Introduction: Efforts to eliminate the kidney transplant waitlist have driven significant policy and operational changes across the United States. In parallel with advances in machine perfusion, post-transplant care, and diagnostic tools, both kidney recovery and transplantation have increased year over year. The introduction of new Centers for Medicare & Medicaid Services (CMS) regulations in 2021 added further momentum by tying organ procurement organization (OPO) performance to donation and transplant rates. While these policies have successfully prompted increased organ recovery, OPOs do not control organ acceptance or utilization. This structural disconnect has contributed to a surge in the recovery of marginal kidneys, particularly those with high Kidney Donor Profile Index (KDPI) as OPOs strive to meet performance benchmarks.
Methods: This study analyzed national data from the Organ Procurement and Transplantation Network (OPTN) between 2015 and 2024, evaluating changes in kidney recovery, transplant, and discard rates across KDPI categories.
Discard rate was defined as: (Recovered – Transplanted) / Recovered
To assess the impact of regulatory pressure, growth patterns from 2020–2024 were compared to trends from the prior five-year period (2015–2019).
Results: From 2015 to 2019, recovered kidneys increased by approximately 11%, while transplants rose by 12%. In contrast, the 2020–2024 period saw much steeper growth: a 33% increase in recovered kidneys and a 20% rise in transplants. Average discard rates rose from 18.3% in 2015–2019 to 29.3% in 2020–2024, reflecting a growing mismatch between supply and utilization.

2020-2024:

• KDPI 0–20: Recovered kidneys declined from 5,981 to 5,067 (–15%), discard rates steady at 2–3%.
• KDPI 21–34: Recovery remained flat from 3,702 to 3,658, discard rates steady at 2–3%.
• KDPI 35–85: Recovered kidneys increased from 11,760 to 16,523 (40%), discard rates were between 21–23%.
• KDPI 86–100: Recovery surged from 2,293 to 6,436 (181%), but only 1,128 were transplanted in 2024, yielding a discard rate of 82%.

Conclusion: Since 2020, regulatory scrutiny and performance-based evaluations have driven OPOs to recover more kidneys, particularly from donors with high KDPI. Although these kidneys may still be transplantable, the transplant community has not kept pace due to limited infrastructure, risk aversion, and lack of reimbursement incentives. The result is a widening gap between recovered and transplanted kidneys, especially in the highest KDPI tier, where discard rates now exceed 80%. To bridge this gap and truly reduce the transplant waitlist, future policies must address transplant center behavior, incentivize marginal kidney use, and invest in systems that enable rapid evaluation and placement of higher-risk organs.