There is nothing equitable about a wasted organ; eliminating out-of-sequence allocation for 30 days decreases utilization of hard-to-place kidneys

Allocation out of sequence (AOOS) is widely used to facilitate placement of deceased donor kidneys at risk of nonuse, yet its impact on utilization remains debated. We conducted a prospective, single-Organ Procurement Organization demonstration project to evaluate the effect of suspending AOOS rescue pathways on kidney utilization. For 30 days beginning July 7, 2025, all deceased donor kidneys recovered by New England Donor Services were allocated strictly according to the Organ Procurement and Transplantation Network kidney match-run sequence, without use of AOOS. Kidney utilization during the intervention was compared descriptively with a 12-month reference period. Donor volume and kidney donor profile index score distribution were comparable between periods. Overall kidney nonuse increased from 29.1% in the reference period to 43.2% during the intervention, with the largest increases observed among higher-kidney donor profile index score kidneys. No kidneys were allocated out of sequence during the project period. Based on prior utilization rates, an estimated 13 additional kidneys would have been transplanted during the project month had utilization remained consistent. Temporary suspension of AOOS rescue pathways was associated with increased kidney nonuse, particularly for medically complex kidneys. These findings suggested that eliminating rescue allocation without a standardized alternative may increase nonuse and underscored the need for transparent, nationally defined rescue allocation strategies.