*Purpose: To assess the usage and variability cold pulsatile perfusion preservation in the United States based on procuring organ procurement organization (OPO).

*Methods: All donors procured for possible kidney transplant between 1/1/2010 and 9/2/2020 in the SRTR database were identified, both transplanted and discarded. Donors procured for research were excluded. The rate of pumping of kidneys was determined for all 58 OPOs and based on donor type, SCD, ECD or DCD.

*Results: Over the time period 176,594 deceased donor kidneys were procured, of which 2 did not have an OPO assigned. A large variation in the rate of cold pulsatile perfusion preservation exists among OPOs.

Some OPOs pumped almost no kidneys while others pumped over 80% of donors. The large differences in pumping rates were seen also with both DCD and ECD donors.

Pumping of brain dead SCD donors correlated strongly with OPOs that pumped a higher percentage of kidneys suggesting that availability of pumping and other logistic considerations may be driving pumping rates.

Based on an earlier analysis suggesting that utilization of donor kidneys is better in pumped DCD and brain dead donors with a KDPI of over 60%, the optimal rate of cold pulsatile perfusion preservation would be 45%, if these and only these kidneys were pumped. Given the additional cost of cold pulsatile perfusion preservation and effects on utilization of donor kidneys, there is both over and underutilization by OPOs of this preservation method.

*Conclusions: There is substantial variation in usage of cold pulsatile perfusion preservation in the United States based on OPO of procurement. Although optimal rates of this preservation technique is debatable, based on cost and efficacy there is both over and underutilization of this preservation technique among different OPOs.

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