Background Discard rate of Public Health Service Increased Risk (PHS‐IR) organs is high despite the absence of worse kidney transplant outcomes. Methods We conducted a retrospective, single‐center study of PHS‐IR kidney offers made to kidney transplant‐only potential recipients from 6/2004 to 5/2015. Overall mortality and transplant outcomes between potential recipients were stratified by response to PHS‐IR kidney offers. Cox regression and Kaplan‐Meier analyses of mortality and allograft failure were performed. Results A total of 2423 potential recipients were offered a PHS‐IR kidney, with 1502 transplanted, with or without a PHS‐IR kidney. Predictors of accepting a PHS‐IR kidney included higher Estimated Post Transplant Survival (EPTS) score, prior kidney transplant, and lower educational achievement on multivariable analysis (P = 0.025, P = 0.004, P = 0.023). A positive response to a PHS‐IR kidney was associated with lower risk of mortality (3.63% vs 11.6%; aHR 0.467, P = 0.0008). PHS‐IR kidney recipients had decreased risk of allograft loss compared to non‐PHS‐IR recipients (P = 0.007), though mortality outcomes were not significantly different based on PHS‐IR status (P = 0.38). No transmission of HIV, HBV, or HCV occurred from PHS‐IR kidney donors in this cohort. Conclusions Efforts must be made to increase awareness of the beneficial outcomes of PHS‐IR organs to maximize appropriate donor allocation.

The TUGT was not associated with waitlist removal or prolonged hospitalization for kidney transplant candidates. Alternative assessments of global health, such as functional status or frailty, should be considered for evaluation of potential kidney transplant candidates.

The number of patients requiring kidney transplantation in the USA has steadily risen over time, by 3000-4000 patients each year, 1 with the gap between allograft supply and demand continuing to grow. As of the year 2019, nearly 103 039 end-stage kidney disease (ESKD) patients were listed on the transplant waiting list at the United Network for Organ Sharing (UNOS) in the USA. An increase in the number of living donor allograft supply is needed to decrease this trend. [2][3][4] Recently, more deceased donor grafts are also being considered for pediatrics to also expand the donor pool. 5 Kidney transplantation is the most effective form of kidney replacement therapy for children. 6 Transplantation is associated with increased survival as well as improvement in neurocognitive development and growth. 7 Medullary Sponge Kidney (MSK) disease is a rare congenital malformation of the distal nephron where cystic dilatation is appreciable in the collecting ducts and kidney papillae. It normally affects the medulla, and cortical structures are almost always spared.Presentation is usually indolent and can include urinary tract infections (UTI), kidney stones, nephrocalcinosis, distal kidney tubular acidosis, and hypocitraturia. 8 Deciding whether to accept a living donor with MSK is a multifaceted task because of the potential challenge of managing pediatric recipients post-transplant given risk of UTI and recurrent nephrolithiasis with progression to chronic kidney disease. 6,9,10 Recently, it was reported that donors with history of MSK had lower kidney stone-related events after nephrectomy compared with non-donors with MSK. 1 Also, the incidence of kidney stone-related