Updating Deceased Donor Kidney Allocation—What Are the Challenges?

It is a well-known fact that the demand for kidneys far outpaces our society’s supply. The kidney allocation system (KAS) was created to ensure a fair distribution of a scarce societal resource. In 2014, the KAS was revised to help balance the equity and utility. Here we examine the many inequalities the KAS 2014 overcame, discuss the barriers that still exist, and evaluate the future implications of the new version of the KAS that is set to begin March 14, 2021. With the implementation of KAS 2014, longevity matching was much improved with decrease in number of recipient and donor age mismatch >15 years. There was an increase in highly sensitized transplants, especially those with calculated panel reactive antibody (cPRA) >98% due to a sliding scale of points and local/regional/national priority. Some groups even reported that it may have advantaged the very highly sensitized patients too much and suggested a more gradual sliding scale of points. The racial/ethnic disparities were much improved with allowance of wait time to start at time of dialysis initiation to capture those who did not have adequate and early access to a transplant center. Despite these improvements, there remains a geographic disparity which was not addressed with KAS 2014. KAS 2021 (set to begin March 14, 2021) was created to lessen the geographic barriers without compromising the utility of the organs. By eliminating donor service area (DSA) and instead using 250 nautical mile (nm) concentric circles around donor hospitals, this new system is intended to broaden the sharing. This change to the allocation is another step toward the goal of improving equality, but how this change will affect the utility remains to be seen.