*Purpose: The new Kidney Allocation System (KAS) implemented in 2014 was designed to facilitate sharing of kidneys due to changes in prioritization of highly sensitized patients and other groups. We sought to determine effects on sharing across pre- and post-KAS eras according to the Kidney Donor Profile Index (KDPI).

*Methods: Using UNOS data, we compared local, regional, and national utilization for deceased donor kidney transplants (DDKT) alone according to KDPI strata and KAS era: Era 1 (2010-2011, pre-KDPI), Era 2 (2012-2013, pre-KAS), Era 3 (2014-2015, early post-KAS), Era 4 (2016-2017), and Era 5 (2018-2020).

*Results: Since KAS, sharing of kidneys increased across all KDPI groups, and is more pronounced with increasing KDPI. Most notably, regional utilization more than doubled for KDPI >85% kidneys while local use decreased by 30% from Era 1 to 5 (Table 1). However, a 60% increase in absolute numbers of DDKTs performed from Era 1 to Era 5 compensated for increased sharing such that local DDKT volumes rebounded by Era 5. Conversely, sharing for calculated panel reactive antibody (cPRA) 99-100% patients increased post-KAS across all KDPI groups but the effect was more pronounced with lower KDPI strata (89% increase in sharing from Era 1 to 5 for KDPI 0-20%, and a 32% increase for KDPI >85%). However, sharing of kidneys for high cPRA patients accounted for only 23% of shared kidneys and 8% of DDKT alone by Era 5. Consequently, in Era 5, 70+% of kidneys in the 3 lower KDPI strata were transplanted locally whereas 50% of kidneys in the highest KDPI strata were shared.

*Conclusions: KAS increased sharing across all KDPI strata with the biggest change occurring in increased regional utilization of KDPI >85% organs. Increasing DDKT volume has offset any reductions in absolute number of local transplants despite increasing sharing. Increased sharing for cPRA 99-100% patients has occurred across KDPI, particularly in the lower KDPI strata, but this represents a minority of kidneys shared.

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