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Patterns and Reasons for Patient-Level Refusal of Deceased Donor Kidney Offers: A Multicenter Descriptive Study
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DOI：10.1016/j.ajt.2026.07.014.png)
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Abstract
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Kidney allocation relies on rapid sequential offers to maximize organ utilization, yet patient-level refusal remains poorly characterized. We conducted a retrospective study of kidney refusal encounters across three transplant centers over two years. Among 841 deceased donor offers where patients were contacted, 108 resulted in patient-level refusals (13%). Donation after circulatory death (DCD) kidneys represented 51% of offers and 54% of refusals, whereas donation after brain death (DBD) kidneys comprised 49% of offers and 46% of refusals. Median kidney donor profile index (KDPI) of refused offers was 50.5 and refusals occurred early in allocation (median match sequence 5; IQR 3-14). Refusal reasons clustered into donor-related concerns: longevity/quality (33.3%), infectious/behavioral risk (23%), patient preference/readiness (15%), logistical constraints (14%), and psychosocial/caregiver limitations (7%). Following refusal, candidates received subsequent offers quickly (median 7.5 days), and 59% underwent transplantation (median 46.5 days). Within 24 months, 23% experienced waitlist inactivation or removal. Most refused kidneys (83%) were transplanted elsewhere with acceptable outcomes. Patient-level refusal is common and multifactorial, reflecting dynamic interactions between candidate readiness, preferences, and donor characteristics. Strategies focused on longitudinal education, preference reassessment, and mitigation of psychosocial and logistical barriers may help reduce refusals while preserving patient-centered decision-making and efficient allocation.
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