*Purpose: Despite a growing number of patients awaiting a kidney transplant, discard rate remains significantly high. The UNOS SRTR data now provides information on all centers about Hard-to-Place Kidneys (HTPK), which by definition are allografts allocated and transplanted after initial 100 offers. Our study is an outcomes analysis study of centers that perform high volumes of HTPK, as well as provides a trends analysis for centers that were deemed as high volume in the previous data cycle.

*Methods: Scientific Registry of Transplant Recipients (SRTR) data for all active US kidney transplant center’s was analyzed to identify centers likely to accept HTPK. Of these programs, High Volume HTPK centers were defined as ones that performed more than a 30 such transplants(tx)/year and their patient and graft survivals were noted. The time period for number of Tx performed was 1/1/19 to 12/31/19 and outcomes analysis from 1/1/17 to 12/31/19. This data was compared to the previous two cycles of data, from 1/1/18 to 12/31/18 and 1/1/17 to 12/31/17.

*Results: A total of 2194 HTPK were transplanted in this time period. Only 21/221 (9.5 %) of all U.S. Tx centers performed high volume HTPK centers but accounted for 1290/2194 (58.7%) of such Tx. 8/21(38.1%) had outcomes as expected , 2/21 (9.5%) had below expected outcomes and 11/21 (52.4%) had outcomes above expected. When analyzing HTPK center locations by UNOS regions, Region 9 and 5 each had 6 centers; 6/21 (28.5% each), Region 11: 3/21 (14.2%), Region 2: 2/21 (9.5%), while Regions 3,4,7, and 8 each had 1 center; 1/21 (4.7% each). 49% of HTPK centers were located in AZ, CA, and NY. Region 9 and 5 continue to transplant the highest number of HTPK’s, along with region 3, transplanting more than 68.2% of all HTPK. Compared to the last data cycle, an upward trend with outcomes data was observed, with a more than 20% increase in acceptable or above expected outcomes, in addition to overall increase in volume transplanting HTPK’s, with a 14% increase.

*Conclusions: Our study demonstrates that only 9.5% of all U.S Tx centers are high volume utilizers of HTPK. Our study locates over 68% of such centers in 4 states: Arizona, California, Florida, and New York. 90% of the HTPK centers had acceptable outcomes or better and best practice at these centers are being captured by our ongoing study. Analyzing these centers practices is imperative to understand how to better allocate kidneys with expected outcomes or better. As new organ allocation policies are formulated, center preferences need to be captured in more granularity to identify centers likely to accept a HTPK. Our study suggests when new allocation policies are formulated, algorithms be considered specifically for organs likely to be classified as HTPK and center experience be factored. Expedited offers to such centers would increase the utilization and reduce discard.

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