OPOs are labeled with their primary administrative state if not clear from the title. Year of opening reflects the first year transplants were

Table S1, SDC: Kidney transplant center closings by Donor Service Area (Organ Procurement Organization)

Organ Procurement Organization Center Year Reason

Extrinsic (6)

LifeShare Transplant Donor Services of Oklahoma Hillcrest Medical Center 2005 Merger

Mid-South Transplant Foundation (Tennessee) William F Bowld Hospital 2005 Merger

Louisiana Organ Procurement Agency Lindy Boggs Medical Center 2006 Natural disaster

Gift of Life Michigan Hurley Medical Center 2008 Merger

Organ Donor Center of Hawaii Hawaii Medical Center 2012 Hospital bankruptcy

Upstate New York Transplant Service Buffalo General Hospital 2012 Merger

Intrinsic (18)

LifeBanc (Ohio) Saint Elizabeth Health Center 2004 Competition

Texas Organ Sharing Alliance Brackenridge Hospital 2004 Competition

Life Alliance Organ Recover Agency (Florida) Cleveland Clinic Hospital Florida 2005 Competition Golden State Donor Services (California) Santa Rosa Memorial Hospital 2006 Violation

OneLegacy (California) Saint Bernadine Medical Center 2006 Competition

TransLife (Florida) Bert Fish Medical Center 2006 Competition

California Transplant Donor Network Kaiser Permanente San Francisco Medical Center 2007 Violation Center for Organ Recovery and Education (Pennsylvania) West Virginia University Hospital 2007 Competition

Alabama Organ Center South Alabama Medical Center 2008 Competition

OneLegacy (California) Saint Mary Medical Center 2008 Competition

Southwest Transplant Alliance Sierra Medical Center 2008 Competition

Washington (DC) Regional Transplant Community Magnuson Clinical Center 2008 Competition

LifeBanc (Ohio) Akron City Hospital 2009 Competition

Nevada Donor Network Sunrise Hospital and Medical Center 2009 Competition

LifeGift Organ Donation Center (Texas) Covenant Medical Center 2010 Competition

Louisiana Organ Procurement Agency University Medical Center 2010 Competition

OneLegacy (California) Arrowhead Regional Medical Center 2010 Competition

Washington (DC) Regional Transplant Community Howard University Hospital 2011 Competition LifeGift Organ Donation Center (Texas) Texas Health Harris Methodist Fort Worth Hospital 2012 Competition LifeGift Organ Donation Center (Texas) University Medical Center closes 2012 Competition

OPOs are labeled with their primary administrative state if not clear from the title. Year of opening reflects the first year transplants were

performed, and year of closing reflects the year after transplants were performed.

Table S2, SDC: Kidney transplant center openings by Donor Service Area (Organ Procurement Organization)

Organ Procurement Organization Center Year Reason

LifeBanc (Ohio) Akron City Hospital 2003 Prior closure

California Transplant Donor Network Kaiser Permanente-San Francisco Medical Center 2004 Market expansion Center for Organ Recovery and Education (Pennsylvania) VA Pittsburgh 2004 Prior closure Mid-South Transplant Foundation (Tennessee) Methodist University Hospital 2004 Prior closure LifeShare Transplant Donor Services of Oklahoma Saint Francis Hospital 2005 Prior closure

Louisiana Organ Procurement Agency University Medical Center 2005 Prior closure

Gift of Life Donor Program (Pennsylvania) Geisinger Wyoming Valley Medical Center 2006 Market expansion Gift of Life Donor Program (Pennsylvania) Christiana Health Care Services 2007 Market expansion Indiana Organ Procurement Organization Lutheran Hospital of Fort Wayne 2007 Market expansion LifeSource Upper Midwest Organ Procurement

Organization (Minnesota) Sanford Health 2007 Market expansion

Southwest Transplant Alliance (Texas) University Hospital 2007 Prior closure

Texas Organ Sharing Alliance McAllen Medical Center 2007 Prior closure

TransLife (Florida) Halifax Medical Center 2008 Prior closure

Indiana Organ Procurement Organization St. Vincent Hospital and Health Care Center 2009 Market expansion

Southwest Transplant Alliance (Texas) Las Palmas Medical Center 2009 Prior closure

Gift of Hope Organ & Tissue Donor Network (Illinois) Advocate Christ Medical Center 2010 Market expansion Gift of Life Donor Program (Pennsylvania) Crozer-Chester Medical Center 2012 Market expansion

LifeGift Organ Donation Center (Texas) Plaza Medical Center 2012 Prior closure

Organ Donor Center of Hawaii The Queen’s Medical Center 2012 Prior closure

OPOs are labeled with their primary administrative state if not clear from the title. Year of opening reflects the first year transplants were

performed, and year of closing reflects the year after transplants were performed.

