Equity in Kidney Allocation: An Examination of Out of Sequence Kidney Transplant Recipients at a Single Center.

Transplant centers and organ procurement organizations (OPOs) collaborate to optimize organ use by facilitating out of sequence (OOS) kidney offers, but national data suggest this may worsen disparities. We retrospectively analyzed all kidney transplant recipients at a single center from July 2022 to July 2024. We compared OOS versus in-sequence (IS) kidney transplants by demographics, panel reactive antibody scores (cPRA), socioeconomic factors, and dialysis vintage. Among 503 recipients, 330 (66%) received OOS kidneys. OOS recipients were older (61 vs. 57 years, p < 0.001), more frequently male (68% vs. 55%, p = 0.004), and had lower cPRA scores (17% vs. 37%, p < 0.001). OOS recipients were more frequently white (61% vs. 50%), had higher education and income levels, were more likely to have private insurance and be pre-emptively transplanted. On multivariable analysis, longer dialysis duration (OR: 0.965 per month, p < 0.0001) and higher cPRA (OR: 0.984 per percentage point, p < 0.0001) were associated with lower odds of OOS transplant. Male gender was not associated with receipt of an OOS kidney (OR: 1.582, p = 0.058). OOS kidneys were more frequently allocated to patients of higher socioeconomic status. These findings highlight the complexity of matching hard-to-place kidneys with medically appropriate recipients while maintaining equity across all factors.