*Purpose: Though a purpose of the kidney allocation system (KAS) enacted in 2014 was to prioritize the transplantation of highly sensitized recipients, we explored the effect of this on pediatric graft quality, wait time, and early graft outcomes.

*Methods: A retrospective analysis of deceased-donor transplants from January 2008- January 2018 was conducted using the UNOS database. The mean donor KDPI was compared between highly sensitized, 0-mismatch (0-mm) and pediatric recipients pre- and post-KAS. The students t-test and X² test were used to compare continuous and categorical variables. Differences in wait times pre and post-KAS, as well as annually post-KAS were calculated. Delayed graft function and 1 year rejection rates were compared. STATA12 was used for all analyses.

*Results: The mean KDPI significantly improved among highly sensitized (39% to 37%, p<0.05) and pediatric allograft recipients (20% to 16%, p<0.05), yet worsened for 0-mm recipients (38% to 44%, p<0.05). While wait time improved for highly sensitized patients (1210 to 1140 days, p<0.05), it worsened for pediatric recipients (350 to 398 days, p<0.05) . There were no observed differences in rates of DGF or early allograft rejection. In the 3 years since implementation of the KAS, pediatric waiting times have remained prolonged.

*Conclusions: Pediatric and 0-mm recipients are not receiving lower quality allografts, likely reflecting the close scrutiny transplant practitioners give these grafts prior to acceptance. Wait times have increased over the two eras. Despite the expected bolus effect from transplantation of highly sensitized patients, pediatric wait times have remained prolonged each year post-KAS. There have not been any differences observed in early graft outcomes like DGF and 1yr rejection rate.

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