{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,27]],"date-time":"2026-08-27T14:01:28Z","timestamp":1787839288666,"version":"build-2784847793"},"reference-count":28,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"1","funder":[{"DOI":"10.13039\/100000002","name":"National Institutes of Health","doi-asserted-by":"crossref","award":["DK116066"],"award-info":[{"award-number":["DK116066"]}],"id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"crossref"}]},{"DOI":"10.13039\/100000002","name":"National Institutes of Health","doi-asserted-by":"crossref","award":["EB032910"],"award-info":[{"award-number":["EB032910"]}],"id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"crossref"}]},{"DOI":"10.13039\/100000002","name":"National Institutes of Health","doi-asserted-by":"crossref","award":["DK126739"],"award-info":[{"award-number":["DK126739"]}],"id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"crossref"}]},{"DOI":"10.13039\/100000002","name":"National Institutes of Health","doi-asserted-by":"crossref","award":["DK130058"],"award-info":[{"award-number":["DK130058"]}],"id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"crossref"}]},{"DOI":"10.13039\/100000062","name":"National Institute of Diabetes and Digestive and Kidney Diseases","doi-asserted-by":"crossref","award":["K23DK133729"],"award-info":[{"award-number":["K23DK133729"]}],"id":[{"id":"10.13039\/100000062","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":["CJASN"],"published-print":{"date-parts":[[2026,1]]},"abstract":"\n Key Points<\/jats:title>\n \n \n \n Out-of-sequence transplantation of deceased donor kidneys has increased dramatically from 2020 to 2023 without regard for organ quality.<\/jats:p>\n <\/jats:list-item>\n \n A limited number of centers are responsible for a third of all out-of-sequence transplants, exacerbating inequality in access to transplants.<\/jats:p>\n <\/jats:list-item>\n \n There has been no improvement in the utilization of deceased donor kidneys despite the increase of out-of-sequence placements.<\/jats:p>\n <\/jats:list-item>\n <\/jats:list>\n <\/jats:p>\n <\/jats:sec>\n \n Background<\/jats:title>\n Deceased donor kidney (DDK) allocation in the United States follows an objective algorithm that is designed to balance equity and utility. Organ procurement organizations (OPOs) are increasingly using out-of-sequence allocation of DDKs to improve organ utilization rates. We investigated trends in the prevalence of out-of-sequence allocation in DDKs, the association with successful organ placement, and its impact on equity and organ utilization.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n Using 2020\u20132023 transplant data from the Scientific Registry of Transplant Recipients and organ offer data from the potential transplant recipient dataset, we identified all organ offers for DDKs, including those placed out-of-sequence, along with donor and recipient characteristics. We obtained the prevalence of out-of-sequence allocation and placement in DDKs and assessed temporal trends across organ quality as measured by the kidney donor profile index. Lorenz curves and Gini coefficients measured inequality for out-of-sequence transplantation at the transplant center and OPO levels.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n From 2020 to 2023, out-of-sequence placement of DDKs increased from 328 kidneys in 2020 (2%) to 3470 in 2023 (18%). Out-of-sequence placements now account for greater than one in six DDK transplants and include kidneys across the organ quality spectrum, with 40% of these occurring with kidney donor profile index <50% (\n i.e<\/jats:italic>\n ., the highest quality) kidneys. By 2023, all 55 OPOs were using out-of-sequence allocation, reflected in the Gini coefficient decreasing from 0.88 to 0.43 with no appreciable impact on utilization rates.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n There has been a sharp increase in out-of-sequence allocation of DDKs including high-quality organs. Most of these kidneys are being placed at a small number of transplant centers, creating preferential access to transplantation and exacerbating inequities in access to transplantation.