*Purpose: Since the 2014 Kidney Allocation System (KAS) changes, patients with a very high calculated panel reactive antibody (CPRA) have received greater priority in deceased donor kidney transplant (DDKT) allocation. This change was supposed to be offset by minor declines in allocation to low CPRA patients. However, the CPRA makeup of candidates listed for a 2^nd DDKT may substantially differ from those listed for their 1^st DDKT. With the high priority given to highly sensitized candidates, we hypothesized that KAS disadvantages unsensitized (CPRA<1%) candidates listed for a 2^nd DDKT.

*Methods: This retrospective SRTR database study analyzed adult kidney transplant candidates waitlisted between 10/1/09 and 11/30/18. Subjects were stratified by Pre-KAS v. KAS Era, by 1^st v. 2^nd listing, and by peak CPRA. The primary outcome was DDKT. We used a competing risk multivariable model to adjust for covariates and competing outcomes that included delisting or death.

*Results: A total of 219,860 waitlist candidates were stratified into 4 cohorts: Pre-KAS 1^st listing, Pre-KAS 2^nd listing, KAS Era 1^st listing, and KAS Era 2^nd listing (n= 109694, 10750, 91493, and 7923 respectively). In the Pre-KAS period, unsensitized candidates had similar DDKT rates of 21.2% and 22.4% for 1^st and 2^nd listing respectively. However in the KAS Era, unsensitized candidates saw the DDKT rate drop by nearly half from 1^st to 2^nd listing (20.0% v. 12.8%, p<.001, Table 1). Our multivariate competing risk model of unsensitized KAS Era candidates showed that 2^nd listing was strongly associated with fewer DDKT (H.R. 0.60, 95% C.I. 0.53-0.68, p<0.0001, Fig. 1). Meanwhile, highly sensitized KAS Era candidates (CPRA 98-100%) had the highest DDKT rates of 36.0% and 30.7% for 1^st and 2^nd listing respectively (Table 1).

*Conclusions: Since the 2014 KAS changes, the DDKT rate significantly fell in unsensitized 2^nd listing candidates. This new inequity in DDKT access may be the result of overprioritizing highly sensitized candidates in a subpopulation with a shift towards higher CPRA values. Further research and predictive modeling by the OPTN/UNOS to determine the impact of point allocation changes should be explored.

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