*Purpose: Despite a growing number of patients awaiting a kidney transplant, 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 (outcomes) were noted. The time period for number of Tx performed was 1/1/20 to 12/31/20. This data was compared to the previous two cycles of data, from 1/1/19 to 12/31/19, 1/1/18 to 12/31/18, and 1/1/17 to 12/21/17. *

*Results: A total of 2490 HTPK were transplanted in this time period. Only 27/218 (12.4%) of all U.S. Tx centers performed high volume HTPK centers but accounted for 1661/2490 (66.7%) of such Tx. 7/27(25.9%) had outcomes as expected , 9/27 (33.3%) had worse than expected outcomes, and 11/27 (40.7%) had outcomes better than expected. When analyzing HTPK center locations by UNOS regions, region 9 transplanted the most HTPK’s with six centers; 6/27 (22.2%), followed by region 3 with five centers; 5/27 (18.5%), region 5 with four centers; 4/27 (14.8%), regions 2 and 4 with three centers; 3/27 (11.1% each), region 11 with two centers: 2/27 (7.4%), while regions 6,7,8, and 10 each had one center; 1/27 (3.7% each). 40.7% of HTPK centers were located in AZ, CA, and NY. Region 9 transplanted highest volume of HTPK’s and accounts for the third highest number of transplanted kidneys by region. Compared to the last data cycle, there has been a 13.5% increase in overall volume of HPTK’s, as well as a 28.6% increase in centers performing transplants with HTPK’s.

*Conclusions: Our study demonstrates that only 12.4% of all U.S Tx centers are high volume utilizers of HTPK. Our study locates over 49% of such centers in 4 states: Arizona, California, Florida, and New York. Of note is the rise in more high volume centers, but a decline in number of expected or above expected outcomes (66.6% this cycle vs 90% last cycle). 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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