*Purpose: Despite a growing number of patients awaiting a kidney transplant, the discard rate remains significantly high. The UNOS SRTR data now provides information on all centers about Hard-to-Place Kidneys (HTPK), which by definition are allografts allocated and transplanted after initial 100 offers. Our study is an outcomes analysis study of centers that perform high volumes of HTPK, as well as provides a trends analysis for centers that were deemed as high volume in the previous data cycle.

*Methods: Scientific Registry of Transplant Recipients (SRTR) data for all active US kidney transplant center’s was analyzed to identify centers likely to accept HTPK. Of these programs, High Volume HTPK centers were defined as ones that performed more than a 30 such transplants(tx)/year and their patient and graft survivals were noted. The time period for number of Tx performed was 1/1/18 to 12/31/18 and outcomes analysis from 1/1/16 to 12/31/18. This data was compared to the time period from 1/1/17 to 12/31/17.

*Results: A total of 1888 HTPK were transplanted in this time period. Only 19/223 (8.5 %) of all U.S. Tx centers performed high volume HTPK centers but accounted for 1080/1888 (60%) of such Tx. 6/19 (31.6%) had outcomes as expected , 6/19 (31.6%) had below expected outcomes and 7/19 (36.8%) had outcomes above expected. When analyzing HTPK center locations by UNOS regions, Region 9; 6/19 (32%), Region 5: 5/19 (26%), while Regions 2,4, and 11 each had 2 centers; 2/19 (11% each). Regions 3 and 8 each had 1 center (5% each). 58% of HTPK centers were located in NY, CA, and AZ.

*Conclusions: Our study demonstrates that only 8.5% of all U.S. Tx centers are high volume utilizers of HTPK. Our study locates over 70% of such centers in 4 states: Arizona, California, Florida, and New York. 68% of the HTPK centers had acceptable outcomes or better and best practice at these centers are being captured by our ongoing study. Region 9 and region 5 continue to transplant the highest number of HTPK’s and transplant more than 50% of all HTPK’s. Analyzing these centers practices is imperative to understand how to better allocate kidneys with expected outcomes or better. As new organ allocation policies are formulated, center preferences need to be captured in more granularity to identify centers likely to accept a HTPK. Our study suggests when new allocation policies are formulated, algorithms be considered specifically for organs likely to be classified as HTPK and center experience be factored. Expedited offers to such centers would increase the utilization and reduce discard.

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