*Purpose: The purpose of this study is to evaluate a protocol designed to (1) enhance early identification of “at risk” single kidney offers (SKO) and (2) guide the selection of suitable recipients for dual kidney transplantation (DKT). This study presents a structured approach to optimize allocation and utilization of DKT, which remains underutilized despite high organ discard rates throughout the United States.

*Methods: Between Jan 1, 2015 and Dec 1, 2019, we identified SKO at risk of discard and requested expedited dual allocation for preselected patients on the associated match run, coding out all other recipients at the time of an initial offer. SKO were considered “at risk” of discard if at least 3 of the following criteria were met: KDPI >85%, moderate or severe interstitial fibrosis, vascular disease or glomerulosclerosis >10%, severe ATN or creatinine >3 mg/dl, anuria, continuous renal replacement therapy, rhabdomyolysis, microthrombi, perforation peritonitis, donation after cardiac death, extracorporeal membrane oxygenation, Hepatitis C antibody , cold ischemic time (CIT) >24 hours, perfusion resistance >0.3ml/min/mmHg, age >70 years , an atrophic kidney, and severe arterial plaque. Suitable recipients were preselected on the match run if they met all of the following criteria: BMI <30, height >170cm, age >50 years, no significant cardiac disease, or iliac atherosclerosis.

*Results: A total of 6,600 single kidney offers received during the study period. Of these, 23(0.34%) kidney pairs were allocated for DKT on request. Twelve dual kidney pairs were imported and transplanted at median sequence number 1983(413-18,133) on the national list, while 10 kidney pairs were recovered and transplanted locally at median sequence number 11(1-264). Mean donor age was 52.3±11years, KDPI was 75±22%, donor creatinine 2.7±2.1mg/dl. Mean recipient age was 61.1±8.5 years, BMI was 28.1±5 with a mean CIT of 25.7±6.9 hours. 3 recipients had a CPRA>90% and 6 were preemptive. Delayed graft function, was seen in 14 (63%) recipients. Median follow up was 730(60-1460) days. Mean recipient creatinine was 1.59±1.1mg/dl with a GFR of 58.3±25.9 ml/min. One kidney in a pair thrombosed with no appreciable loss of graft function. 1 year death censored graft survival was 100%, while 1 year patient survival was 95.4%.

*Conclusions: Early identification of “at risk” single kidney offers and suitable recipient pairs allows for successful transplantation by dualization, reducing potential organ discards. Non-elderly , highly sensitized and preemptive recipients can be successfully transplanted with marginal organs, in short cold times, mitigating risk of graft loss as well as list exhaustion by making an early “pitch” for dualization.

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