Michael L. Volk, Amber R. Wilk, Cameron Wolfe, Daniel R. Kaul

The Public Health Service "Increased Risk" (PHS IR) designation identifies donors at increased risk of transmitting hepatitis B, C, and human immunodeficiency virus. Although the risk remains very low in the era of nucleic acid testing, we hypothesized that this label may result in decreased organ utilization. Organ Procurement and Transplantation Network (OPTN) data were used to compare utilization rates between PHS-IR and non-PHS-IR donors, as well as to compare export rates and variation in utilization. Among adult standard criteria donors between 2010 and 2013 with a known PHS-IR status, covariate-adjusted utilization rates were lower among PHS-IR donors than non-PHS-IR donors for all organs. For example, 4,073/5,314 (76.7%) PHS-IR kidneys were used, compared with 25,490/30,456 (83.7%) non-PHS-IR kidneys - an absolute difference of 7%. Furthermore, all PHS-IR organs had higher export rates than non-PHS-IR organs. For example, 28.7% of PHS-IR kidneys were exported, versus 19.7% of non-PHS-IR kidneys. Finally, the utilization rate of PHS-IR organs varied by Donation Service Area; utilization ranged from 20% to 100% among adult kidneys, suggesting significant variation in practices. Similar patterns were seen among pediatric donors. Based on the covariate-adjusted model, if the PHS-IR label did not exist there could be an additional 313 transplants performed in the U.S. each year. The PHS "increased risk" label appears to be associated with nonutilization of hundreds of organs per year, despite the very low risk of disease transmission. Better tools are needed to communicate the magnitude of risk to patients and their families.