Abstract
Deceased donor kidney transplantation (DDKT) rates for highly sensitized (HS) candidates increased early after implementation of the Kidney Allocation System (KAS) in 2014. However, this may represent a bolus effect, and a granular investigation of the current state of DDKT for HS candidates remains lacking. We studied 270 722 DDKT candidates from the SRTR from 12/4/2011 to 12/3/2014 ("pre-KAS") and 12/4/2014 to 12/3/2017 ("post-KAS"), analyzing DDKT rates for HS candidates using adjusted negative binomial regression. Post-KAS, candidates with the highest levels of sensitization had an increased DDKT rate compared with pre-KAS (cPRA 98% adjusted incidence rate ratio [aIRR]:(1.27) 1.77(2.46) P = .001, cPRA 99% aIRR:(3.18) 4.36(5.98) P < .001, cPRA 99.5-99.9% aIRR:(16.91) 24.29(34.89) P < .001, and cPRA 99.9%+ aIRR:(8.79) 11.58(15.26) P < .001). To determine whether these changes produced more equitable access to DDKT, we compared DDKT rates of HS to non-HS candidates (cPRA 0-79%). Post-KAS, cPRA, 98% candidates had an equivalent DDKT rate (aIRR:(0.65) 0.94(1.36) , P = .8) to non-HS candidates, whereas 99% candidates had a higher DDKT rate (aIRR:(1.19) 1.68(2.38) , P = .02). Although cPRA 99.5-99.9% candidates had an increased DDKT rate (aIRR:(2.46) 3.50(4.98) , P < .001) compared to non-HS candidates, cPRA 99.9%+ candidates had a significantly lower DDKT rate (aIRR:(0.29) 0.40(0.56) , P < .001). KAS has improved access to DDKT for HS candidates, although substantial imbalance exists between cPRA 99.5-99.9% and 99.9%+ candidates.