Organ procurement organization (OPO) listing rates for expanded criteria donor (ECD) kidneys vary greatly across the US. The goal of ECD listing is to shorten wait times for candidates at higher risk of death or delisting while awaiting transplant. We hypothesize that overuse of ECD listing is associated with decreased benefit in terms of expedited transplant for patients listed for ECD.

We performed a probability analysis to show the expected differential effect of ECD listing rates on probability of finding a potential ECD recipient during a given match run (Figure 1). Low listing rates increased the chances of going deeper into the list to find an ECD willing candidate increasing the differential in waiting time for ECD listed candidates. To determine if this occurs within the population of candidates listed for kidney transplant in the US we analyzed 205 031 adult candidates listed for kidney transplant alone in the SRTR database between 2003 and 2010. Though 47.8% of all candidates were listed for ECD organs, OPO listing habits varied considerably with ECD listing rates that ranged from 16.7% to 88%. Figure 2 shows the observed relative difference in waiting time between candidates willing and unwilling to accept an ECD kidney by OPO listing rates. Candidates listed at OPOs with a listing rate of 20% or less showed a large differential in waiting time while higher rates of ECD listing (>40%) resulted in less than a 15% difference in waiting time.

Conservative listing rates for ECD kidneys appears to increase the differential in waiting time for ECD willing candidates. This has important implications for listing strategy with the new allocation system and classification of marginal organs.

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