Quantifying the Effect of Consent for High-Kidney Donor Profile Index Deceased Donor Transplants in the United States

Background Despite known benefits of kidney transplantation, including transplantation from donors with increased risk factors, many waitlisted candidates die before transplantation. Consent to receive donor kidneys with lower expected survival (e.g., Kidney Donor Profile Index [KDPI] >85%) is typically obtained at waitlist placement. The presumed benefit of consent to receive high-KDPI donor kidneys is higher likelihood and timeliness of donor offers for transplantation. However, the specific effect of consent on access to transplantation is unclear. Our aims were to evaluate the characteristics of candidates consenting to high-KDPI donor kidneys and the likelihood of receiving a deceased donor transplant over time on the basis of consent. Methods We used national Scientific Registry of Transplant Recipients data between 2015 and 2022 (n=213,364). We evaluated the likelihood of consent using multivariable logistic models and time to deceased donor transplant with cumulative incidence plots accounting for competing risks and multivariable Cox models. Results Overall, high-KDPI consent was 41%, which was higher among candidates who were older, were Black or Hispanic, had higher body mass index, had diabetes, had vascular disease, and had 12-48 months prelisting dialysis time, with significant center-level variation. High-KDPI consent was associated with higher rates of deceased donor transplant (adjusted hazard ratio=1.15; 95% confidence interval, 1.13 to 1.17) with no difference in likelihood of deceased donor transplant from donors with KDPI <85%. The effect of high-KDPI consent on higher rates of deceased donor transplantation was higher among candidates older than 60 years and candidates with diabetes and variable on the basis of center characteristics. Conclusions There is significant variation of consent for high-KDPI donor kidneys and higher likelihood of transplantation associated with consent.