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Purpose of Review <p>The KAS250 policy introduced a broader kidney allocation radius, increasing system complexity and inefficiency, with kidney nonuse now approaching 30%. Simultaneously, new performance metrics have pressured organ procurement organizations (OPOs) to maximize utilization. In this landscape, out-of-sequence (OOS) allocation—bypassing the match run to expedite placement—has become more frequent. This review examines the rise of OOS allocation and its implications for equity, utility, and efficiency.</p> Recent Findings <p>Originally infrequent and intended for hard-to-place kidneys, OOS allocation now accounts for nearly 20% of transplants. Its use spans ranges of kidney quality and is concentrated among select OPOs and centers. The demographics of OOS recipients raise equity concerns regarding who benefits from access to OOS kidneys. It remains unclear if the practice of OOS allocation will help reduce kidney nonuse rates.</p> Summary <p>The rise of OOS allocation highlights the complexities of kidney allocation and challenges in balancing equity, utility, and efficiency. Without transparency and oversight, this practice risks worsening transplant disparities. Policy reforms are needed to ensure fair and effective kidney allocation.</p>

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Equity, Utility, and Efficiency in Kidney Allocation: Understanding the Rise of Out-of-Sequence Allocation

  • 期刊论文

  • 发表日期：

    2025年2月25日

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  • David C. Cron,
  • Joel T. Adler

摘要

Purpose of Review

The KAS250 policy introduced a broader kidney allocation radius, increasing system complexity and inefficiency, with kidney nonuse now approaching 30%. Simultaneously, new performance metrics have pressured organ procurement organizations (OPOs) to maximize utilization. In this landscape, out-of-sequence (OOS) allocation—bypassing the match run to expedite placement—has become more frequent. This review examines the rise of OOS allocation and its implications for equity, utility, and efficiency.

Recent Findings

Originally infrequent and intended for hard-to-place kidneys, OOS allocation now accounts for nearly 20% of transplants. Its use spans ranges of kidney quality and is concentrated among select OPOs and centers. The demographics of OOS recipients raise equity concerns regarding who benefits from access to OOS kidneys. It remains unclear if the practice of OOS allocation will help reduce kidney nonuse rates.

Summary

The rise of OOS allocation highlights the complexities of kidney allocation and challenges in balancing equity, utility, and efficiency. Without transparency and oversight, this practice risks worsening transplant disparities. Policy reforms are needed to ensure fair and effective kidney allocation.