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

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.