Table S3, SDC: Stratified Cox proportional hazards model for risk of patient mortality after transplantation

Values are presented as hazard ratios and 95% confidence intervals. KDRI is set to 0.85 for living donor kidneys. HHI, Herfindahl Hirschman Index. KDRI, kidney donor risk index. ANN, average nearest neighbor.

Deceased donor recipients Living donor recipients Characteristic HR (95% CI) P value HR (95% CI) P value Competition (inverse HHI) 1.28 (1.10 – 1.50) 0.002 1.19 (0.87 – 1.64)

New listings (100s) 0.99 (0.99 – 1.001) 0.99 0.99 (0.97 – 0.99) 0.02 Deceased donors (100s) 0.98 (0.93 – 1.02) 0.31 0.98 (0.89 – 1.07) 0.61 Dialysis incidence (100s) 1.00 (0.99 – 1.002) 0.28 1.00 (0.99 – 1.01) 0.18 Geography (by ANN)

Single Ref . Ref .

Clustered 0.86 (0.77 – 0.97) 0.01 0.78 (0.62 – 0.99) 0.04 Random distribution 0.89 (0.79 – 1.002) 0.054 0.90 (0.70 – 1.15) 0.47 Dispersed 0.87 (0.78 – 0.98) 0.02 0.92 (0.73 – 1.16) 0.39 Age (years) 1.05 (1.04 – 1.06) <0.001 1.05 (1.04 – 1.06) <0.001 Male gender (reference female) 1.19 (1.14 – 1.23) <0.001 1.22 (1.13 – 1.31) <0.001 Waiting time (years) 1.04 (1.02 – 1.05) <0.001 1.08 (1.04 – 1.11) <0.001

KDRI 1.65 (1.56 – 1.73) <0.001 . .

Race/ethnicity (reference White)

Black 0.88 (0.84 – 0.92) <0.001 1.00 (0.90 – 1.10) 0.93

Hispanic 0.77 (0.72 – 0.82) <0.001 0.66 (0.58 – 0.77) <0.001

Asian 0.59 (0.54 – 0.65) <0.001 0.53 (0.42 – 0.68) <0.001

Other 0.94 (0.82 – 1.07) 0.34 1.11 (0.84 – 1.47) 0.48

Table S4, SDC: Stratified Cox proportional hazards model for risk of graft failure after transplantation

Values are presented as hazard ratios and 95% confidence intervals. KDRI is set to 0.85 for living donor kidneys. HHI, Herfindahl Hirschman Index. KDRI, kidney donor risk index. ANN, average nearest neighbor.

Deceased donor recipients Living donor recipients Characteristic HR (95% CI) P value HR (95% CI) P value Competition (inverse HHI) 1.72 (1.46 – 2.01) <0.001 1.48 (1.11 – 1.98) 0.008 New listings (100s) 1.00 (0.99 – 1.003) 0.32 0.99 (0.98 – 0.99) 0.02 Deceased donors (100s) 1.01 (0.97 – 1.06) 0.59 1.01 (0.93 – 1.10) 0.777 Dialysis incidence (100s) 1.00 (0.99 – 1.001) 0.09 0.99 (0.99 – 1.01) 0.73 Geography (by ANN)

Single Ref . Ref .

Clustered 0.75 (0.67 – 0.84) <0.001 0.76 (0.61 – 0.94) 0.01 Random distribution 0.79 (0.70 – 0.89) <0.001 0.75 (0.60 – 0.95) 0.02 Dispersed 0.74 (0.66 – 0.84) <0.001 0.67 (0.54 – 0.83) <0.001 Age (years) 0.98 (0.98 – 0.99) <0.001 0.98 (0.97 – 0.99) <0.001 Male gender (reference female) 1.08 (1.04 – 1.12) <0.001 0.95 (0.89 – 1.01) 0.10 Waiting time (years) 1.01 (0.99 – 1.02) 0.08 1.03 (1.00 – 1.06) 0.04

KDRI 2.74 (2.61 – 2.88) <0.001 . .

Race/ethnicity (reference White)

Black 1.22 (1.17 – 1.27) <0.001 1.78 (1.65 – 1.93) <0.001

Hispanic 0.90 (0.85 – 0.96) <0.001 0.93 (0.84 – 1.04) 0.19

Asian 0.75 (0.69 – 0.83) <0.001 0.62 (0.51 – 0.76) <0.001

Other 1.07 (0.93 – 1.22) 0.36 1.04 (0.79 – 1.36) 0.80