Jodi M. Smith

Background The United States organ allocation policies prioritize kidney–pancreas and other multiorgan candidates above pediatric kidney‐alone candidates, but the effects of these policies are unclear. Methods We used OPTN data to describe trends in multiorgan and kidney–pancreas transplantation and identify 377 next‐sequential pediatric kidney‐alone candidates between 4/1/2015 and 10/31/2019 for individual‐level analysis. Results Eleven percent of all kidneys were allocated as part of a multiorgan or kidney–pancreas transplant and 6% of pediatric kidney candidates were impacted. Pediatric next‐sequential candidates accrued a median of 118 days (IQR 97–135 days) of additional wait time, and this was significantly longer for children who were Hispanic ( p = .02), blood type B or O ( p = .01), or had a cPRA ≥20% ( p < .01). Eight pediatric next‐sequential candidates (2%) were removed from the waitlist due to death or “too sick to transplant.” 63% were transplanted with a kidney with a higher KDPI than the original multiorgan match ( p < .01). Donor service areas with higher volumes of kidney–pancreas transplants had significantly longer additional wait times for pediatric next‐sequential candidates ( p = .01). Conclusions Current allocation policy results in longer waiting times and higher KDPI kidneys for pediatric kidney candidates. As multiorgan transplant volume is increasing, further consideration of allocation policy is necessary to maximize equality and utility.