Key PointsQuestionHow often do kidney transplant centers skip candidates with the highest priority to place kidneys with recipients with lower-ranked allocation prioritization?FindingsThis cohort study of 26 579 organ offers from 3136 donors to 4668 recipients found that at 11 geographically isolated transplant centers, kidneys were placed further down the match-run than the candidate with the highest priority 68% of the time. Lower-quality kidneys were statistically significantly more likely to be placed with candidates further down the list than higher-quality kidneys.MeaningThese findings suggest that transplant centers frequently skip over candidates to place kidneys with recipients with lower allocation priority, with limited oversight and transparency.