REVIEW

C URRENT
OPINION Renal transplantation: the last iteration of the rest
of the world
Keighly Bradbrook, Katrina Gauntt and David Klassen

Purpose of review
Renal transplantation systems across the world aim to achieve an optimal balance between fair access to
deceased donor kidney transplants (equity) and efficient use of organs (utility). Kidney allocation systems
are measured across a host of metrics, and there is no single agreed upon definition of success, which
looks different for each system depending on the desired balance between equity and utility. This article
evaluates the United States renal transplantation system’s efforts to balance equity and utility while drawing
comparisons to other national systems.
Recent findings
The United States renal transplantation system is expected to undergo major changes with the transition to
a continuous distribution framework. The continuous distribution framework removes geographic
boundaries and takes a flexible and transparent approach to balancing equity and utility. The framework
leverages transplant professionals and community members input with mathematical optimization strategies
to inform weighting of patient factors to allocate deceased donor kidneys.
Summary
The United States’ proposed continuous allocation framework lays the groundwork for a system allowing
transparent balancing of equity and utility. This system approach addresses issues common to those in
many other countries.
Keywords
continuous distribution, organ allocation, renal transplantation

INTRODUCTION allocation policy but does not specify the degree

Organ allocation in the United States has been
happening in some form for decades, although,
the formal system that now governs US solid organ
allocation is fairly young. In 1984, the United States
(US) Congress passed the National Organ and Trans-
plant Act (NOTA), which established the Organ
Procurement and Transplantation Network (OPTN),
the system linking public and private stakeholders
responsible for maintaining the national registry for
organ matching. The OPTN is currently and has
historically been operated by the United Network
for Organ Sharing (UNOS) under a contract overseen
by the US Department of Health and Human Serv-
ices (HHS) and the Health Resources and Services
Administration (HRSA). In 2000, HRSA imple-
mented the Final Rule, which established a set of
principles and guidelines for the execution of the
OPTN contract and is what underlies allocation
of solid organ transplantation in the United States
[1–3]. It clearly states that allocation must take into
account utility (efficient use of organs) and equity
(fair access) principles when developing organ
to which either should be prioritized [2–4]. Equity
and utility principles govern the decisions made
within transplantation systems across the world
but not all systems are built to achieve the same
balance between these two principles [5,6].
This paper aims to evaluate the growth of the US
system in the context of worldwide renal transplan-
tation with particular focus on the complexities of
balancing equity and utility in a system.
EQUITY VERSUS UTILITY
Comparing international systems is difficult when
there is no consensus on operationalizing equity
and utility principles in deceased donor kidney
United Network for Organ Sharing (UNOS), Richmond, Virginia, USA
Correspondence to Keighly Bradbrook, United Network for Organ
Sharing, Richmond, VA, USA.
E-mail: Keighly.bradbrook@unos.org
Curr Opin Organ Transplant 2023, 28:207–211
DOI:10.1097/MOT.0000000000001059

1087-2418 Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved. www.co-transplantation.com

Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.

