*Purpose: The Organ Procurement and Transplantation Network (OPTN) implemented a new, distance based, kidney transplant allocation system (nKAS) for recipients of deceased donor kidney transplant (DDKT) in the United States on 3/15/2021. We examined the clinical impact of this new policy on post-transplant kidney function.

*Methods: This is a retrospective, single center cohort study of patients who underwent kidney transplant at a large volume transplant center before and after the nKAS was implemented. Patient and donor demographics, cold ischemia times (CIT), and delayed graft function (DGF) were examined. Pediatric recipients (<18y), multi-visceral transplants, and living donor recipients were excluded. Mann-Whitney U and Fisher Exact tests were performed at the bivariate level comparing pre to post-allocation for donor and recipient demographic and outcome variables. A multiple regression model was fitted to CIT and DGF to compare pre- and post-nKAS changes in outcomes.

*Results: Seven-hundred-thirty-one patients (454 males, 277 females) underwent DDKT from 1/1/2018 to 6/30/2021; 666 recipients in the pre-nKAS period, and 65 post-nKAS. Recipients in the pre- and post-nKAS groups had similar demographics, pre-transplant time on dialysis, and kidney function. 119 recipients (18%) experienced DGF in pre-nKAS group and 16 recipients (37%) in the post-nKAS group (p=0.004). The median CIT for the pre-nKAS group was 13.14 hours (IQR,7.73 – 18.12) compared to 20.75 hours (IQR,16.62 – 25.75) for the post-nKAS recipients (p<0.001). Additionally, in the post-nKAS cohort, match days were longer (966 vs 1220 days, p=0.0483), distance traveled was greater (8nmi vs 142nmi, p<0.001) and length of stay was longer (4 vs 5d, p=0.0411). After adjusting for distance travelled, calculate panel reactive antibodies, and machine perfusion, there was a 1.9 fold increase in CIT post-nKAS (6.6h pre, 12.6h post, p-value=0.0064). Similarly, after adjusting for DCD donation, terminal creatinine, donor age, CIT, and recipient dialysis status, the odds of DGF post-nKAS was 2.4 times than pre-nKAS group (p=0.0362).

*Conclusions: We note an increase in CIT and DGF rates following the implementation of the nKAS in our center. This could be explained by the distance traveled by the graft before implantation and reperfusion. Additional research should examine the changes in the allocation system that may impact graft function and survival.

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