SETI—The Semi-Elective Transplant Initiative

OBJECTIVE: To evaluate whether formal integration of preservation strategy with predictable operating room access was associated with measurable changes in transplant timing, preservation practice, the logistical profile of transplanted grafts, and early clinical outcomes. SUMMARY BACKGROUND DATA: Deceased donor kidney transplantation remains a reactive process requiring urgent mobilization of hospital resources. As volumes increase and hospitals operate near capacity, this creates operational barriers that limit organ utilization. We report a retrospective evaluation of a prospectively implemented operational redesign; the design does not support causal inference. METHODS: Adult deceased-donor kidney transplants (January 2022-June 2025) were grouped into pre-SETI, SETI-1 (expanded machine perfusion), and SETI-2 (morning operating room access). A contemporaneous SRTR cohort (N=12,302) served as the comparator. RESULTS: Among 936 transplants, mean cold ischemia time (CIT) increased after SETI (20.2→21.9 h, P=0.0039). Donation after circulatory death (DCD) kidneys with CIT >30 hours increased from 0.5% pre-SETI to 7.7% after full implementation (P<0.0001). Overnight perfusion increased more than 3-fold, and operative starts shifted toward 8-10 AM. Kidney Donor Profile Index rose across eras (median: 29→33→43, P<0.001). No significant differences were observed in DGF (41.4→38.2%, P=0.071) or graft failure (5.4→3.2%, P=0.34); these comparisons were underpowered and do not establish equivalence. Donor hypertension predicted graft failure, whereas CIT, DCD status, and SETI era did not. CONCLUSIONS: Systems-based operational redesign transformed reactive deceased-donor kidney transplantation into a proactive model, enabling transplantation of a greater proportion of logistics-sensitive grafts, including DCD kidneys and organs with prolonged CIT, within existing healthcare resources. Whether this increases net organ utilization was not established by these data.