*Purpose: Of 2.5M deaths in the US every year, only 10,000 are recovered for transplantation; recovery of organs from older donors is rare although similar donors are routinely used in Europe. Current OPO performance metrics may disincentivize OPOs from pursuing marginal donor candidates. We present an OPO aggressiveness index to identify OPOs that aggressively pursue marginal kidney donors.

*Methods: Using SRTR data from 2013-2017, we evaluated the proportion of eligible deaths in each OPO that fell into one of 7 categories of “marginal donor candidate” (age>60, BMI>35, KDPI>85%, serum creatinine (SCr)>2, Hepatitis C, infectious risk donor (IRD), and donor after cardiac death (DCD)) and evaluated the correlation between these proportions and deceased donors per 1000 total deaths in each OPO in 2015 (“overall donor rate”). We used decile scores of four of these categories (age>60, BMI>35, KDPI>85%, SCr>2) to construct an index of OPO aggressiveness (“aggressiveness score”), and compared this and current OPO performance metrics to overall donor rate.

*Results: Of 7 categories of marginal donor candidate, four were correlated with total donor rate (r>0.4) (Table 1A). The aggressiveness score demonstrated substantial variation between OPOs (Figure 1A). OPO aggressiveness score was more strongly correlated with overall donor rate (r=0.61) than were the standard OPO performance metrics of standardized donation ratio (r=0.49), organs transplanted per donor (r=0.54), or observed:expected ratio (r=0.59) (Table 1B).

*Conclusions: OPOs differ in their willingness to classify marginal donor candidates as “eligible deaths”. Our results suggest that OPOs that are more aggressive in pursuing marginal kidney donors have more deceased donors per deaths available for transplant. Altering OPO performance metrics to incentivize aggressive classification of eligible deaths may expand the deceased donor pool.

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