*Purpose: In 2014 the updated Kidney Allocation System (KAS) allowed for allocation of blood type A2 kidneys to B recipients in an effort to ameliorate the disparity in wait times for B recipients, who are often minorities. Post-KAS, there has been an increase in the utilization of A2 to B (A2i) deceased donor kidney transplantation (DDKT), however its maximum use has been limited to 25% of transplant centers without an improvement in access for minorities. Cited barriers to its implementation have been increased resources and costs.

*Methods: We performed a retrospective cost analysis at our center of all patients in a 3-year cohort who received either A2i vs. B to B (BB) DDKT from December 2014 through December 2017 including all phases of transplant: pre-, in-hospital, and post-. Pre-transplant eligibility was determined by testing anti-A titers quarterly in all blood group B waitlisted candidates. Eligibility for A2i DDKT included at least two consecutive anti-A IgG titers <1:8 and anti-A IgG/M titers <1:64. For those patients with anti-A IgG titers <1:8 and anti-A IgG/M <1:64, plasma exchange (PLEX) daily for 5 days beginning on postoperative day #1, followed by intravenous immunoglobulin (IVIG) 2 gm/kg and rituximab 375 mg/m² were administered. Post-transplant anti-A titers were monitored prospectively at discharge, two weeks, one month, and three months post-transplant. We collected costs in all phases of care and compared means between A2i and BB utilizing a two-sample t-test.

*Results: There were 29 recipients of A2i DDKT (19 of which underwent PLEX, IVIG, and rituximab) and 50 recipients of BB DDKT. All phases of care for A2i DDKT has increased costs compared to BB DDKT (Table1). Pre-transplant titer cost was $2,640 for each A2i DDKT performed. In-hospital total costs and net costs were significantly more for A2i vs. BB DDKT, respectively ($114, 638 vs. $97, 577 [p<0.001], $42,355 vs. $21, 192 [p<0.001]) since organ acquisition costs were similar ($72,283 vs. $70,385 [p=0.192]). The following in-hospital categories had significantly increased costs: pharmacy, nursing/room board, dialysis/PLEX, blood bank and lab fees (all p<0.001, Table1). Post-transplant titer costs were approximately $400 per patient. When A2iDDKT recipients did not require PLEX, IVIG, or rituximab, the net costs were not different from BB DDKT ($22,219 vs. $21,192 [p=0.64]).

*Conclusions: A2i DDKT costs significantly more than BB DDKT during all phases of kidney transplant care, primarily driven by the need for PLEX, IVIG, and rituximab when indicated based on titers. The Medicare cost report addresses the pre-transplant titer testing, and the post-titer testing is minor with insurance likely covering. However, the significantly increased in-hospital costs must be absorbed the individual transplant centers and may represent a deterrent to A2i DDKT adoption and prevent the full realization of its ability to improve access for minority DDKT recipients. In those patients where additional immunologic therapies are not given, added costs are minimal; this may be reassuring to centers not yet pursuing these transplant for cost-related reasons.

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