Background The use of procurement biopsies for assessing kidney quality has been implicated as a driver of the nearly 20% kidney discard rate in the United States. Yet in some contexts, biopsies may boost clinical confidence, enabling acceptance of kidneys that would otherwise be discarded. We leveraged a novel organ offer simulation platform to conduct a controlled experiment isolating biopsy effects on offer acceptance decisions. Methods Between November 26 and December 14, 2018, 41 kidney transplant surgeons and 27 transplant nephrologists each received the same 20 hypothetical kidney offers using a crossover design with weekend "washout" periods. Mini-study 1 included four, low serum creatinine (,1.5 mg/dl) donor offers with arguably "poor" biopsy findings that were based on real offers that were accepted with successful 3-year recipient outcome. For each of the four offers, two experimental variants-no biopsy and "good" biopsy-were also sent. Mini-study 2 included four AKI offers with no biopsy, each having an offer variant with "good" biopsy findings. Results Among low serum creatinine donor offers, we found approximately threefold higher odds of acceptance when arguably poor biopsy findings were hidden or replaced with good biopsy findings. Among AKI donor offers, we found nearly fourfold higher odds of acceptance with good biopsy findings compared with no biopsy. Biopsy information had profound but variable effects on decision making: more participants appeared to have been influenced by biopsies to rule out, versus rule in, transplantable kidneys. Conclusions The current use of biopsies in the United States appears skewed toward inducing kidney discard. Several areas for improvement, including reducing variation in offer acceptance decisions and more accurate interpretation of findings, have the potential to make better use of scarce, donated organs. Offer simulation studies are a viable research tool for understanding decision making and identifying ways to improve the transplant system.

Solid organ transplantation is an inherently complex enterprise requiring robust systems of quality assurance and process controls to ensure that procedures are safely performed. The community has demonstrated the ability to act decisively to improve care processes, especially following sentinel events. In response to the accidental transplantation of an ABO incompatible heart-lung allograft at Duke in 2003, the United Network for Organ Sharing developed procedures to ensure that compatibility is assured prior to organ recovery and transplantation. 1 Similarly, following the transmission of human immunodeficiency virus (HIV) to 4 patients in Chicago in 2007, a system of universal nucleic acid testing was implemented for deceased donors. 2 In each case, the transplant community enacted national standards and practices to protect safety without regard to cost or efficiency. Unfortunately, the same diligence has not been practiced to ensure the safety of members of transplantation teams and organ procurement organization (OPO) personnel who must travel to other centers to recover lifesaving organs. In 2007, the tragic loss of a University of Michigan team in a plane crash over Lake Michigan should have been a sentinel event, warranting the same thoughtful and universal standards as the events noted

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