Organ allocation and procurement
KEY POINTS
 Renal transplantation systems seek to achieve a
transparent balance between equity and utility but a
perfect balance of equity and utility is hard to define
and likely differs between nations based on different
value systems.
 The United States’ new proposed deceased donor
kidney allocation scheme, referred to as continuous
distribution, provides a flexible and promising template
for transparently balancing equity and utility.
 The United States’ proposed continuous distribution
system approach addresses issues common to those in
many other countries.
allocation, although there are notable similarities.
In addition, there are no standardized metrics for
comparison, which is important when procurement
practices and donor characteristics vary across
nations [5–7].
Factors like blood group, inadequate access to
dialysis, pediatric priority, prior living donor status,
sensitization (percentage of deceased donor pool a
patient is incompatible with based on unacceptable
antigens), and some form of waiting time (dialysis
time and/or waiting time) are used to balance the
equity in a system, while factors like human leuko-
cyte antigen (HLA) and longevity matching are used
to ensure the utility of the system. Although there
are small differences in the ways in which countries
operationalize the equity of a system, countries
differ most dramatically in the way that they
approach utility, particularly with longevity match-
ing. Longevity matching seeks to maximize the
survival benefit from each kidney transplant by
matching kidneys with the lowest relative risk of
graft failure to candidates with the longest estimated
posttransplant survival. Longevity matching is
often discussed as trying to maximize the ‘added
life years’ and avoiding unrealized graft life-years
[5,6]. However, it is difficult to estimate the ‘added
life years’ and even harder to know how to maximize
it. Countries like the United Kingdom use a ‘young-
to-young’ approach and avoid matching ‘young-to-
old’, while Spain and countries in Euro-transplant
have a Senior Program where aged at least 65
deceased donor kidneys are allocated to aged at least
&
65 recipients [5,6,8 ].
Although a perfect balance of equity and utility
is hard to define and likely differs between nations
based on different value systems, there are a key set
of metrics under which systems are often evaluated.
Inclusive in these metrics are waitlist mortality,
208 www.co-transplantation.com
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
transplant rates, utilization rates, organs unable to
be utilized (discard rate), and posttransplant survival
outcomes. Renal transplant systems, unlike other
solid organ types, uniquely struggle with achieving
an acceptable utilization and discard rate. High dis-
card rates suggest a failure to make use of all avail-
able organs and suggest a less than fully tapped
supply [7]. In fact, the US renal system reports a
discard rate, defined as the number of deceased
donor kidneys recovered for the purpose of trans-
plant but not transplanted, of about 24–25% [9]. In
comparison, in the United States, other organs like
heart (1.1%), lung (6.5%), and liver (9.5%) do not
experience discard rates as high as those reported for
renal transplantation, potentially suggesting a
unique challenge in achieving the correct balance
between equity and utility [7,10–12]. Optimized
systems achieve a balance of equity and utility that
minimizes the discard rate without exacerbating
demographic or biological inequities.
Although metrics like discard rate are not stand-
ardized across countries, they provide context for
measuring growth of a system within a country, over
time [7]. For example, Spain has been widely recog-
nized for more than doubling transplant rates fol-
lowing the implementation of a new care model in
&
1989 [8 ]. In addition to defining how systems oper-
ationalize their goals and evaluation metrics, it is
also important to consider the institutions and
shared decision-making processes that these systems
work within. Ultimately, systems must operate
within the confines of the institutions that govern
them and the shared values of the community that
work and live within them. What is possible in one
country may not be feasible in another because of
different value systems, institutions, regulations,
and structures.
THE CURRENT UNITED STATES KIDNEY
ALLOCATION SYSTEM
Under the current US kidney allocation system,
implemented in March 2021, candidates are placed
into classification groups based on their pediatric
status, sensitization, medical urgency status
(defined as imminent loss of access to dialysis),
geographic proximity to the donor organ, HLA
and blood type compatibility, and expected sur-
vival. Once placed in classification groups, candi-
dates are sorted based on criteria including waiting
time [13].
The US primarily operationalizes the utility of its
system through a combination of Estimated Post-
Transplant Survival (EPTS) and Kidney Donor Profile
Index (KDPI) as well as geography. EPTS is calculated
for every adult candidate on the US kidney OPTN
Volume 28  Number 3  June 2023

