Declining allocation out of sequence is associated with fewer kidneys recovered and transplanted

Allocation out of sequence (AOOS) increased after Kidney Allocation System 250 (KAS250) and declined during heightened regulatory and public scrutiny beginning in August 2024. In 2025, deceased donor kidney recovery and transplant volume also decreased for the first time after KAS250. Because the donor pool had been shifting toward higher KDRI donors, we asked whether the decline in kidney recovery during this period exceeded that predicted by KDRI, donor type, and seasonality. Using the pre-August 2024 relationship between KDRI, donor type, seasonality, and kidney recovery, a donor-level model estimated expected recovery among the observed post-August 2024 donors. The model predicted 870 more kidney recoveries than were observed. This difference coincided with declining AOOS but could also reflect unmeasured donor characteristics and other changes occurring at the same time. Under alternative post-recovery utilization assumptions, the model-estimated recovery difference corresponded to approximately 360 to 630 potential additional transplants. The highest KDRI kidneys also experienced the greatest declines in recovery and increases in cold ischemic time. These findings document concurrent national trends and support further evaluation of placement pathways for hard-to-place kidneys as the donor pool shifts toward higher KDRI.