*Purpose: Sensitized kidney transplant candidates represent a growing population on the waiting list. Transplantation of patients with high calculated panel reactive antibody (CPRA) can be challenging due to comorbidities associated with long-term dialysis and a postoperative course characterized by higher rates of acute rejection. The purpose of this study was to evaluate the practice patterns and outcomes of transplant centers in the US depending on their volume of sensitized kidney transplants.

*Methods: We queried the UNOS OPTN transplant registry for kidney transplant candidates and recipients during the post-KAS era 2015 to 2018. Patients with a PRA<98%, age <18 years, missing PRA data or multiorgan transplantation were excluded. The study population was divided by transplant center volume and we compared the 5 highest volume centers vs all remaining centers. Post-transplant survival was estimated using the Kaplan-Meier method.

*Results: A total of 2132 kidney transplant recipients met inclusion criteria. 1184 recipients had a CPRA of 100% (55.5%). We observed no differences in short-term outcomes of recipients with a CPRA of 98%, 99% or 100%. The 3-year graft survival ranged between 80.7 and 88.0%. The 5 highest volume centers performed 18.9% of the included transplants. We observed no difference in delayed graft function reported by high vs low center groups (22.4% vs 18.7%, p=0.103). The 5 highest volume centers did experience higher rates of acute rejection during index hospitalization (2.7% vs 1.2%, p=0.043); however, 3-year graft survival rate was not impacted (89.0% vs 83.3%, p=0.09, Figure 1). When we analyzed the waiting list outcomes, we observed that the 5 highest volume centers progress a greater portion of sensitized patients towards transplantation (34.6% vs 29.4%,p<0.001) and have a lower mortality rate (16.2% vs 19.0%, p=0.023).

*Conclusions: We observed no significant difference in 3-year graft survival of highly sensitized kidney transplant recipients when transplanted at high or low-volume centers. However, high volume centers progress candidates to transplantation more effectively and have therefore lower waiting list mortality.

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