*Purpose: During the first wave of the COVID-19 epidemic in March-April 2020, waitlist registrations and living/deceased donor kidney transplants (LDKT/DDKT) dropped substantially. A second wave of infection peaked in August; a third wave began in late October and has not yet peaked. The effects on kidney transplantation in the US during the most recent waves have not yet been described.

*Methods: Using SRTR data, we compared observed waitlist registrations, waitlist mortality, LDKT, and DDKT 3/15/2020-10/31/2020 to expected events based on calculations from pre-epidemic data 1/2016-2/2020, overall and stratifying by state-level COVID-19 incidence, while accounting for patient casemix.

*Results: New listings bottomed at 45% below expected in May (IRR = _0.520.55_0.57) but steadily recovered to 6% below expected by October (IRR = _0.910.94_0.97) (Table, Figure). Waitlist deaths peaked at 72% above expected in March/April (IRR = _1.601.72_1.85), bottomed at 7% above expected in June (IRR = _0.961.07_1.20), and have since risen only slightly to 16% above expected in August (IRR = _1.041.16_1.29); July/August waitlist mortality increases were restricted to states with the highest COVID-19 burden (August IRR = _1.051.19_1.36). DDKT was below expected through June in states with the highest COVID-19 burden (IRR = _0.640.80_0.99). Nationwide, DDKT peaked in July at 11% above expected (IRR = _1.061.11_1.17) and have since dropped only slightly to 5% above expected by October (IRR = _0.991.05_1.10). LDKT bottomed at 87% below expected in March/April (IRR = _0.100.13_0.15), peaked at 10% below expected in July (IRR = _0.820.90_0.98), before the second wave peaked, and then dropped slightly to 14% below expected during September and October (IRR = _0.790.86_0.94).

*Conclusions: Each successive wave had a lesser impact on transplant and waitlist mortality rates. New listings have approached pre-pandemic rates, suggesting that the medical system has successfully adapted to the challenges of COVID-19, despite occasionally high patient load caused by additional epidemic waves. Decreased mortality may reflect improved care, but may also indicate that true COVID-19 incidence during the first wave was substantially higher than detected.

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