*Purpose: Multi-Organ Transplants (MOTs) have variable allocation policies and often take precedence over other waitlist candidates. Lack of defined MOT guidelines divert kidneys to MOT recipients who have worse morbidity and mortality and supersede qualified pediatric candidates who generally are healthier and have much greater estimated post-transplant survival; however, the impact of this allocation policy is poorly defined.

*Methods: We analyzed UNOS kidney transplant alone (KTA) match list data from 4/1/2015-10/31/2019 for kidneys with a Kidney Donor Profile Index <35% that were allocated to a MOT. Our cohort consisted of pediatric candidates listed for KTA who were the next-sequential candidate and who did not receive the contralateral kidney from the same donor.

*Results: Of the next-sequential candidates on the kidney-match run lists for kidneys allocated to MOT recipients, 256 were pediatric candidates. Overall, 6.9% of pediatric recipients were affected by MOT allocation. At the time of the offer 78.1% of these candidates were receiving dialysis. Subsequent kidney transplants occurred in 80.9% of the next-sequential pediatric candidates, at a median additional wait time of 84 days (IQR 37-187 days). Forty-nine children (19.1%) had no documented transplant as of 3/20/2020. No pediatric candidates died or were removed from the waitlist during the study period. Median additional accrued wait time was significantly longer for recipients with B blood type (118 days (IQR 64-208 days), p=0.004) and calculated panel reactive antibody >0% (125.5 days (IQR 33-150 days), p=0.014). There were no significant differences by recipient ethnicity or UNOS region.

*Conclusions: Multiorgan allocation policies affect pediatric KTA wait times, with more significant effect seen in individuals already at a disadvantage, such as those with sensitization or B blood type. Further discussion of MOT allocation policies is needed to ensure that policies maximize utility and equity.

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