waiting list based on time on dialysis, diabetes sta-
tus, prior solid organ transplant status, and candi-
date age [14]. KDPI combines a variety of donor
factors summarizing the likelihood of graft failure
[15,16]. Currently, candidates with the highest 20%
estimated posttransplant survival are prioritized for
donors with the lowest likelihood of graft failure (i.e.
best to the best). Kidneys are offered first to candi-
dates listed at transplant hospitals within 250 naut-
ical miles of the donor hospital. Offers not accepted
for any of these candidates are then made to can-
didates beyond the 250 nautical mile distance. In
contrast, Spain, UK, British Columbia, and the
Euro-transplant system employ, in some capacity,
age-based matching, which has been credited for
increased transplantation and donation rates
&
[6,7,8 ]. Indeed, longevity matching is one of the
largest differences between the United States and
most European allocation systems that utilize
age matching.
About a decade ago, the United States consid-
ered adopting age-based matching after seeing the
successes that other systems were having. In 2011,
the OPTN Kidney Transplantation Committee, the
group of volunteer transplant professionals respon-
sible for developing policy, developed a proposal to
include age-based matching where the 80% of kid-
neys not allocated via EPTS and KDPI matching
would be allocated using age-based matching with
a fairly large, with or without 15-year window.
Ultimately the policy was not accepted because of
concern that the policy violated the Age Discrim-
ination Act of 1975 and did not meet the NOTA
requirement for equitable distribution of organs
[17].
The United States is currently working on revi-
sing kidney allocation policy, described in the next
section, and will revisit tradeoffs between equity in
utility, including how factors like longevity match-
ing are operationalized in the system.
A NEW WAY OF BALANCING EQUITY AND
UTILITY: THE NEXT ITERATION
For the United States, the next iteration to kidney
renal transplantation will have allocation points
based on a system of continuous distribution. The
goal of continuous distribution is to create a border-
less and more equitable system where candidates
for deceased donor kidney transplant are awarded
priority points based on a range of factors, referred
to as attributes. Attributes are weighted and put into
groups based on the goal of each attribute. Grouping
the attributes into goals has no functional value
but allows transparent comparisons of value-
based decision between, for example, patient access
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Renal transplantation Bradbrook et al.
and placement efficiency. The proposed goals of
continuous distribution and attributes are outlined
below:
(1) Medical urgency
(a) Imminent loss of dialysis
(2) Posttransplant outcomes
(a) DR mismatch
(b) Longevity matching
(3) Candidate biology
(a) Blood type
(b) CPRA
(4) Patient access
(a) Pediatrics
(b) Prior living donor
(c) Safety net (kidney after liver, heart, lung)
(d) Qualifying time
(5) Placement efficiency
(a) Distance from donor hospital to transplant
center (nautical miles)
In this way, each candidate is awarded a con-
tinuous allocation score (CAS) that is the weighted
&
sum of the attributes outlined above [18 ].
The United States leverages a shared decision
making framework for policy making where trans-
plant professionals, patients, and others can partic-
ipate in policy making by applying to be on 1 of 20
OPTN committees, like the OPTN Kidney Trans-
plantation Committee [19]. The OPTN Kidney
Transplantation Committee is currently developing
the new continuous distribution policy proposal.
Historically, OPTN Committees iteratively
developed, implemented, and reviewed policy with-
out always having explicit conversations about the
trade-offs between equity and utility and how best
to operationalize these principles. Continuous dis-
tribution flips that approach on its head and,
instead of identifying the problem and then con-
structing a solution, requires stakeholders to have
very transparent conversations quantifying the
trade-offs between equity and utility before creating
solutions. In fact, at the beginning of the policy
development process, an analytic hierarchy process
(AHP) was used to gather transplant community
feedback to determine, which attributes should con-
tribute to allocation priority the most. Stakeholders
including transplant candidates and/or recipients,
transplant hospital professionals, laboratory staff,
and others most often selected medical urgency
(imminent loss of dialysis access), biologically diffi-
cult to match candidates, prior living donors, and
pediatric priority. This prioritization would suggest
that United States stakeholders tend to prioritize
equity over utility [4].
www.co-transplantation.com 209
Organ allocation and procurement
In a system where supply falls short of demand, a
particular balance between equity and utility may
appear attractive but may not be quite as attractive
in practice when the consequences of increasing the
priority of one subgroup results in deprioritizing
another. For example, implementing expanded lon-
gevity matching may mean longer waiting time for
