Offered Deceased Donor Kidneys With Little or No Chance of Being Transplanted

BACKGROUND: With a broadening deceased donor pool and recent allocation policy changes, US transplant programs have reported challenges managing an influx of suboptimal kidney offers. We hypothesized that the number of offered kidneys with a minuscule chance of being transplanted has risen. If so, targeted innovations may be needed to reduce administrative burden and improve system efficiency. METHODS: Using Organ Procurement and Transplantation Network data on kidneys offered in 2016-2024, we developed a multivariable model to predict the probability that an offered kidney was transplanted (PrTx). We examined trends in the number and proportion of offered kidneys having PrTx ≤2%, ≤5%, and ≤10%. RESULTS: Donor factors most predictive of PrTx were age, donation after circulatory death, serum creatinine (terminal, peak, nadir), presence and duration of diabetes and hypertension, infectious disease test results, and body mass index. From 2016 to 2024, the annual number of kidneys offered with PrTx ≤2%, PrTx ≤5%, and PrTx ≤10% increased 13-fold (from 18 to 236), 12-fold (84 to 1055), and 10-fold (299 to 2856), respectively. Of the 236 offered kidneys with PrTx ≤2% in 2024, none was transplanted. The 2856 kidneys with PrTx ≤10% accounted for 7.9% (n = 1 208 883) of manually refused offers but just 1.1% (n = 239) of transplanted kidneys. Organ procurement organizations and centers varied substantially in offering and transplanting low-PrTx kidneys. CONCLUSIONS: The number of offered kidneys with extremely low predicted transplant probability has risen sharply, most notably in 2024. Innovations, such as improved offer filtering capabilities and standardized expedited allocation pathways, are needed to improve kidney placement efficiency.