Expanding Use of Lower-Quality Kidneys Could Boost Transplants, Improve Equity, With Matthew Kaufmann, PhD

Allocating lower but acceptable quality kidneys to high-risk patients could introduce equity, along with shortened waiting times for underrepresented patient populations, according to new research.1

The findings also highlighted the cost-effective nature of having transplant centers utilize lower quality kidneys for adults ≥65 years of age, especially when assessing the effects of increasing transplant rates by 25%.2

“Hispanic and Black patients have longer than average wait times, and we found that increasing the rate of transplantation for all patients provides even greater health benefits for patients who have historically longer wait times,” said Matthew Kaufmann, PhD, Midwest Analytics and Disease Modeling Center Postdoctoral Fellow. “Therefore, we estimate that it would improve health equity.”

Within the US allocation system, approximately 20% of deceased donor kidneys are discarded each year. Specifically, >50% of those with a KDPI > 85 are discarded. In most clinical cases, when compared with staying on dialysis, even a KDPI = 99 kidney is suggested to offer improved longevity to transplant candidates.3

To address this gap, investigators selected a synthetic cohort of adult candidates ≥ 65 years of age with end-stage kidney disease (ESKD) on the transplant waiting list, a patient population with markedly reduced rates of transplants compared to those <65 years of age.1

“We believe there are clear benefits to honoring patient preferences—not just for older candidates, but also for patients with lower expected post-transplant survival and poorer outcomes on dialysis or the waitlist. We initially thought lower—but still acceptable—quality kidneys might offer limited benefit in this population. However, our findings show the opposite: these patients can derive substantial benefit, and this approach can be cost-effective. Ultimately, any patient who prioritizes shorter wait times and is willing to accept the risks of lower-quality kidneys should have access to them.”

What were the Clinical Findings?

Clinically, investigators found an association between deceased donor transplantation rate with a substantially decreased deaths on the waiting list and decreased waiting list removals as well as increased total net number of people undergoing transplants. Additionally, using lower-quality donor kidneys was associated with an increased risk of delayed graft function (DGF), but reduced wait times were associated with a decrease in this risk.1

At a 5% increase in transplant rate, the DGF rate increased from the status quo. However, as the rate increased to 25%, the DGF rate moved back toward the status quo because of offsetting risk factors, a recurring pattern for the graft failure rate. Although lower kidney quality was associated with an increased risk of graft failure, reduced pretransplant dialysis time had a protective association.1

The scenario analysis revealed that even if as many as 20% of transplanted kidneys were of lower quality than their given KDPI, increasing the transplantation rate by 25% would still be associated with 141 (range, 118-161) averted waiting list deaths and 375 (range, 350-396) waiting list removals per 10,000 candidates and 175 (range, 25-385) additional DGF cases and 103 (range, 9-266) additional graft loss events per 10,000 recipients.1

Why Would this Be Cost Effective?

Economically, when transplantation rates were increased by 25%, investigators noted an improvement in HRQOL cost-effectively, along with the most QALYs and lowest costs.1

From the health care sector perspective, this would cost $8100 (95% credible interval [CrI], $700 to $141,00) per QALY gained. Notably, smaller increments of increased transplant rates cost more per QALY gained. Investigators believe smaller increases would mean fewer people undergo transplants, along with an increased mean time to transplant, which can result in additional adverse outcomes and costs.1

Compared with the status quo, investigators observed a gain of 0.56 QALYs (95% CrI, 0.35 to 0.90 QALYs) and savings of $10,200 (95% CrI, $3400 to $17,900) for older adults.1

Even for individuals ≥ 75 years of age, increasing deceased donor transplants by 25% was associated with HRQOL gains and cost $7800 (95% CrI, $1300 to $14,500) per QALY gained.1

At a WTP threshold of $100,000 per QALY gained, choosing the status quo as opposed to the 25% increase transplantation rate was predicted to result in an expected loss of $51,400 per person, for a total of $886 million, from the health care sector perspective, and $58,300 per person, for a total of $1 billion, from the modified health care sector perspective.1

While the study did not consider the downstream effects of new policies on younger candidates, investigators noted they would expect to see younger candidates benefit from shorter waiting times for all candidates.1

Editor’s Note: Kaufmann reports no relevant disclosures.

References

1. Kaufmann MB, Tan JC, Owens DK, Chertow GM, Goldhaber-Fiebert JD. Cost-Effectiveness of Acceptable-Quality Deceased Donor Kidneys for Transplant in Older Candidates. JAMA Network Open. 2026;9(1):e2555428. doi:https://doi.org/10.1001/jamanetworkopen.2025.55428

2. Kaufmann M. Using Lower Quality Kidneys to Reduce Costs, Increase Transplants for Older Adults, With Matthew Kaufmann, PhD. HCPLive. Published March 9, 2026. Accessed March 17, 2026. https://www.hcplive.com/view/using-lower-quality-kidneys-to-reduce-costs-and-increase-transplants-for-older-adults

3. Friedewald JJ, Schantz K, Mehrotra S. Kidney organ allocation: reducing discards. Current Opinion in Organ Transplantation. 2023;28(2):145-148. doi:https://doi.org/10.1097/mot.0000000000001049