certain EPTS groups. Whether that particular trade-
off is tolerable is difficult to decide, but continuous
distribution provides the tools for having these
important conversations while maintaining the
ability to continuously adjust weighting of prior-
ities. In fact, the OPTN is leveraging external exper-
tise and working with research groups to develop
tools for evaluating these trade-offs in real-time
through machine learning and optimization [20].
Despite major steps to transform allocation,
United States renal allocation is still far from its last
iteration. As Stewart et al. states in a recent summary
of the state of US renal allocation, ‘major changes to
organ allocation do not come easy’, and for good
&&
reason [21 ]. When the currency we are dealing in is
patient lives, the cost of making risky bets on new
and innovative allocation schemes could be steep.
THE PARKING LOT: FUTURE ITERATIONS
The parking lot of ideas for system improvements
continues to grow as the United States works to
transition to continuous distribution. A monumen-
tal change, the move to continuous distribution has
sparked a degree of innovation in the community
where members, excited about the new system or
frustrated with the current, are coming to the table
with increasingly creative ideas. Continuous distri-
bution provides a flexible and promising template
for future, quicker, and more transparent changes.
Examples of such potential improvements
include implementing an ‘equal opportunity allo-
cation supplemented by fair innings’ to address
equity and ‘dealing from the bottom of the deck’
to expedite allocation to likely accepting candidates
and transplant centers as opposed to the ‘first come
&&
first served’ approach in current allocation [17,21 ].
The ‘first come first served’ strategy approaches
equity by placing candidates with very long wait
times at the top of the list. Proposed alternatives
advocate for reconsidering how waiting time is used
to prioritize patients and instead, ‘get the right
kidney to the right person at the right time’, how-
&&
ever, that is defined [21 ].
In addition to the aforementioned approaches,
developing criteria for placing more challenging kid-
neys, expediting placement of harder to place kid-
neys, more detailed data collection for understanding
discard reasons, and improved measures of kidney
210 www.co-transplantation.com
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
quality and estimated posttransplant survival are
&&
among the other parking lot ideas [22 ]. The United
States system, like others across the world, seeks to
improve kidney allocation by continuously bringing
innovative approaches to the table.
THE LAST ITERATION: GOING BEYOND
ALLOCATION
As Spain has demonstrated with their intensive care
program to facilitate donation and expansion of
donation after circulatory death (DCD), achieving
success in transplantation goes beyond allocation by
addressing organ supply issues. In recent years, the
field of transplantation has focused energy and
resources on 3D printing of organs, xenotransplan-
tation (cross species organ transplantation), and
procurement of DCD donors providing expanded
access to organs. In 2021, the first genetically engi-
neered, nonhuman kidney was transplanted into a
&
human in the United States [23 ].
In the United States, the OPTN and UNOS are
actively working on a host of initiatives beyond
allocation improvements. Examples include com-
municating with the United States Secretary of
Transportation to discuss improving transportation
of kidneys on commercial flights, tools that trans-
plant programs can use to automatically bypass
offers from organs that do not meet their criteria
for transplantation, and organ-tracking [24,25].
CONCLUSION
The US allocation system has implemented major
changes, and recently bore witness to its one-mil-
lionth transplant. Despite the growth and successes
that the system and its patients have experienced,
there is work to be done to attain a system in which
supply meets demand; a reality where a patient
experiencing end-stage renal failure who is in need
of a kidney transplant efficiently and equitably
receives one. This can only be achieved if and
when allocation, patient care and support models,
travel efficiency, clinician decision-making, tech-
nology, desensitization therapies, and living dona-
tion are optimized.
Acknowledgements
We would like to thank Amber Wilk for her assistance in
editing and reviewing the manuscript.
Financial support and sponsorship
This work was funded by the US Department of Health
and Human Services, Health Resources and Services
Administration (HRSA), Health Systems Bureau,
Division of Transplantation under contract number
Volume 28  Number 3  June 2023

HHSH250201900001C, and was conducted under the
auspices of the United Network for Organ Sharing
(UNOS), the contractor for the Organ Procurement and
Transplantation Network (OPTN). The interpretation
and reporting of these data are the responsibility of
the author(s) and in no way should be seen as an
official policy of or interpretation by the OPTN or the
US Government.
Conflicts of interest
There are no conflicts of interest.
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