*Purpose: Recent UNOS policy proposals have changed kidney allocation from local Designated Service Areas (DSA) to geographic distribution areas of varying widths. Since crossmatch of patients is performed in the DSA, wider distribution will be dependent on virtual crossmatches for sensitized patients. Allocation of kidneys based on Class I antigen HLA matching was previously found to be discriminatory against African Americans’(AA) access for transplantation, and consequently eliminated from allocation schemes. The hypothesis to be tested was that virtual crossmatches (VXM) for highly sensitized patients awaiting renal transplant would adversely affect AA access for transplant.

*Methods: To test this, AA and Caucasian (CAU) waiting list candidates with CPRA between 98 and 100%(Hi PRA) were examined for likelihood for transplant, since allocation for transplant is based on a negative VXM. The nationally mandated share for high CPRA was mandated in 2014, so the patients transplanted in 2017 and 2018 were compared to the national waiting list of 98-100% candidates.

*Results: The waiting list has 1710 CAU, 989 Hispanic (HIS), and 3187 AA Hi PRA candidates, with significantly more AA patients waiting more than 5 years compared to Whites and HIS (p<.03). In 2018, 414 CAU and 421 AA Hi PRA candidates received cadaver renal transplants. In 2017, 499 CAU and 421 AA patients were transplanted. Access for transplant compared to candidates on the Hi PRA waiting list was significantly less for AA compared to whites and HIS by Chi Square analysis (P<.0001). No significant difference in transplant rate between CAU and HIS Hi PRA patients was noted. To determine whether the national sharing affected access to transplantation, each ethnic group of Hi PRA patients were compared to the same ethnic group of 80-97% transplant recipients (Mid PRA) who drew kidney allografts from their own DSA without the benefit of national sharing. Both CAU and HIS patients had no difference in access comparing Hi to Mid PRA patients in access to transplant. Only for AA patients were the HiPRA patients disadvantaged for transplant access compared to Mid PRA AA recipients(p<.00001), despite the Hi PRA group had access to the national donor pool.

*Conclusions: Given the lack of uniformity in defining the threshold for unacceptable antigens, as well as the recognized limitations of donor specific antibodies (DSA) to correlate with transplant outcomes, it is no surprise that VXMs using DSA against Class I HLA antigens would result in this inequitable access for sensitized AA candidates. These results of the distribution of these kidneys for Hi PRA patients demand a reexamination of policies that would distribute all kidneys beyond DSA boundaries for the fair access of sensitized patients for this altruistic gift. Without regional centers crossmatching sensitized patients, as in Illinois and Michigan, expansion of mandatory kidney sharing beyond DSA boundaries should not take place.

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