<\/jats:p>\n <\/jats:sec>","DOI":"10.2215\/cjn.0000000869","type":"journal-article","created":{"date-parts":[[2025,9,24]],"date-time":"2025-09-24T16:02:05Z","timestamp":1758729725000},"page":"130-138","update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":9,"title":["Out-of-Sequence Placement of Deceased Donor Kidneys Is Exacerbating Inequities in the United States"],"prefix":"10.2215","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5305-9685","authenticated-orcid":false,"given":"Sumit","family":"Mohan","sequence":"first","affiliation":[{"name":"Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York"},{"name":"Columbia University Renal Epidemiology Group, New York, New York"},{"name":"Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5491-0278","authenticated-orcid":false,"given":"Miko E.","family":"Yu","sequence":"additional","affiliation":[{"name":"Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York"},{"name":"Columbia University Renal Epidemiology Group, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8190-3444","authenticated-orcid":false,"given":"Joel T.","family":"Adler","sequence":"additional","affiliation":[{"name":"Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, Texas"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-9875-4087","authenticated-orcid":false,"given":"Lindsey M.","family":"Maclay","sequence":"additional","affiliation":[{"name":"Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York"},{"name":"Columbia University Renal Epidemiology Group, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9488-6847","authenticated-orcid":false,"given":"David C.","family":"Cron","sequence":"additional","affiliation":[{"name":"Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5341-7286","authenticated-orcid":false,"given":"Jesse","family":"Schold","sequence":"additional","affiliation":[{"name":"Department of Surgery, University of Colorado, Aurora, Colorado"},{"name":"Department of Epidemiology, School of Public Health, University of Colorado, Aurora, Colorado"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1823-0117","authenticated-orcid":false,"given":"Syed Ali","family":"Husain","sequence":"additional","affiliation":[{"name":"Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York"},{"name":"Columbia University Renal Epidemiology Group, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2025,9,24]]},"reference":[{"issue":"6","key":"B1-20260318","doi-asserted-by":"crossref","first-page":"2007","DOI":"10.1111\/ajt.16441","article-title":"Greater complexity and monitoring of the new kidney allocation system: implications and unintended consequences of concentric circle kidney allocation on network complexity","volume":"21","author":"Adler","year":"2021","journal-title":"Am J Transplant."},{"issue":"1","key":"B2-20260318","doi-asserted-by":"crossref","first-page":"26","DOI":"10.1681\/ASN.2022040471","article-title":"Early effect of the circular model of kidney allocation in the United States","volume":"34","author":"Puttarajappa","year":"2023","journal-title":"J Am Soc Nephrol."},{"issue":"8","key":"B3-20260318","doi-asserted-by":"crossref","first-page":"1842","DOI":"10.1681\/ASN.2013070784","article-title":"New national allocation policy for deceased donor kidneys in the United States and possible effect on patient outcomes","volume":"25","author":"Israni","year":"2014","journal-title":"J Am Soc Nephrol."},{"issue":"8","key":"B4-20260318","doi-asserted-by":"crossref","first-page":"e1910312","DOI":"10.1001\/jamanetworkopen.2019.10312","article-title":"Association between declined offers of deceased donor kidney allograft and outcomes in kidney transplant candidates","volume":"2","author":"Husain","year":"2019","journal-title":"JAMA Netw Open."},{"issue":"8","key":"B5-20260318","doi-asserted-by":"crossref","first-page":"1212","DOI":"10.2215\/CJN.06220617","article-title":"Achieving equity through reducing variability in accepting deceased donor kidney offers","volume":"12","author":"Mohan","year":"2017","journal-title":"Clin J Am Soc Nephrol."},{"issue":"8","key":"B6-20260318","doi-asserted-by":"crossref","first-page":"1209","DOI":"10.1016\/j.ajt.2023.05.005","article-title":"Increased volume of organ offers and decreased efficiency of kidney placement under circle-based kidney allocation","volume":"23","author":"Cron","year":"2023","journal-title":"Am J Transplant."},{"issue":"10","key":"B7-20260318","doi-asserted-by":"crossref","first-page":"1885","DOI":"10.1097\/TP.0000000000004127","article-title":"Increased logistical burden in circle-based kidney allocation","volume":"106","author":"Wood","year":"2022","journal-title":"Transplantation."},{"issue":"4","key":"B8-20260318","doi-asserted-by":"crossref","first-page":"1111","DOI":"10.1016\/j.ekir.2025.01.021","article-title":"Outcomes for patients with a deceased donor kidney offer in the new allocation system","volume":"10","author":"Mohan","year":"2025","journal-title":"Kidney Int Rep."},{"issue":"4","key":"B9-20260318","doi-asserted-by":"crossref","first-page":"e14925","DOI":"10.1111\/ctr.14925","article-title":"Current landscape of kidney allocation: organ procurement organization perspectives","volume":"37","author":"Concepcion","year":"2023","journal-title":"Clin Transplant."},{"issue":"5","key":"B10-20260318","doi-asserted-by":"crossref","first-page":"1109","DOI":"10.1016\/j.ekir.2023.02.1081","article-title":"Increasing discards as an unintended consequence of recent changes in United States kidney allocation 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History"}},{"value":"2025-09-19","name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}}]}}