BACKGROUND: The likelihood that a deceased donor kidney will be used evolves during the allocation process. Transplant centers can either decline an organ offer for a single patient or for multiple patients at the same time. We hypothesize that refusals for a single patient indicate issues with individual patients, whereas simultaneous refusals for multiple patients indicate issues with organ quality. METHODS: We investigate offer refusal patterns between January 1, 2022, and December 31, 2023, using Organ Procurement and Transplantation Network data. We aggregate refusals at the same timestamp by a center and define a multiple patient refusal as >1 or >5 patients simultaneously refused. We report the refusal codes associated with single and multiple patient refusals and the nonutilization rate after receiving single and multiple patient refusals by cross-clamp. RESULTS: Patient-related refusal reasons are more commonly single patient refusals, whereas organ-related refusal reasons are more commonly multiple patient refusals. Multiple patient refusals before cross-clamp are associated with nonutilization, but single patient refusals are positively correlated with utilization. The nonutilization rate was 28% for organs without pre-clamp refusals, 35% with a single center sending a multiple patient refusal, but only 12% with a single center sending a single patient refusal. CONCLUSIONS: The risk of nonutilization can be assessed early in the offering process based on the number of single and multiple patient refusals received by a specific time (e.g., cross-clamp). Understanding refusal patterns can guide the development of transparent protocols for accelerated placement.
