*Purpose: One major goal of the Kidney Allocation System (KAS) was to improve access to transplantation. The impact of KAS on rural populations has been poorly studied; here we assess access to the waitlist for rural populations compared to their urban counterparts.

*Methods: Using the Scientific Registry of Transplant Recipients, we assessed changes in demographics of rural and urban patients listed pre-KAS (2010-2013) and post-KAS (2015-2018). Rurality was determined by candidate home address with Rural-Urban Commuting Area Codes. Access to transplant, measured via waitlist composition, being listed pre-dialysis, and dialysis time at registration, was analyzed using multiple regression.

*Results: Overall, listings increased by 5,966 patients under KAS. Although rural patients make up 24.3% of the total waitlist registrant cohort, only 12.5% (n=746) of increased listings post-KAS were rural, suggesting they had less benefit from KAS than urban patients (P<0.001, Table). Adjusting for patient demographics, comorbidities, and organ procurement organization (OPO), post-KAS new listings were less likely to be from rural areas than pre-KAS (OR 0.97 [0.94-0.98], P<0.001). 5 OPOs increased rural registrants while 2 decreased (P<0.05, Figure) after KAS. Post-KAS status was associated with a slight increase in days on dialysis (95.3±5.2 days, P<0.001) and being listed preemptively (OR 1.51 [1.47-1.54], P<0.001), but neither were related to rural status (P=0.95).

*Conclusions: Although KAS increased overall access to listing by increasing waitlist registration and preemptive listing, it generally disfavors rural versus urban populations. Further efforts are needed to evaluate causes of these disparities and the downstream effects on transplantation.

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