Long-Term Trends in Kidney Transplant Access, Survival, and Disparities: Analysis of Organ Procurement and Transplantation Network Data, 2003-2025

Background: The Kidney Allocation System (KAS) 2014, 2021 policy revision and the COVID 19 pandemic were the major players that affected the practice of Kidney Transplant (KT) among End Stage Kidney Disease patients. In this study we aim to evaluate 23 year longitudinal trends, survival outcomes of KT and highlight geographic disparities impacting current practice. Methods: We analyzed national Organ Procurement Transplant Network (OPTN) data from 2003 to 2025. Linear Longitudinal Regression and Survival analysis incorporating Kaplan-Meier estimates for graft and patient survival stratified by age,race/ethnicity,PRA,HLA mismatch,diagnosis,donor type/age,and transplant type (primary vs repeat) was done using R studio.State-level transplant volumes were assessed by donor source.Trends were examined relative to three inflection points: the 2014 KAS launch,the 2021 policy update,and the COVID-19 pandemic. Results: 1.1-year patient survival remains high across all groups (>97%), 5-year graft survival favors living donors (85.6%) vs deceased donors (74.4%). 2.COVID-19 caused a transient decline in transplant volume in 2020, particularly in living donor transplants, with recovery by 2022. 3.The 2021 KAS revision modestly increased access for highly sensitized patients but left persistent disparities. 4.Repeat recipients showed better 5-year patient survival than primary recipients (88.3% vs 86.6%) despite lower graft survival. 5.States with the highest transplant volumes (NY, PA) had lower relative living donor utilization, revealing missed opportunities. 6.Donor age ≥65 was associated with markedly reduced 5-year survival (graft:74%,patient:73.5%. 7.Polycystic kidney disease and congenital etiologies had superior long-term outcomes (patient survival:92%, graft:87%. 8.Despite policy revisions, Black and highly sensitized patients (PRA ≥80%) continued to show 2-year transplant probabilities <15%. Conclusion: Over two decades, kidney transplant outcomes have improved,yet marked disparities in access and survival remain. Policy changes,including the 2021 KAS update,have not fully addressed racial and immunologic inequities. The superior survival associated with living donor transplants and select recipient groups underscores the need for targeted strategies to expand access,optimize matching,and promote long-term graft function across all populations.