Equitable Donor Assessment Model of Deceased Donor Kidney Quality

Background The Kidney Donor Profile Index (KDPI) guides organ allocation but blends donor and recipient influences, potentially misclassifying organ quality and contributing to inequity. We developed the Equitable Donor Assessment Model (EDAM)—a donor-focused index that isolates intrinsic graft-failure risk independent of recipient survival. Methods Using UNOS data (2010–2020; n=122,646), we modeled death-censored graft failure with death as a competing event via Fine–Gray regression. Donor coefficients were adjusted for recipient and transplant covariates—including HLA mismatch and ischemia time—to derive donor-specific sub-hazard ratios for the EDAM score. Performance was evaluated using Harrell's C-index and internal–external cross-validation across five geography-aligned US super-regions. Results Higher donor age, diabetes, hypertension, stroke as cause of death, proteinuria, CMV seropositivity, and elevated creatinine independently increased graft-failure risk . EDAM demonstrated robust discrimination (C-index=0.69) and excellent calibration across US regions (pooled slope=1.02; intercept=–0.002). Stratification into five data-driven categories showed a graded rise in cumulative incidence of graft failure (Gray's P<0.05) . Nearly half of kidneys classified as moderate-to-high KDPI (≥0.20) were reclassified as low-risk by EDAM (<0.80) and achieved identical 10-year graft survival to conventional KDPI <0.20 organs . Conclusions EDAM provides an equitable, donor-centric framework for assessing kidney quality. While these categorical thresholds were derived in a data-driven manner within the US system and require external validation in international cohorts, EDAM's ability to safely expand the low-risk pool without compromising outcomes suggests it could significantly refine allocation policy and enhance fairness in kidney transplantation.