantation

In out-of-sequence (OOS) allocation of deceased donor kidney transplants (DDKTs), providers are allowed to choose recipients irrespective of waitlist priority. Whether candidate obesity affects OOS recipient selection is unknown.

We examined access to OOS-DDKT by candidate body mass index (BMI) using kidney offers from Organ Procurement and Transplantation Network data (1/2022-12/2023). We compared characteristics of OOS-DDKT versus being last-skipped candidate at the same center using donor-level conditional logistic regression and multilevel modeling among the top-20 OOS-performing centers.

We identified 4970 OOS-placements and 4588 list-skipped candidates. OOS candidates were older and less likely to be Black. We found a dose-response relationship between weight class and odds of OOS-DDKT. Compared to normal weight candidates, candidates with Class 1, 2, and 3 obesity had 32%, 50%, and 69% lower odds of receiving OOS-DDKT. Mediation analysis suggested candidate BMI partially explained higher access among Asian and Hispanic candidates. There was substantial center-level variation; a 10-unit increase in BMI was associated with >50% lower odds of OOS-DDKT at 3/20 centers, 20%-50% lower odds at 12/20 centers, and comparable odds at 5/20 centers.

DDKT candidates with obesity have lower access to OOS kidney allocation. However, equitable distribution irrespective of candidate obesity was observed at a small number of top-performing centers.