Global trends and challenges in deceased donor kidney allocation

Worldwide, the number of patients able to benefit from kidney transplantation is greatly restricted by the severe shortage of deceased donor organs. Allocation of this scarce resource is increasingly challenging and complex. Striking an acceptable balance between efficient use (utility) and fair access (equity) to the limited supply of donated kidneys, raises controversial but important debates at ethical, medical and social levels.
There is no international consensus on the recipient and donor factors that should be considered in the kidney allocation process. There is a general trend towards a reduction in the influence of human leukocyte antigen mismatch and a rise in the importance of other factors shown to affect post-transplant outcome, such as cold ischaemia, duration of dialysis,donor and recipient age and comorbidity. Increased consideration of equity has led to improved access to transplantation for disadvantaged patient groups. There has been a welcomed overall improvement in the transparency and accountability of allocation policies.
Novel and contentious approaches in kidney allocation include the use of survival prediction scores, as a criterion for access to the waiting list, as well as at the point of organ offering with matching of predicted graft and recipient survival.
This review compares the diverse international approaches to deceased donor kidney allocation and their evolution over the last decade.